national alcohol strategy development consultation

Summary of Recommendations

cohealth is broadly supportive of the proposed goals, guiding principles, priority populations, and priority areas for the National Alcohol Strategy. cohealth suggests some specific initiatives as effective strategies to achieve the aims under a number of the priority areas, as summarised below (note that numbers refer to recommendation numbers in the main body of this submission). These recommendations are consistent with the World Health Organisation Global Strategy to reduce harmful use of alcohol, which can be found at: http://www.who.int/substance_abuse/activities/gsrhua/en/

At the outset, cohealth has two key recommendations:

1. cohealth strongly recommends that the Commonwealth reinstate the Alcohol and Other Drugs Council of Australia to ensure that the national strategy is implemented harmoniously and in a way that allows for the recommendations in the strategy to be met. The de-funding of the Alcohol and Other Drugs Council of Australia in 2014 has left Australia without a national body to inform policy initiatives in the field of alcohol and other drugs; and
2. cohealth calls on the Commonwealth to confirm the funding of nearly $800 million in key health initiatives over the next four years under the Health Flexible Funds. The failure to provide this funding will jeopardise the viability of many AOD service providers and the capacity of the community sector and AOD sector to respond to the recommendations of a national strategy.

Demand side initiatives

• Enact regulations imposing mandatory standardised warning labels on all packaged alcohol products to raise community awareness about the dangers of alcohol consumption. (1.1)
• Implement a national program to raise awareness about the risks of alcohol consumption during pregnancy, which includes information about Fetal Alcohol Spectrum Disorder (FASD). (3.1)
• Develop empathetic and culturally sensitive interventions in Aboriginal communities delivered by community members and health professionals which are aimed at raising the awareness of the risks associated with alcohol consumption during pregnancy. (3.2)
• Establish a time frame for banning the broadcasting of alcohol advertising on television, in print, and on the internet.(6.1)
• Immediate ban on television alcohol advertising during live, and delayed, television broadcasts of sport.(6.2)
• Establish a timeframe for banning alcohol marketing and promotions at, and sponsorship of, all public events. (6.3)
• Immediate ban on alcohol sponsorship of all events that attract the patronage of minors, or people under the age of 18. (6.4)
• Establish an independent body comprised of public health and health marketing experts to set standards and conduct periodic reviews of alcohol advertising, promotion, marketing and sponsorship. (6.5)
• State governments should be funded to establish the infrastructure to obtain data on:
  • total alcohol sales;
  • data collection on alcohol outlets;
  • alcohol related harms; and
  • types of alcohol sold across their respective jurisdiction. (9.1)
• Establish enforceable national guidelines on alcohol outlet density and opening hours. (9.3)

Taxation

Taxation is a critical supply side policy option for reducing both the supply of, and demand for alcohol.

• Australia’s alcohol taxation system needs to be reformed to minimise alcohol‐related harms.(7.1)
• The Wine Equalisation Tax should be abolished in favour of a volumetric tax. This taxation initiative would be applied to all products containing alcohol. This new tax should have the capacity to:
  • ensure the real price of alcohol increases over time; and
  • ensure there is minimum price at which alcohol can be sold. (7.2)
• A proportion of alcohol tax revenue should fund alcohol prevention and treatment programs and other costs associated with the public response to alcohol. (9.2)

Workforce capacity

• Training to support health care workers in primary healthcare settings to identify and respond to excessive alcohol consumption should be embedded in all entry level qualifications in healthcare.(2.1)
• Education of FASD to be included in all entry level qualifications for healthcare and allied health care workers. (3.4)
• Initiate a program to resource GPs to respond to alcohol related health issues more effectively. This may include:
  • Mentoring program where recently registered GPs can opt in to a program to be mentored by experienced GPs with expertise AOD medicine;
  • Improved resources to support GPs to identify the complex health needs that can arise from excessive consumption of alcohol (8.1)

Priority populations: treatment and care

• Initiate programs that fund education around alcohol consumption in communities of place and communities of identity. This includes a continuum of care and support from early education with boys and young men in schools and sporting clubs to workplaces and social venues and social settings to engage LGBTI and Queer communities, Aboriginal communities and recently arrived migrants where mainstream language and programs around alcohol awareness may be exclusionary. (4.1)

