Alcohol Misuse Review Paper 2018 Part B

Interventions

Prevention Model

There are a range of influences within local communities that impact alcohol and drug use behaviour, and that can therefore be targeted in local efforts to reduce alcohol and drug problems. Figure 17.1 below provides a summary from Loxley, et al., (2004) of areas of focus that can be tackled to reduce drug related harm. As relevant to community-level prevention strategies, Figure 17.1 suggests that a carefully coordinated mix of prevention activity (investments), rather than any single activity has the greatest chance of leading to reductions of community problems. The range of possible strategies suggests the importance of tailoring the mix of investments to the specific and distinct needs of particular communities.

Figure: A summary of recommended prevention strategies to reduce drug related harm (modified from Loxley et al, 2004 as cited above)

Universal strategies

The box on the left of the above Figure lists a range of universal prevention strategies that have demonstrated evidence that they can be implemented to reduce problems associated with legal drugs such as alcohol and tobacco.

• Some of these such as Taxation & Price have an important impact, but require national action and are difficult to directly influence at the regional and local levels.

• Regulation involves a broad class of strategies enacted by state and local government that include laws that influence where and to whom alcohol and tobacco can be sold and used.

• Enforcement of regulations typically includes strategies involving a local community component and may include community police and municipal officers working closely with state authorities to provide education and enact penalties for rule violations.

• Also included in this list is Education that includes broad-based strategies such as quality school education and school organisational improvement together with more specific drug education strategies.

• Parent support involves a range of strategies aiming to maximise family effectiveness that can be influenced at a community-level.

• Community improvement includes a broad range of strategies aimed at enhancing community amenity and access to services while attempting to reduce norms that are favourable to unhealthy behaviours and social marginalisation and economic disadvantage.

Prevention strategies

• Targeted early age prevention includes a range of strategies directed at vulnerable mothers and families providing maternal and family support to ensure healthy child development through infancy, pre-primary and primary school.

• Targeted adult interventions such as treatment with involvement of family members and harm reduction strategies, delivering services to families or to young people in the family formation age group also provide opportunities for targeting early age prevention strategies.

• Where they are well coordinated at the community level, universal and targeted strategies work in conjunction to improve community systems.

• The circles to the right of the Figure depict the integrated relationship between adolescent drug use and the patterns of drug use modelled more broadly by adults, emphasising the importance of addressing drug use in different age groups.

Population-level benefits

The box to the right of the Figure identifies that there are potentially multiple benefits that can flow from a well-coordinated set of community prevention strategies. This potential for multiple benefits suggests the advantage of integrating community drug prevention investments with different sectors including those concerned with social improvement, mental health promotion and crime prevention.

Good practice principles

Good practice principles that can be identified from the evaluated strategies detailed in later sections include the following:

• Reductions in alcohol-related harm at a community level are often achieved through local enforcement and support for effective national and state policies and programs. For example where state policies prohibit the supply of alcohol to intoxicated patrons or underage youth, effective local actions can be implemented to enforce these policies.

• Effective programs are guided by logical links between the intervention activities and the community processes that can result in harms.

• Activities often focus on mobilising community support before attempting to change policies, regulations or enforcement practices.

• Data systems are a potentially important component in the evaluated interventions and assess a range of factors including: influencing factors, policy and program impacts on influencing factors, markets, behaviours and harms to be addressed. In most cases specialist data and indicators (underage confederate alcohol purchasing, organising hospital data on alcohol harms) needs to be developed within communities.

• Effective community actions require partnerships that: encourage community involvement and ownership; provide training and access to technical expertise through links to university teams and other experts and; build capacity in key community institutions that are relevant to prevention such as schools, the police and local retailers.

Lenses for Interventions

Across the region there are diverse geographic areas that are important to understand and consider for health promotion planning regarding alcohol. The following four areas or lenses are described below. The implications for interventions in later sections relevant to distinct risks associated with alcohol-related harms:

1. Region-wide issues that affect the whole population
2. Areas projected to house large populations of children
3. Disadvantaged communities
4. Entertainment precincts and alcohol sales areas

Region-wide issues

Region-wide issues that affect the whole population in relation to alcohol include:

• Regular use of alcohol at amounts that exceed the national guideline recommending no more than two standard alcoholic drinks per day (fourteen drinks per week) increases the risk of long-term health problems (NHMRC, 2009). Regular drinking alcohol in amounts that exceed the recommended guidelines contributes to over 61 disease diagnoses. In 2010 of the Australian population aged 14 or older 20.1% reported average alcohol use that exceeded guidelines to reduce long-term risks (AIHW, 2011).

