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Chapter 19: Alcohol Use in Adolescence

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Chapter 19

Alcohol use in adolescence

David FergussonChristchurch Health and Development Study, University of Otago, Christchurch

Joseph BodenChristchurch Health and Development Study, University of Otago, Christchurch

Summary• There is consistent evidence to suggest that a substantial fraction of New Zealand

young people engage in heavy drinking including hazardous drinking, alcohol abuse andalcoholdependence.Overa thirdof youngpeopleengage inbingedrinkingorhazardousdrinkingandbytheageof25over20%willhavedevelopedasignificantalcohol related problem.

• Themisuseofalcoholbyyoungpeoplehasbeenassociatedwithincreasedrisksofanumberofadverseoutcomesincluding:motorvehiclecollisions,injuriesanddeaths;crime;violence;sexualrisktaking;mentalhealthproblemsandvictimisation.

• There is increasing internationalevidenceonthetypesofpolicies thatareeffectivein reducing the risksofalcohol relatedproblems inyoungpeople.Effectivepoliciesinclude: increased alcohol taxation; regulating the availability of alcohol; regulationof drinkdriving; alcoholmarketing restrictions; developmentof effective treatmentservices.

• Approaches having little or no effectiveness include: alcohol and drug education inschools;publicserviceadvertisementsadvocatingresponsibledrinkingandavoidanceofdrinkdriving;warninglabelsonalcoholcontainers.

• The recent Law Commission report provides a comprehensive and evidence-basedframeworkforreformingthesupplyandregulationofalcoholinNewZealand.

• Key reforms that are likely to benefit young people include: increasing the cost ofalcohol;raisingthedrinkingageandtheageatwhichalcoholmaybepurchasedto21years;adoptingazerotolerancepolicyfordrinkdrivingbyunder21yearolds;furtherrestrictionontheadvertisingofalcohol;greaterregulationofhoursofsale,numberofoutletsandsupplyofalcoholinlicensedpremisesfrequentedbyyoungpeople;greaterinvestmentintreatmentforyoungpeoplewithsignificantalcoholrelatedproblems.

• Greaterinvestmentisrequiredinevaluationresearchtoascertaintheextenttowhichpolicy changes have beneficial effects in reducing the misuse of alcohol by youngpeople.


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1. IntroductionThepurposeofthischapteristoexaminetheuseandmisuseofalcoholbyyoungpeople;todescribetheharmsassociatedwithalcoholmisuseandtooutlinepolicyoptions forbothregulatingtheuseofalcoholandreducingalcoholrelatedharms.

2. What is the question?AlcoholiswidelyusedandmisusedbyyoungNewZealanderswithestimatessuggestingthat over 1 in 3 young people aged 12-16 engage in binge drinking [1]with a similarfractionofyoungpeopleaged16-21engaginginhazardousdrinking[2].Therehavebeenongoing public concerns expressed about young people and alcohol in both the NewZealandmediaandinofficialreports.Thegrowingstatisticalevidenceandpublicconcernsraisethreeimportantquestionsaboutalcoholandyoungpeople.

• Thefirstquestionconcernstheextenttowhichalcoholusehasharmfulconsequencesforyoungpeople.

• Thesecondquestionconcernsthebestwaysofregulatingthepurchase,supplyandconsumptionofalcoholbyyoungpeopletominimisealcoholrelatedharms.

• Thethirdquestionconcernsthedevelopmentofprevention,treatmentandrelatedservices aimed at both reducing heavy drinking by young people and providing treatmentforyoungpeoplewithalcoholrelatedproblems.

3. Why is alcohol use important in the transition to adolescence?There isgrowingand internationallyconsistentevidencetosuggest thattheheavyuseofalcoholbyyoungpeoplemakessubstantialcontributionstorisksofarangeofadverseconditionsinadolescence.Amongsttheadverseeffectsthathavebeendocumentedarethefollowing.

3.1 Increased risks of motor vehicle collisions, injuries and deathsThetransitiontoadolescence includestworitesofpassagethathaveconsequencesofincreasingtherisksofinjuryandmortalityfrommotorvehicles.First,overtheperiodofadolescencethemajorityofyoungpeoplebegintousealcoholaspartofsocialactivities.Forexample,estimatesfromtheChristchurchHealthandDevelopmentstudysuggestthatbytheageof15over70%ofyoungpeoplereporteddrinkingwithinthelastyearwith30%reportingdrinkingatleastoncepermonth[3].Second,theonsetofdrinkingbehaviourscoincideswithageatwhichadrivinglicencecanbeobtainedwith15beingtheageforacquiringalearner’slicence.Thecombinationofthesetwoeventsplacesadolescentsatriskofdrinkdrivingwiththeattendantharmsofmotorvehiclecollisions,injuryanddeath[4-7].