Treatment

• Improve pathways from primary care to specialised care, like counseling, and acute care for people with alcohol related disease progression. (8.2)
• Fund healthcare workers with specific expertise in alcohol, and alcohol related harms, in all residential and non-residential (day centre) AOD detox and rehabilitation programs; (8.3)
• Fund a social media campaign that provides links to information about alcohol and links to treatment through social media and other on-line media; (8.4) and
• Provide rapid referral programs and on the spot assessment for emergency department staff. (8.5)
• Recognise FASD as a disability for the purposes of being eligible for disability support pension and disability support services. (3.3)
• Set up wet rooms, or drying out centres, as an alternative to police cells. (10.1)
• Increase the range of options for courts to provide links to treatment for harmful alcohol use including:
  • deferred sentencing;
  • restorative justice and intensive alcohol treatment programs; and
  • the establishment of specific ‘alcohol courts’. (10.2)
• Increase post-correctional facility release support programs for chronically dependent people fast tracking this service for those people that are potentially homeless and dependent on other substances; (10.3)

Priority Areas

cohealth agrees that the proposed priority areas are appropriate. Furthermore, below we suggest some specific initiatives as effective strategies to achieve the aims under a number of the priority areas.

Priority 1: Change the current drinking culture in Australia to reduce harmful drinking

It has been calculated that there are more than 42 million occasions of binge drinking per year in Australia[1] with alcohol consumption contributing to 3% of the burden of chronic and complex health conditions and injuries per year in Australia.[2]

Further:

• Alcohol consumption is a major co-factor in the development of chronic and complex diseases in Australia.[3] Almost 1 in 5 (18.2%) people aged 14 or older consumed more than 2 standard drinks per day on average, exceeding the lifetime risk guidelines.
• Almost 5 million Australians aged 14 or older (26%) were victims of an alcohol-related incident in 2013 with most of these incidents involving verbal abuse (22%);
  • A further 8.7% involved physical abuse.[4]
• About half (49%) of drinkers took action to reduce their alcohol intake in 2013;
  • The main reason for taking this action was health related.

The full extent of the effect of alcohol in Australia is not limited to the increased risk of poor health outcomes. The additional effects include:

• road accidents,
• alcohol fueled violence: including the impact of alcohol on family violence and increased experiences of trauma amongst children
• law enforcement; and
• demand on ambulances and emergency departments in hospitals.

Recommendation

• 1.1 Enact regulations imposing mandatory standardised warning labels on all packaged alcohol products to raise community awareness about the dangers of alcohol consumption.

Priority 2: Prevent and reduce alcohol related injury and violence

Alcohol consumption is attributable to other forms of injury in the community, beyond the health of the individual consumer of alcohol.  Within the context of family relationships involving a man and woman, and children, alcohol can fuel male attitudes of control and coercive behavioural responses to threats to male dominance.

Our organisation’s work in family violence and alcohol and other drugs shows that consumers of alcohol are more likely to disclose associated problems with excessive alcohol consumption in primary healthcare settings than in a specialist family violence service or AOD setting.

The health system is a critical space to support the identification of and response to alcohol consumption; both from the perspective of the individual consuming alcohol and in the context of women and children who experience alcohol related violence.

Health care services need to be skilled in identifying and responding to excessive alcohol consumption in the community. In this space, community health services which offer health services based on the social model of health are well placed to respond to alcohol related violence in the community. Community health organisations are accessible for local communities, and key populations providing a range of services in the one setting. This model enables the individual to access multiple services at once, and in a way that is not feasible in a fee paying service.

Recommendation

• 2.1 Training to support health care workers in primary healthcare settings to identify and respond to excessive alcohol consumption should be embedded in all entry level qualifications in healthcare.

Priority 3: Prevent alcohol use during pregnancy

It is accepted that excessive consumption of alcohol during pregnancy can lead to damaged fetal development in an unborn child.[5] Further the minimum or threshold level at which alcohol poses a threat to pregnancy remains unknown.

20% of birth parents drank alcohol in contravention of guidelines which recommend abstention during pregnancy.

Fetal Alcohol Spectrum Disorder (FASD) covers the range of abnormalities that can occur to a person if their fetus is exposed to alcohol consumption during pregnancy. The prevalence of FASD in Australia is considerable amongst Aboriginal communities, where one study reported that 23 per cent of birth parents of Aboriginal children reported drinking alcohol in pregnancy.[6]

Recommendations

• 3.1 Implement a national program to raise awareness about the risks of alcohol consumption during pregnancy, which includes information about FASD.
• 3.2 Develop empathetic and culturally sensitive interventions in Aboriginal communities delivered by community members and health professionals which are aimed at raising the awareness of the risks associated with alcohol consumption during pregnancy.
• 3.3 Recognise FASD as a disability for the purposes of being eligible for disability support pension and disability support services.
• 3.4 Education of FASD to be included in all entry level qualifications for healthcare and allied health care workers.

Priority 4: Protect young people from alcohol related harm

In Australia, specific populations are more likely to drink at levels that are harmful.