• Occasions of alcohol use that exceed the national guideline recommending no more than four alcoholic drinks in a single session increases the risk of short-term harm (NHMRC, 2009). Short-term harms from excessive amounts of alcohol use include: injuries; accidents; violence; social problems; and risky sex. In 2010 39.7% of Australians aged 14 years or older drank, at least once in the last 12 months, in a pattern that increased their risk of short-term harms (AIHW, 2011).

• There are opportunities for regional and local interventions to prevent harms by reducing alcohol use to recommended levels through: social marketing; community mobilisation; health education; enforcement of liquor licensing regulations; brief interventions; and treatment interventions (Loxley, et al., 2004).

Areas projected to house large populations of children

Areas projected to house large populations of children have the challenge of reducing the influence of alcohol for parents, children and adolescents. These challenges include:

• Pregnant and breastfeeding mothers – one in five women continues to consume alcohol while pregnant after knowledge of pregnancy, or while breastfeeding despite national alcohol guidelines which state that it is best to avoid alcohol altogether during pregnancy and breastfeeding (FARE, 2012).

• Children and adolescents – Although the national alcohol guidelines recommend no alcohol use until adolescents turn 18, the majority of secondary school adolescents drink alcohol. Early age alcohol use leads to heavy use during adolescence which predicts adverse physiological and neurological changes and life-long patterns of harmful alcohol use. Drinking contributes to the three leading causes of death among adolescents, namely unintentional injuries, homicide and suicide, and risk-taking behaviour, unsafe sex, sexual coercion and alcohol overdose (NHMRC, 2009).

• There are opportunities for regional and local interventions to prevent and reduce these problems through: social marketing, community mobilisation; health education; and enforcement of underage drinking liquor licensing regulations.

Disadvantaged communities

Disadvantaged communities often have more entrenched alcohol problems and require a greater focus on early intervention and treatment responses to reduce harmful alcohol use and interventions to protect against inter-generational transmission by integrating with early years work.

• Heavy alcohol and drug use and harmful practices such as alcohol use and tobacco smoking while pregnant or breastfeeding are more common for those with lower levels of education.

• Alcohol and drug problems are more common amongst clients on unemployment benefits and not in the workforce and receiving income support (e.g., sickness, disability benefits).

• Aboriginal and Torres Strait Islanders – Indigenous Australians have lower overall rates of alcohol use, but where using alcohol may be up to six times more likely to drink at high-risk levels than non-Indigenous people (Commonwealth of Australia, 2008).

• Heavy alcohol use is more common for “working class” people employed in the agriculture, retail, hospitality, manufacturing, construction industries and for some professions such as the financial services industries (VicHealth, 2012).

Entertainment precincts and alcohol sales areas

Entertainment precincts and alcohol sales areas often require a special focus of attention to encourage safe venues, reduce situational harms and to enforce liquor license regulations.

• The density of alcohol sales outlets and their marketing and sales practices influence the levels of alcohol use and harm within their surrounding communities.

• People aged 18-24 (31% of whom consume alcohol in risk y quantities on a weekly basis) are more likely to attend and experience harms at alcohol entertainment venues.

• Males (48% of males drink alcohol in quantities that placed them at risk from a single occasion of drinking compared to 29% of females) are more likely to be perpetrators and victims of alcohol-related violence, while females are more likely to experience alcohol-related sexual abuse. These problems are more likely to occur during entertainment nights and on weekends and are influenced by drinking venues.

Categories of Intervention

Interventions devised to prevent and manage alcohol-related harms are based on the principles of demand reduction, supply reduction and harm reduction. Seven categories of interventions have been defined, as follows (Commonwealth of Australia, 2008).

1. Regulating physical availability
2. Taxation and pricing
3. Drink-driving countermeasures
4. Treatment and early intervention
5. Altering the drinking context
6. Regulating promotion
7. Education and persuasion

Addressing the social determinants

We define social determinants in this document as influences that impact large national and state populations. These may include the national and state economy, and government policies and investments in areas that include employment, social security, health, human services, and education. As relevant to alcohol, national policies such as taxation and price controls have solid evidence for reducing alcohol related harm. State policies including alcohol industry regulation also have evidence for effectiveness. Implementing these interventions will rely on federal and state political will (Vos). Social determinants can be responded to in regional and local planning, and this is particularly useful in contexts where regional health planning is supported by national and state policies.