3.2 Increased risks of crimeThereisnowsubstantialevidencetosuggestthatthedisinhibitingeffectsofalcoholplaceteenagersat increasedrisksofa rangeofcrimes including:violence;vandalism;sexualcrimes; partner violence andproperty crimes [8-29]. This scientific evidence has beensupplementedbygrowingamountsofvideomaterialofpublicareasthathasdocumentedthewaysinwhichthemisuseofalcoholfuelsantisocialbehavioursbyyoungpeople[30].


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3.3 Increased risks of sexual risk takingThe heavy use of alcohol is also associated with increased risks of sexual risk takingincludingmultiplesexualpartnershipsandunprotectedsex[31-33].Inturnthisincreasedrate of sexual risk taking is associatedwith increases in sexually transmitted diseases,pregnancyandabortion[32-35].

3.4 Mental health problems and suicidal behavioursThere is increasingevidence to implicate themisuseof alcohol in thedevelopmentofmentaldisorderssuchasdepression[3,36-44]andthedevelopmentofsuicidalbehavioursinyoungpeople[13,45-47].

3.5 VictimisationThe social context within which alcohol is consumed means that not only are youngdrinkersatriskofbehavinginatriskways,theyarealsoatincreasedriskofbecomingthevictimsofdrinkdrivingandalcoholfuelledcrimes[19,29,48-52].

Inreviewingtherisksassociatedwithteenagedrinking inNewZealandtherecentLawCommission’sreport[53,54]concludes:

“One of the greatest challenges we face around alcohol is how to reconcile the new evidence of the risks alcohol presents to young people with our cultural norms. Drinking to intoxication is commonly seen in our society as a rite of passage and drinking to intoxication is not only socially accepted but expected. New research has shown that young people experience more harm per standard drink than older drinkers. The highest risk is for those under 15 years but there is still an elevated risk of harm per drink for young people up to the age of 25 years.”(p.83)[53]

Inaddition,theLawCommissionnotes:

“It is hard to think of any other lawful product available in our society that contributes to so many social ills. While alcohol misuse is only one of several risk factors contributing to these harms, alcohol distinguishes itself because, like many other factors associated with crime, injury and social dysfunction, the harmful use of alcohol is a modifiable risk factor.” (p.7)[54]

4. What is the scale of the problem?AnumberofNewZealandpublicationshave sought to estimate the fractionof youngpeoplewhoareat riskbecauseof theheavyconsumptionofalcohol [1,2,18,53-59].However,differentstudieshaveusedsomedifferentapproaches. Instudiesofyoungerteenagers, ratesofbingedrinkinghavebeenused toassess thesizeofalcohol relatedproblems. Forexample theYouth2007 survey reports34%of youngpeopleage12 to17 engaged in binge drinking in the lastmonth where binge drinking was defined asdrinkingmorethan5alcoholicdrinksinfourhours[1].TheNewZealandMentalHealthSurvey(TeRauHinengaro)reportedarangeofmeasuresappliedto16to24yearolds[2,55].Thesemeasuresincludeassessmentofthenumberofyoungpeopleengaginginhazardousdrinkingaswellasthosemeetingformaldiagnosticcriteriaforalcoholabuseanddependence.TeRauHinengarofoundthat79%ofyoungpeopleaged16-24drankintheprevious12monthsand49%ofthosedrinkersdrankhazardouslyinthatperiod.Thesamestudyshowedthat,regardlessofdrinkingstatus,nearly17%hadevermetDSMIVcriteria foralcoholabusewith6.5%havingmetcriteria foralcoholdependence.These


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figuresclearlysuggestthatoverathirdofyoungNewZealandersareatriskofalcoholrelatedproblemseachyearbecauseoftheirbingedrinkingand/orhazardousdrinking.Thepercentagewhowillhavemetformaldiagnosticcriteriaforanalcoholrelateddisorderbythetimetheyare25yearsofagewillbewellover20%.

Allofthesefiguresareindicativeofalargeandgrowingproblemwiththemisuseofalcoholby youngpeople [53, 54].Given the consequences of themisuse of alcohol by youngpeopleforawiderangeofoutcomes,findingconstructivewaysofmeansofregulatingtheuseofalcoholbyyoungpeopleandmitigatingtheadverseeffectsofalcoholmisuseisamatterofhighpriorityintheareaofadolescentpolicy.