Young adults (aged between 18-24) are more likely to drink at harmful levels on a single occasion than the rest of the adult population. Males were more likely to drink at harmful levels than females.

• Alcohol consumption amongst this age group is characterised by:
  • increased risk of harm due a greater risk of accidents and injuries
  • lower alcohol tolerance than older adults; and
  • increased risk of cognitive impairment and alcohol dependence in later life.[7]

Aboriginals and Torres Strait Islanders – who consume alcohol – are more likely to drink at levels that are considered high risk with those aged 15 or above being 17% more likely to consume at levels that are risky/high risk levels.[8]

Mainstream service delivery responses to address alcohol consumption often involve language that is not inclusive of minority communities, or is conducted in settings that are not culturally or community oriented towards engaging these communities.

Sexually and gender diverse communities consume alcohol at levels that are higher than individuals who do not identify as sexually and gender diverse.

• Lesbians consume alcohol at risky levels compared with heterosexual women (7% compared to 3.9%)[9]
• A recent study of 1,546 gay men in Australia concluded that 16% of participants drank at levels that were high risk, while 42% of participants drank at levels that were moderate to risky.[10]

Recommendations

• 4.1 Initiate programs that fund education around alcohol consumption in communities of place and communities of identity. This includes a continuum of care and support from early education with boys and young men in schools and sporting clubs to workplaces and social venues and social settings to engage LGBTI and Queer communities, Aboriginal communities and recently arrived migrants where mainstream language and programs around alcohol awareness may be exclusionary.

Community health organisations have developed a critical role in supporting key populations at risk of chronic and complex health conditions. This includes providing treatment and prevention interventions from primary care to secondary and tertiary care in the one setting. These settings are well equipped to respond to the needs of key populations in relation to addressing harmful alcohol consumption.

Priority 6: Provide an effective framework for advertising, promotion and sponsorship

Alcohol packaging is an essential part of building specific brands. In the marketing of alcohol, product design and colour scheme are part of this branding. The packaging and colours of the product are developed to target specific consumer groups to attract consumers and specific groups. Branding and advertising can also be used to falsely reassure consumers about the potential dangers of products. For instance, the packaging and branding of products can focus the consumer’s attention away from the harms associated with alcohol products and the levels of alcohol or other toxins in these products.

To limit the opportunities to exploit marginalised individuals and communities and address patterns of alcohol consumption in Australia there is a need to impose increased restrictions on alcohol advertising, promotion and sponsorship.

Recommendations

• 6.1 Establish a time frame for banning the broadcasting of alcohol advertising on television, in print, and on the internet.
• 6.2 Immediate ban on television alcohol advertising during live, and delayed, television broadcasts of sport.
• 6.3 Establish a timeframe for banning alcohol marketing and promotions at, and sponsorship of, all public events.
• 6.4 Immediate ban on alcohol sponsorship of all events that attract the patronage of minors, or people under the age of 18.
• 6.5 Establish an independent body comprised of public health and health marketing experts to set standards and conduct periodic reviews of alcohol advertising, promotion, marketing and sponsorship

Priority 7: Enhance effective enforcement and controls on availability.

The price of alcohol is critical to alcohol consumption and levels of excessive alcohol consumption. There is strong and consistent evidence that higher alcohol prices decrease both alcohol consumption and alcohol related harms while lower prices increase them. A price increase of 10 per cent is estimated to reduce overall alcohol consumption by an average of 5 per cent. Demand for wines and spirits more responsive to price than is the demand for beer.[11] [12]  Increased alcohol prices have also been shown to reduce the proportion of young people who consume excess levels of alcohol. This includes reducing underage and binge drinking, delaying intentions among younger teenagers to start drinking and to slow progression towards drinking larger amounts.[13]

Recommendations

• 7.1 Australia’s alcohol taxation system needs to be reformed to minimise alcohol‐related harms.
• 7.2 The Wine Equalisation Tax should be abolished in favour of a volumetric tax. This taxation initiative would be applied to all products containing alcohol. This new tax should have the capacity to:
  • ensure the real price of alcohol increases over time; and
  • ensure there is minimum price at which alcohol can be sold.

Beer and spirits are already taxed using a volumetric system of taxing. Imposing a volumetric tax on wine would ensure consistency in the taxation of alcohol products. Volumetric taxes also raise the price of the cheaper alcohol products on the market, which weakens demand for these products.

There is concern at the alcohol industry’s propensity to heavily discount alcohol products in marginalised and remote communities to attract custom from key populations with identified levels of harmful alcohol consumption, like aboriginal communities and young people. The concern relates to discounts for bulk alcohol purchases and discounts that are activated to fall on the same day as pension and welfare payments. To ensure that marginalised communities are not exploited by alcohol industry pricing, improvements in data collection and monitoring as set out under Priority 9 below should accompany taxation reform of alcohol products.