Addressing modifiable risk/protective factors at the regional and local levels

Supply reduction, demand reduction, harm reduction (Australia’s National Drug Strategy) aim is to prevent the uptake and minimise the harmful effects of drug use in Australian society’. This is a harm minimisation approach, that also adopts the ‘prevention paradox’ which suggests that more harm may be prevented through universal interventions that focus on the majority who are less seriously involved in harmful alcohol and drug use, rather than through interventions that only target the smaller proportion of high-risk users (Commonwealth of Australia, 2001).

Examples of Interventions

The sections below summarise the published evaluations of community interventions that have demonstrated population reductions in alcohol and drug related harm and related influences. Research was identified from previous systematic literature reviews (Loxley et al., 2004; Toumbourou et al., 2007; Toumbourou et al., 2013). In what follows the evidence that these projects had a positive impact is summarised together with the community processes these interventions utilised to achieve positive impacts.

The sections presented here outline policies and interventions that can be implemented at the regional and local community levels to address the following four planning issues:

• Region-wide issues that affect the whole population
• Areas projected to house large populations of children
• Disadvantaged communities
• Entertainment precincts and alcohol sales areas.

Region-wide interventions to reduce risky alcohol use patterns that affect the whole population

The table below summarises interventions and the evidence for regional and local interventions to prevent harms and reduce alcohol use to recommended levels across the whole regional population. The interventions described in this section include: community mobilisation; health education and social marketing; development and enforcement of alcohol laws and liquor licensing regulations; brief interventions; police and court actions to motivate alcohol treatment entry; treatment; and harm reduction (road, transport and community safety) interventions.

To be effective alcohol health promotion, treatment and harm-reduction interventions need to be well planned as a whole-system and monitored using data examining the: quality of implementation; impacts on targeted processes such as attitudes and alcohol supply practices; and outcomes on alcohol use behaviours.

Table: Region-wide interventions aimed at reducing risky alcohol use patterns that affect the whole population (Loxley, et al., 2004) (Toumbourou, et al., 2007).

The following symbols are used to indicate the current level-of-evidence for health promotion strategy impacts on alcohol and drug use (Loxley et al, 2004 cited above):

★ Evidence for implementation.

★★ Evidence for outcome efficacy

★★★ Evidence for effective dissemination.

In addition to the above regionally implemented interventions advocacy efforts are also warranted to encourage national and state policies that can effectively reduce local and regional levels of alcohol use and harm. National policies should be encouraged to increase: the taxation; and price of alcohol. National and state policies should aim to restrict freedoms to: market; sell; and supply alcohol.

Interventions for parents, children and adolescents in areas projected to house large populations of children

The table below summarises strategies for preventing early age and frequent adolescent alcohol use in areas where the projected population profile is expected to include large numbers of families with children. The Table describes the level of evidence for actions that can be implemented at the regional and local community levels to modify family, school and community environments. To be effective intervention plans can be tailored to address youth reports of risk and protective factors within their family, school and community environments and monitored for their adherence to effective intervention processes using the Communities That Care youth survey.

Table: Evidence for intervention strategies aimed at reducing the rate of child and adolescent alcohol and drug use (Loxley, et al., 2004) (Toumbourou, et al., 2007) (Toumbourou, Olsson, Rowland, Renati, & Hallam, 2013)

The following symbols are used to indicate the current level-of-evidence for health promotion strategy impacts on alcohol and drug use (Loxley et al, 2004 cited above):

★ Evidence for implementation.

★★ Evidence for outcome efficacy

★★★ Evidence for effective dissemination.

Intervening within disadvantaged communities

The table below summarises interventions for reducing heavy and harmful alcohol and drug use within in communities that house high concentrations of socioeconomically disadvantaged populations. Interventions in these contexts seek to reduce alcohol as a cause of disadvantage by integrating across treatment, employment and housing support and by protecting children from inter-generational transfer of alcohol and drug problems. Higher levels of disadvantaged are associated in Australia with higher fertility and childbirth at younger ages, hence effective child and adolescent interventions can reduce inter-generational problems.

Late-stage crisis interventions are common in these communities but have not been effective at reducing growing social differentials and problems such as child neglect. The Table describes preventative actions that can be taken at the regional and local community levels and have evidence for effectiveness. Monitoring data such as the Australian Early Development Index (AEDI) and the Communities That Care primary school student self-report surveys can be used to plan and monitor regional progress in encouraging healthy environments and reducing the burden of alcohol-related problems for children in disadvantaged communities.