5. What does research tell us about causative factors?Therehasbeenextensiveresearchintothefactorsassociatedwiththeuseandmisuseofalcoholbyyoungpeople.Thesefactorsincludethefollowing.

5.1 Genetic factorsThere has been growing evidence from both twin studies and behavioural geneticresearchtosuggestgeneticfactorsmayplayanimportantroleindeterminingindividualsusceptibilitytoalcoholabuseanddependence[60-65].Estimatessuggestthatupto60%ofthevariationinalcoholabuseanddependencemaybeaccountedforbygeneticfactors[66].Itislikelythatgeneticfactorsinteractwithenvironmentalinfluencessothatthosemostatriskofalcoholrelatedproblemsarebothgeneticallysusceptibletotheseproblemsandareexposedtosocialenvironmentsthatencouragethemisuseofalcohol[67].

5.2 Socio-demographic factorsThere is extensive evidence which suggests higher rates of alcohol misuse amongstcertain groups within the population. Males are more likely to misuse alcohol thanfemalesalthoughrecentevidencesuggeststhatthegendergapinthisarea isreducingamongst young people [68-72]. Youngpeople from socially disadvantagedbackgroundcharacterisedbylowfamilyincomeandsocio-economicstatusareatgreaterrisk[73,74].InNewZealandyoungMāorihaveratesofalcoholabuseanddependencethatarehigherthanthoseofnonMāori[53,54,75,76].

5.3 Family factorsAlargeamountofresearchsuggeststhatthenatureandqualityofthefamilyenvironmentplaysan importantrole inpredisposingyoungpeopletothemisuseofalcohol.Factorsassociatedwithalcoholmisusebyyoungpeopleinclude:parentalalcoholproblems;earlyageoffirstdrink;familydysfunction,childhoodmaltreatmentandrelatedconditions[21,77-85].

5.4 Peer influencesAmongst adolescents peer affiliations play an important role in the development ofsubstanceuseandabuse,withyoungpeoplewhoaffiliatewithsubstanceusingfriendsandacquaintancesbeingatincreasedrisksoftheuseandmisuseofalcohol[85-89].

5.5 Access to alcoholThere is extensive evidence to suggest that factors that influence the availability and


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accessibilityofteenagerstoalcoholplayanimportantroleinthedevelopmentofalcoholuseandmisuseinthisgroup.Thesefactorsinclude:(i)thepriceofalcohol;(ii)thelegaldrinkingage;(iii)theavailabilityofliquoroutlets;(iv)licensinghours;(v)theenforcementofalcohollaws;and(vi)advertising.Thisresearchmakesitabundantlyclearthatthewaysinwhichtheaccessofyoungpeopletoalcoholisregulated,canplayanimportantroleininfluencingratesofalcoholuseandmisuseinthispopulation[9,90,91].

Themajor conclusions that emerge from research into the causative factors involvedinthedevelopmentofalcoholuseandmisuseare likelyto involveacomplex interplayofbiological, social, familial,peerandother factorswhichcombine todetermineratesofalcoholuseandmisuse intheadolescentpopulation.Considerationof thesefactorssuggeststhatapproacheswhichfocusonregulatingtheaccessofyoungpeopletoalcoholofferthegreatestpotentialforminimisingalcoholmisuseinthispopulation.

6. Prevention, treatment and management of alcohol use/misuse in adolescence

There is a large and extensive literature on the effective policies for the regulation ofalcohol and the prevention, treatment andmanagement of alcohol related problems.Thismaterialhasbeenablysummarisedintheaward-winningtextAlcohol – No Ordinary Commodity [91]. Chapter 16 of that text provides an overview and summary of theeffectivenessof42strategiesandpoliciesthathavebeenusedaroundtheworldfortheregulation,preventionandtreatmentofalcoholmisuse.Keyconclusionsofthisreviewaresummarisedbelow.

6.1 Increased alcohol taxationThereisconsistentevidencefromaroundtheworldthatincreasingthetaxationofalcohol(andthencethepriceofalcohol)isoneofthemosteffectivemethodsforreducingalcoholconsumptionandrelatedharms.Thisapproachhasbeenfoundtobemoreeffectiveinreducing heavy drinking and is likely to be effective in reducing alcohol consumptionamongstyoungerdrinkers[92-95].