Priority 8: Improve treatment capacity, particularly within primary, acute and other health care settings.

Recommendations

• 8.1 Initiate a program to resource GPs to respond to alcohol related health issues more effectively. This may include:
  • Mentoring program where recently registered GPs can opt in to a program to be mentored by experienced GPs with expertise AOD medicine;
  • Improved resources to support GPs to identify the complex health needs that can arise from excessive consumption of alcohol and
• 8.2 Improve pathways from primary care to specialised care, like counseling, and acute care for people with alcohol related disease progression.
• 8.3 Fund healthcare workers with specific expertise in alcohol, and alcohol related harms, in all residential and nonresidential (day centre) AOD detox and rehabilitation programs;
• 8.4 Fund a social media campaign that provides links to information about alcohol and links to treatment through social media and other on-line media; and
• 8.5 Provide rapid referral programs and on the spot assessment for emergency department staff.

Priority 9: Guide practice through appropriate data collection and evaluation, and be responsive to emerging issues

Recommendations

• 9.1 State governments should be funded to establish the infrastructure to obtain data on:
  • total alcohol sales;
  • data collection on alcohol outlets;
  • alcohol related harms; and
  • the types of alcohol sold across their respective jurisdiction.

The data generated from this initiative would inform the need for targeted strategies to respond to specific issues, for example specific alcohol products (for example, alco pops and other alcohol products (that is, sweet, low cost, high percentage of alcohol) that are designed to introduce young drinkers to alcohol products , or promote heavier alcohol consumption.

• 9.2 A proportion of alcohol tax revenue should fund alcohol prevention and treatment programs and other costs associated with the public response to alcohol.
• 9.3 Establish enforceable national guidelines on alcohol outlet density and opening hours.

Priority 10: Improve responses for emergency services

Recommendations

• 10.1 Set up wet rooms, or drying out centres, as an alternative to police cells.
• 10.2 Increase the range of options for courts to provide links to treatment for harmful alcohol use including:
  • deferred sentencing;
  • restorative justice and intensive alcohol treatment programs; and
  • the establishment of specific ‘alcohol courts’
• 10.3 Increase post-correctional facility release support programs for chronically dependent people, fast-tracking this service for those people that are potentially homeless and dependent on other substances;

References

[1] Australian Government- National Preventative Health Taskforce, Australia: The Healthiest Country By 2020, 30 June 2009, p 236

[2] Begg S, et al., The burden of disease and injury in Australia 2003. PHE 82. 2007, Australian Institute of Health and Welfare: Canberra.

[3] Australian Guidelines to Reduce Health Risks  from Drinking Alcohol, National Health Medical Research Council, 2009 https://www.nhmrc.gov.au/guidelines-publications/ds10

[4] National Alcohol and Drug Survey, 2013, see http://www.aihw.gov.au/alcohol-and-other-drugs/ndshs-2013/ch4/

[5] Henderson J, Gray R, Brocklehurst P. Systematic review of effects of low-moderate prenatal alcohol

exposure on pregnancy outcome, BJOG. 2007;114(3):243-52

[6] Zubrick S, et al. The West Australian Aboriginal Child Health Survey: The Health of Aboriginal children and young people. Perth: Curtin University and Telethon Institute of Child Health Research, 2004

[7] National Alcohol and Drug Survey, 2013, Chapter 4 see http://www.aihw.gov.au/alcohol-and-other-drugs/ndshs-2013/ch4/

[8] The National Aboriginal and Torres Strait Islander Social Survey (NATSISS) 2008

[9] Hillier, L., de Visser, R. O., Kavanagh, A., & McNair, R. (2004). The drug-use patterns of heterosexual and non heterosexual women: Data from the Women’s Health Australia Study. In D.W. Riggs & G.A. Walker, (Eds.) Out in the Antipodes: Australian and New Zealand Perspectives on Gay and Lesbian Issues in Psychology, Bentley WA

[10] Zablotska I, Alcohol use among a community-based sample of gay men: Correlates of high-risk use and implications for service provision. Drug Alcohol Rev. 2015 Jul;34(4):349-57

[11] Meier P et al. Independent Review of the Effects of Alcohol Pricing and promotion. Part A: Systematic Reviews.  The University of Sheffield; 2008

[12]   Gallett CA. The demand for alcohol: a meta‐analysis of elasticities. Australian Journal of Agricultural and Resource Economics 2007; 51:121‐35.

[13] Anderson P, Baumberg B. Alcohol in Europe: a public health perspective.  A report for the European Commission.  Institute of Alcohol Studies, UK; 2006