Table: Health promotion strategies aimed at reducing harmful alcohol and drug use in disadvantaged communities (Loxley, et al., 2004) (Toumbourou, et al., 2007) (Toumbourou, Olsson, Rowland, Renati, & Hallam, 2013) (Toumbourou, et al., 2007)

The following symbols are used to indicate the current level-of-evidence for health promotion strategy impacts on alcohol and drug use (Loxley et al, 2004 cited above):

▼ Warrants evaluation research

★ Evidence for implementation

★★ Evidence for outcome efficacy

★★★ Evidence for effective dissemination

Interventions within entertainment and alcohol sales precincts

The table below summarises interventions and their evidence for managing alcohol within entertainment and alcohol sales precincts. Management intervention often begin by establishing local agreements to: eliminate discounting and limit operating hours (e.g., packaged outlets close at 10pm, in-house bar sales at 2am) and increase enforcement of regulations. To be effective alcohol management plans require monitoring data using strategies such as: alcohol test purchase attempts with decoy patrons that appear underage; observation or measurement of intoxicated patrons; record linkage to examine sources of alcohol supply for alcohol-affected attendees in police and health emergency files; using data on harmful alcohol supply to prevent injury and crime and enforce liquor regulations.

Table: Intervention strategies aimed at managing alcohol within entertainment and alcohol sales precincts (Loxley, et al., 2004) (Toumbourou, et al., 2007) (Toumbourou, Olsson, Rowland, Renati, & Hallam, 2013) (Toumbourou, et al., 2007)

The following symbols are used to indicate the current level-of-evidence for health promotion strategy impacts on alcohol and drug use (Loxley et al, 2004 cited above):

★ Evidence for implementation.

★★ Evidence for outcome efficacy

★★★ Evidence for effective dissemination.

References

ABS. (2012). 4832.0.55.001 - Alcohol Consumption in Australia: A Snapshot, 2007-08. Australian Bureau of Statistics. Retrieved from http://www.abs.gov.au/ausstats...

AIHW. (2011). 2010 National Drug Strategy Household Survey report. Drug statistics series no. 25. Cat. no. PHE 145. Canberra: Australian Institute of Health and Welfare. Retrieved from http://www.aihw.gov.au/publica...

AIHW. (2012). Australia’s Health 2012 Australia’s health series no. 14, Cat. No. AUS 156. Canberra: Australian Institute of Health and Welfare. Retrieved from http://www.aihw.gov.au/WorkAre...

AIHW. (2012). Risk factor trends: age patterns in key health risks over time. Cat. No. PHE 166. Australian Institute of Health and Welfare. Retrieved from http://www.aihw.gov.au/WorkAre...

Australian Government. (2004). Parenting influences on adolescent alcohol use. Australian Institute of Family Studies. Retrieved from https://aifs.gov.au/sites/defa...

Australian Government. (2009). Australia: The Healthiest County by 2020 National Preventative Health Strategy – the roadmap for action. National Preventative Health Taskforce.

Bowley, A. (2011). Living with the chain stores. DrinksTrade. Retrieved from http://www.drinkstrade.com.au/...

Briscoe, S., & Donnelly, N. (2001). Assaults on licensed premises in inner-urban areas. Alcohol Studies Bulletin No 2. Retrieved from http://www.popcenter.org/probl...

Campbell, C. e. (2009). The Effectiveness of Limiting Alcohol Outlets Density as a Means of Reducing Excessive Alcohol Consumption and Alcohol Related Harm. American Journal of Preventative Medicine, 556. Retrieved from http://www.thecommunityguide.o...

Collins, D., & Lapsley, H. (2008). The costs of tobacco, alcohol and illicit drug abuse to Australian society in 2004/05. Canberra: Commonwealth of Australia. Retrieved from http://www.health.gov.au/inter...

Commonwealth of Australia. (2001). Alcohol in Australia: Issues and Strategies, A background paper to the National Alcohol Strategy: A Plan for Action 2001 to 2003/04. Canberra: Commonwealth of Australia. Retrieved from http://www.health.gov.au/inter...

Commonwealth of Australia. (2006). National Alcohol Strategy 2006 - 2011. Canberra: Commonwealth of Australia. Retrieved from http://webarchive.nla.gov.au/g...

Commonwealth of Australia. (2008). National Preventative Health Taskforce, Technical Report Number 3-Preventing Alcohol-related harm in Australia: a window of opportunity. Canberra: Commonwealth of Australia. Retrieved from http://www.health.vic.gov.au/v...

Donnelly, N., Poynton, S., Weatherburn, D., Bamford, E., & Nottage, J. (2006). Liquor outlet concentrations and alcohol-related neighbourhood problems. AER Foundation. Retrieved from http://www.bocsar.nsw.gov.au/D...