6.2 Regulating the availability of alcoholThereisalsostrongevidencethatregulatingtheavailabilityofalcoholalsohasbenefitsin reducing alcohol consumption and harm. The evidence suggests that by restrictingthehoursofsale,thetimesofthedaywhenalcoholissoldandthelocationofalcoholsalepremisesandsimilarfactorsitispossibletoreducelevelsofconsumptionandratesofalcoholrelatedproblems[96-99].Aformofalcoholregulationthat isusedwidely isregulationofthelegalageatwhichalcoholcanbepurchased.ThereisgoodevidencefromUS-basedresearchthatraisingtheminimumdrinkingageto21andadequatelyenforcingthelawleadstoreductionsinalcoholrelatedharmsamongstyoungpeople[100-104].

6.3 The regulation of drink drivingAfurthermovethathasbeenshowntobeeffective in reducingalcohol relatedharmsisrestrictionsondrinkdrivingincludingloweringthelegalbreathalcoholconcentrationand ensuring that drink driving laws are visibly enforced by the use of check points,randombreathtestsandstrongpenalties[105-108].Withrespecttoadolescentsithasbeenproposedthatzerotolerancepoliciesregardingbreathalcoholconcentrationsare


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effective in reducing ratesofdrinkdrivingamongst thosebelowthe legaldrinkingage[109-112].

6.4 Alcohol marketing restrictionsThereisincreasingevidencetosuggestthatrestrictingalcoholadvertisingandmarketingmayhavemodesteffectsondrinkinginyoungpeople[113,114].Conversely,thereisnoevidencethevoluntaryselfregulationcodesbythealcoholindustryhavebeensuccessfulinreducingratesofalcoholconsumptionamongstyoungpeople[113].

6.5 Altering the drinking contextAfurtherstrategythathasbeenfoundtohavemodesteffectsinreducingrisksofalcoholconsumptionandharmisgreaterregulationandoversightofdrinkingestablishmentsandalcoholsupplyoutletstoensurethatregulationsregardingalcoholconsumptionrelatingtoageofsupplyandlevelsofintoxicationareadequatelyenforced[115-117].

6.6 Development of effective treatment servicesThe preceding approaches have all relied on changing the policy environment in various ways to reduce levelsofhazardousdrinkingandalcohol relatedharms.However,evenwiththemosteffectivepopulationlevelpoliciesanumberofyoungpeoplewilldevelopsignificantalcoholrelatedproblemsandrequiretreatmentandsupport.

Therehasbeenagrowingresearchliteratureonthedevelopmentofinterventionsaimedattreatingandassistingpeoplewithalcoholrelatedproblems.Thisresearchhasidentifiedanumberoftreatmentapproachesasbeingeffective.Theseinclude:briefinterventionsaimedatreducingtherisksfacedbyhazardousandhighriskdrinkers;cognitivebehavioural,motivationalenhancementandrelatedtherapies;andmutualaidtreatments[118-120].Paralleltothedevelopmentoftheseinterventionstherehasbeenagrowingnumberofbest practice guidelines for the development of treatment for adolescent populationswithalcoholrelatedproblems[46,121-123].

7. What does not workWhilethereisgrowingevidenceoneffectivestrategiesforreducingalcoholrelatedharm,thereisalsoagrowingconsensusabouttheapproacheswhicharelikelytobeineffective.Theseapproachesincludethefollowing.

7.1 Alcohol and drug education in schoolsAround the world there have been investments made in alcohol and drug educationprogrammesthatseektoteachyoungpeopleabouttherisksofalcoholanddrugsandreducetherisksoffutureuseandabuseofsubstances.Thereisnowgenerallyconsistentevidence to suggest that while alcohol and drug education increases young people’sknowledgeaboutthesesubstances, itdoesnotgenerallyreducetherisksoffutureuseandabuseofsubstances[124-127].

Therehave,however,beensomeexceptionstothesefindings.Inparticular,therehasbeenpromisingevidencethatthe“Keepin’ itREAL”programmemaybeeffectiveinreducingdrug and alcohol abuse in young people [128-133]. Keepin’ it REAL is amulticultural,school-based substance use prevention program for students 12-14 years old. Keepin’itREALusesa10-lessoncurriculumtaughtbytrainedclassroomteachers in45-minute


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sessionsover10weeks,withboostersessionsdeliveredinthefollowingschoolyear.Thecurriculumisdesignedtohelpstudentsassesstherisksassociatedwithsubstanceabuse,enhancedecisionmakingandresistancestrategies,improveanti-drugnormativebeliefsandattitudes,andreducesubstanceuse.

7.2 Mass media campaignsParalleltoalcoholanddrugeducation,therehavebeenlargeinvestmentsmadeinmediacampaigns aimed at encouraging responsible drinking and highlighting the hazards ofbehaviourssuchasdrinkdriving.Despitetheinvestmentmadeintosuchcampaignstheevidencefortheireffectivenessinreducingalcoholconsumptionoralcoholrelatedharmsis very limited.Manyprogrammeshavenot shown theexpectedgainsandchanges inbehaviours[134,135].IncommentingonthisareaBaboretal[91]note:

“Despite their good intentions, Public Service Advertisements are not an effective antidote to the high quality pro drinking messages that appear much more frequently as paid advertisements in the mass media.” (p.202)

Thesefindingssuggestthatinvestmentsintomediaadvertisingtoencourageresponsibledrinkingor avoidhazardousdrinkingneed tobeapproachedwith cautionand requirecarefulevaluationtoestablishtheireffectivenessandcostbenefitratio.

7.3 Warning labelsAthirdapproachthathasbeenusedhasbeentorequirethatalcoholbeveragecontainerscarry labels warning consumers of the risks of excessive alcohol use. Reviews of theevidence suggest that such labels have nomeasureable beneficial effects on levels ofalcoholconsumptionoralcoholrelatedharm[136-138].

Acommonthemethatappearstouniteinterventionsthatdonotworkisthatallinvolvemethodsofeducationandrationalpersuasionthatseektodiscouragetheexcessiveuseofalcohol.Regrettablytheweightoftheevidencesuggeststhatreasonableandrationalappeals are not effective in reducing rates of alcohol consumption or alcohol relatedharms.

8. Where are policy/intervention currently focused?Recently there have been growing public concerns stated about the issue of problemdrinkinginNewZealandwithmanyoftheseconcernsfocusingontheissueofhazardousdrinking by young people. These concerns have been reinforced by highly publicisedeventsinwhichyoungpeoplehavediedasaresultoftheexcessiveuseofalcoholbothfromalcoholpoisoningandmotorvehicleaccidents.Paralleltotheseconcernstherehavebeenrecentsuggestionsforamajorreviewofthelegislationandregulationofalcohol.Themostambitiousattemptinthisareahasbeentherecent2009LawCommissionreportwhichprovidesacomprehensiveoverviewoftheregulationofalcoholwithinNewZealandandsetsforthaseriesofproposalsforthepossibleintroductionofnewlegislationcentredarounddemandreduction(e.g.increasingthepriceofalcohol);supplycontrol(e.g.raisingthedrinkingage)andproblemlimitationstrategies(e.g.reducingthelegalbloodalcohollimit)[53,54,139].

TheworkoftheLawCommissionhasbeensupplementedbyapublicadvocacycampaignby Alcohol Action [140] who has proposed what has come to be known as the 5+solution.Thissolutionis: (1)raisealcoholprices;(2)raisethepurchaseage;(3)reduce


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alcohol availability; (4) reduce marketing and advertising; (5) increase drink-drivingcountermeasures+(increasedtreatmentopportunitiesforheavydrinkers).

BoththeLawCommissionreportandtheadvocacybyAlcoholActiondrawheavilyfromtheevidencebasereviewedintheprevioussection.

9. Implications for future policyItisclearthatthemisuseofalcoholbyyoungNewZealandersposesamajorsocialandhealthproblemthat requiresurgentattention.The foundations forchangeand reformhavebeenwelldevelopedintheLawCommissionreportandsummarisedintheadvocacyofAlcoholAction’s5+plan.Keyareasofreformthatarelikelytohaveanimpactonalcoholmisuse in adolescence are:

• increasingthecostofalcohol;

• raisingthedrinkingageandtheageatwhichalcoholmaybepurchasedto21years;

• adoptingazero-tolerancepolicyfordrinkdrivingbyunder21yearolds;

• furtherrestrictionontheadvertisingofalcohol;

• greater regulation of hours of sale and supply of alcohol in licensed premisesfrequentedbyyoungpeople;and

• greaterinvestmentintreatmentforyoungpeoplewithsignificantalcoholrelatedproblems.