FARE. (2012). The Australian Foetal Alcohol Spectrum Disorders Action Plan 2013-2016. Foundation for Alcohol Research and Education. Retrieved from http://www.fare.org.au/wp-cont...

Government of Australia. (n.d.). The Right Mix. Retrieved from Government of Australia Department of Veteran Affairs: www.therightmix.gov.au

Government of Canada. (2014). What is Foetal Alcohol Spectrum Disorder (FASD). Retrieved from Public Health Agency of Canada: http://www.phac-aspc.gc.ca/hp-...

Gruenewald, P. (2011). Regulating Availability: How Access to Alcohol Affects Drinking and Problems in Youth and Adults. Alcohol Research & Health, 248. Retrieved from http://pubs.niaaa.nih.gov/publ...

Hudson, S. (2011). Alcohol Restrictions in Indigenous Communities and Frontier Towns. The Centre for Independent Studies. Retrieved from http://cis.org.au/images/stori...

Leicester, A. (2011). Alcohol Pricing and Taxing policies Briefing Note BN124. Institute for Fiscal Studies. Retrieved from http://www.ifs.org.uk/publicat...

Livingston, M. (2012). The Social Gradient of alcohol availability in Victoria,. Australian and New Zealand Journal of Public Health, 45. Retrieved from http://ndarc.med.unsw.edu.au/p...

Livingston, M., Chikritzh, T., & Room, R. (2007). Changing the density of alcohol outlets to reduce alcohol- related problems . Drug and Alcohol Review Vol 26, 562.

Loxley, W., Toumbourou, J., Stockwell, T., Haines, B., Scott, K., Godfrey, C., . . . Williams, J. (2004). The prevention of substance use, risk and harm in Australia: a review of the evidence. Canberra: Commonwealth of Australia. Retrieved from http://espace.library.curtin.e...

NHMRC. (2009). Australian Guidelines to Reduce the Health Risks from Drinking Alcohol. National Health and Medical Research Council. Canberra: Commonwealth of Australia. Retrieved from National Health and Medical Research Council: http://www.nhmrc.gov.au/your-h...

Nielson, A. (2006). Australian liquor research. North Ryde, Australia.

Richardson, D. (2012). The liquor industry - Technical Brief No. 14. The Australia Institute. Retrieved from http://www.fare.org.au/wp-cont...

State Government of Victoria. (2012). Consequences of Drinking - Alcohol and Mental Health. Retrieved from Better Health Channel: [http://www2.betterhealth.vic.gov.au/saywhen/know-the-facts/consequences-of-drinking-alcohol-and-mental-health]

State Government Victoria. (2011). Licensed premises: Assessing Cumulative Impact. Melbourne: State Government Victoria. Retrieved from http://www.dpcd.vic.gov.au/__d...

Toumbourou, J., Hemphill, S., Tresidder, J., Humphreys, C., Edwards, J., & Murray, D. (2007). Mental health promotion and socio-economic disadvantage: Lessons from substance abuse, violence and crime prevention and child health. Australian Journal of Health Promotion, 184-190. Retrieved from http://www.ncbi.nlm.nih.gov/pu...

Toumbourou, J., Olsson, C., Rowland, B., Renati, S., & Hallam, B. (2013). Health Psychology intervention in key social environments to promote adolescent health. Australian Psychologist. Retrieved from http://www.researchgate.net/pu...

Toumbourou, J., Stockwell, T., Neighbours, C., Marlatt, G., S. J., & Rehm, J. (2007). Interventions to reduce harm associated with adolescent substance use. The Lancet, 1391 -1401. Retrieved from www.ncbi.nlm.nih.gov/pubmed/17...

Turning Point. (2012). Preloading Booze Danger. Turning Point Alcohol and Drug Centre. Retrieved from http://www.turningpoint.org.au...

VicHealth. (2012). Reducing alcohol-related harm in the workplace (An evidence review: summary report). Melbourne: Victorian Heath Promotion Foundation. Retrieved from http://ndri.curtin.edu.au/loca...

WHO. (2006). Framework for Policy in the WHO European Region. World Health Organization. Retrieved from http://www.euro.who.int/__data...

WHO. (2011). Addressing the harmful use of alcohol. World Health Organisation. Retrieved from http://www.wpro.who.int/public...

WHO. (2014). Global status report on alcohol and health 2014. World Health Organisation. Retrieved from http://www.who.int/substance_a...

Wicki, M., & Gmel, G. (2011). Hospital admission rates for alcohol intoxication after policy changes in the canton of Geneva, Switzerland. Drug and Alcohol Dependence, 210.