It is also important that greater investment is made into research and evaluation todocumenttheconsequencesofpolicychange.Thereductionofthedrinkingageto18in1999providesaclearexampleoftheneedforevaluationtobebuiltintopolicychange.Whilstthereductionofthedrinkingageto18wasamajorsocialpolicychange,noclearplanwasdeveloped toevaluate the consequencesof this change.Whilst anumberofevaluations have been conducted [e.g. 141-143] these have been limited because ofproblemsofdataqualityanddataavailability. Inturn,thelackofsystematicevaluationof the evidence has complicated the process of policy debate and reform. It may besuggestedthathadaclearplanbeendevelopedforevaluatingtheconsequencesof1999reformswith this informationbeing provided to Parliament,manyof thedebates andconcerns thathavebeenexpressedabout furtherchanges to the lawcouldhavebeenaddressedbyevidenceratherthanopinion.Forthesereasonsitisimportantthatwhenmajorpolicy change is contemplatedevaluation isbuilt into thepolicy changeprocessso thatclearconclusionsmaybedrawnabout theeffectivenessorotherwiseofpolicychange. If applied consistently this strategy could result in an evolutionary process inwhichgoodpoliciesarestrengthenedand reinforcedby researchevidencewhilstpoorpoliciesareidentifiedanddiscarded.

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232

Appendix 1: Summary of evidence on effective treatmentsThe review in the main chapter provides an overview of the evidence regarding theeffectiveinterventionstoaddressalcoholrelatedproblemsinyoungpeople.Thisevidenceisbasedonalargebodyofresearchconductedaroundtheworld.ThemajorfindingsfromthisbodyofresearchhavebeensummarisedbyBaboretal. intheaward-winningtextAlcohol – No Ordinary Commodity[91].

Table19.1isreproducedfromthattextandprovidesasummaryoftheevidenceontheeffectivenessof42interventionsintermsof:

(a)overalleffectiveness

(b)breadthofresearchsupport

(c)cross-nationaltesting.

Overall effectiveness is scored as:

0 Evidenceindicatesalackofeffectiveness

+ Evidenceforlimitedeffectiveness

++ Evidenceformoderateeffectiveness

+++ Evidenceforahighdegreeofeffectiveness

? Nocontrolledstudieshavebeenundertakenorthereisinsufficientevidenceuponwhichtomakeajudgement

Breadth of research support is scored as:

0 Nostudiesofeffectivenesshavebeenundertaken

+ Oneortwowell-designedeffectivenessstudiescompleted

++ Several effectiveness studies have been completed, sometimes in differentcountries,butnointegrativereviewwasavailable

+++ Enough studies of effectiveness have been completed to permit integrativeliteraturereviewsormeta-analyses

Cross-national testing is scored as:

0 Thestrategyhasbeenstudiedinonlyonecountry

+ Thestrategyhasbeenstudiedinatleasttwocountries

++ Thestrategyhasbeenstudiedinseveralcountries

+++ Thestrategyhasbeenstudiedinmanycountries

Inaddition,thetableprovidesnarrativecommentsonspecificinterventions.Table19.1maybeusedtoclarifyandelaborateonthegeneralrecommendationsmadeinthemainchapter.


233

Tabl

e 19

.1. S

umm

ary

of e

ffec

tive

pro

gram

mes

for t

he p

reve

ntion

and

trea

tmen

t of a

lcoh

ol p

robl

ems

(fro

m B

abor

et a

l. [9

1], w

ith

perm

issi

on)

Stra

tegy

or i

nter

venti

onEff

ectiv

enes

sBr

eadt

h of

re

sear

ch

supp

ort

Cros

s-

natio

nal

testi

ng

Com

men

ts

Pric

ing

and

taxa

tion

Gen

erallyevaluated

inte

rmsofhow

pricecha

ngesaffe

ctpop

ulati

on-le

velalcoh

ol

consum

ption

,alcoh

ol-related

problem

san

dbe

veragepreferences.

Alcoh

olta

xes

+++

+++

+++

Increa

sedtaxesredu

cealcoh

olcon

sumpti

onand

harm.Eff

ectiv

enessde

pend

son

go

vernmen

toversightand

con

trolofthe

totalalcoh

olsup

ply.

Minim

umprice

?+

0Logicba

sedon

priceth

eory,b

utth

ereisverylitt

leevide

nceofeffe

ctivene

ss.Co

mpe

tition

regu

latio

nsand

trad

epo

liciesmayre

strictim

plem

entatio

nun

lessachievedviataxatio

npo

licy.

Bansonpricediscou

ntsan

dprom

otion

s?

+0

Onlywea

kstud

iesingen

eralpop

ulati

onsofth

eeff

ecto

frestrictio

nsonconsum

ption

or

harm

;effe

ctivene

ssdep

endsonavailabilityofalte

rnati

vefo

rmsofche

apalcoh

ol.

Differen

tialp

ricebybe

verage

++

+Highe

rpricesfo

rdistilledspiritsshiftsconsum

ption

tolo

wer-alcoh

olcon

tentbeverages

resulting

inlessoverallconsum

ption

.Evide

ncefortheim

pactoftaxbreakson

low-alcoh

ol

prod

uctsissug

gestive.

Specialo

rad

ditio

naltaxati

on

onalcop

opsan

dyouth-oriented

be

vera

ges

++

+Eviden

ceth

athighe

rpricesre

ducecon

sumpti

onofa

lcop

opsbyyou

ngdrinkerswith

out

completesubstituti

on;n

ostud

iesofim

pactonha

rms.

Regu

lati

ng p

hysi

cal a

vaila

bilit

yGen

erallyevaluated

inte

rmsofhow

cha

ngesin

availabilityaff

ectp

opulati

on-le

velalcoh

ol

consum

ption

and

alcoh

ol-related

problem

s.Ba

non

sales

+++

+++

++Ca

nredu

cecon

sumpti

onand

harmsub

stan

tially,b

utoften

with

adverseside-eff

ectsfrom

blackmarket,whichisexpen

siveto

sup

press.In

effectiv

ewith

oute

nforcemen

t.Ba

nsondrinking

inpub

licplaces

?+

+Affe

ctsyoun

gorm

argina

lised

high-riskdrinkers;m

aydisplaceha

rmwith

outn

ecessarily

redu

cing

it.

Minim

umlegalp

urchaseage

+++

+++

++Eff

ectiv

einre

ducing

traffi

cfataliti

esand

otherharmswith

minim

alenforcemen

tbut

enforcem

entsub

stan

tiallyin

crea

seseff

ectiv

enessan

dcost.

Ratio

ning

++++

++Eff

ectsgreateronhe

avydrinkers.

Governm

entm

onop

olyofre

tail

sale

s++

+++

++Eff

ectiv

ewayto

limitalcoho

lcon

sumpti

onand

harm.P

ublichea

lthand

pub

licordergoa

lsby

governmen

tmon

opoliesincrea

seben

eficialeffe

cts.

Hou

rsand

daysofsalerestricti

ons

++++

+++

Effectiv

ewhe

recha

ngesin

trad

ingho

ursmea

ning

fullyre

ducealcoh

olavailabilityorwhe

re

prob

lemssuchaslate-nightviolencearespecificallyre

latedtohou

rsofsale.


234

Tabl

e 19

.1. S

umm

ary

of e

ffec

tive

pro

gram

mes

for

the

prev

enti

on a

nd tr

eatm

ent o

f alc

ohol

pro

blem

s (c

onti

nued

)

Stra

tegy

or i

nter

venti

onEff

ectiv

enes

sBr

eadt

h of

re

sear

ch

supp

ort

Cros

s-

natio

nal

testi

ng

Com

men

ts

Restricti

onson

den

sityofo

utlets

++++

+++

Eviden

cefo

rbo

thcon

sumpti

onand

problem

s.Cha

ngesto

outletn

umbe

rsaffe

ctavailability

mostinarea

swith

lowprioravailability,butbun

chingofoutletsintohigh-de

nsity

en

tertainm

entd

istrictsm

aycau

seproblem

swith

pub

licorderand

violence.

Differen

tavailabilitybyalcoh

ol

stre

ngth

++++

++Mostly

tested

inte

rmsofdifferen

tstren

gthsofb

eeran

dforbroa

dene

davailabilityofwine.

Mod

ifyin

g th

e dr

inki

ng

envi

ronm

ent

Gen

erallyevaluated

inte

rmsofhow

stafftraining

,enforcemen

t,and

legalliabilityaff

ect

alcoho

l-related

violencean

dothe

rha

rms.

Staff

training

and

hou

sepolicies

relatin

gtore

spon

siblebe

verage

service(RBS

)

0/+

+++

++Notallstud

iesha

vefo

undasign

ificanteffe

ctofR

BStraining

and

hou

sepolicies;nee

dsto

be

backed

byen

forcem

entforsustained

effe

cts.

Staff

and

man

agem

enttrainingto

betterm

anageaggression

+++

++Eviden

cecurrentlylimite

dtoone

rand

omised

con

trolledstud

yan

dsupp

ortiv

eresultsfrom

multi-compo

nentprogram

mes.Evide

nceisavailablefrom

Australia,C

anad

a,and

Swed

en.

Enha

nced

enforcemen

tof

on-premiseslawsan

dlegal

requ

iremen

ts

++++

++Su

staine

deff

ectsdep

endon

makingen

hanced

enforcemen

tparto

fong

oing

policepractic

es.

Serverliab

ility

++++

+Eff

ectstron

gerwhe

reeffo

rtsmad

etopub

liciseliability.Resea

rchlim

itedtoUSA

and

Can

ada.

Voluntarycode

sofbarpracti

ce0

++

Ineff

ectiv

ewhe

nstrictlyvolun

tarybutm

aycon

tributetoeffe

ctsasparto

fcom

mun

ityacti

on

projects.

Late-nightlo

ckou

tsoflicen

sed

prem

ises

?+

0Limite

dresearch,and

nostud

iesha

veid

entifi

edeffe

ctiveapp

roache

s.

Dri

nk-d

rivi

ng c

ount

erm

easu

res

Mostresea

rchha

sfocusedon

interven

tioneff

ectsontraffi

caccide

ntsan

drecidivism

after

crim

inalsan

ction

s.So

brietyche

ckpoints

++++

+++

+Eff

ectsofp

olicecampa

ignsty

picallysho

rtte

rm.Effe

ctivene

ssasade

terren

tisprop

ortio

nal

tofreq

uencyofim

plem

entatio

nan

dhigh

visibility.

Rand

ombreathtesting

+++

++++

Effectiv

enessde

pend

son

num

berofdriversdire

ctlyaffe

cted

and

theextentofcon

sisten

tan

dhigh

profileen

forcem

ent.

Lowered

BAC

limits

+++

+++

+++

Thelowerth

eBA

Clegallim

it,th

emoreeff

ectiv

ethepo

licy.VerylowBAC

levels(‘zero

tolerance’)a

reeffe

ctivefo

ryouth,and

can

beeff

ectiv

eforad

ultd

rivers,b

utBAC

limits<0.02

aredifficulttoenforce.


235

Tabl

e 19

.1. S

umm

ary

of e

ffec

tive

pro

gram

mes

for

the

prev

enti

on a

nd tr

eatm

ent o

f alc

ohol

pro

blem

s (c

onti

nued

)

Stra

tegy

or i

nter

venti

onEff

ectiv

enes

sBr

eadt

h of

re

sear

ch

supp

ort

Cros

s-

natio

nal

testi

ng

Com

men

ts

Adm

inistrati

velicencesuspen

sion

++++

++Whe

npu

nishmen

tissw

ift,effe

ctivene

ssisin

crea

sed.Effe

ctivein

cou

ntrieswhe

reitis

appl

ied

cons

iste

ntly

.LowBAC

foryoun

gdrivers(‘zero

tolerance’)

+++

++++

Clea

reviden

ceofe

ffecti

vene

ssfo

rthosebe

lowth

elegald

rink

ingoralcoh

olpurchaseage.

Gradu

ated

licensingforno

vice

driv

ers

++++

++Ca

nbe

usedtoin

corporatelowerBAC

limitsand

licensingrestricti

onswith

inone

strategy.

Somestud

iesno

teth

at‘zerotolerance’provision

sarerespon

sibleforthiseffe

ct.

Designa

teddriversan

dride

se

rvic

es0

++

Maybeeff

ectiv

eingetti

ngim

paire

ddrinkersnotto

drive,b

utcan

alsoen

couragepa

ssen

gers

todrink

more.Doe

sno

taffe

ctalcoh

ol-related

crashes.

Severityofp

unishm

ent

0/+

++++

Mixed

evide

nceconcerning

man

datoryortoug

hersanctio

nsfo

rdrink-drivingconvictio

ns.

Effectsdecayovertim

eun

lessaccom

panied

byrene

wed

enforcemen

tormed

iapub

licity.

Rest

ricti

ons

on m

arke

ting

Drawson

twosepa

rateliteratures:effe

ctsofadvertisingan

dprom

otion

onyouthdrinking

an

datti

tude

s,and

effe

ctsofin

itiati

ngorremovingad

vertising

ban

san

dothe

rinterven

tions.

Legalrestrictio

nsonexpo

sure

+/++

+++

++Strong

evide

nceofdose-respon

seeffe

ctofe

xposureon

you

ngpeo

ple’sdrinking

,but

eviden

ceofsmallo

rinsign

ificanteffe

ctson

per-cap

itacon

sumpti

onfrom

partia

ladvertising

bans;advertisingba

nsorrestricti

onsmayshiftm

arketin

gactiv

itiesintoless-regulated

med

ia

(e.g.Interne

t).

Legalrestrictio

nsonconten

t?

00

Eviden

ceth

atadvertisingconten

taffe

ctsconsum

ption

butnoeviden

ceofthe

impa

ctof

conten

trestrictio

nsasem

bodied

inin

dustryself-regu

latio

ncode

s.Alcoh

olin

dustry’svolun

taryself-

regu

latio

ncode

s0

++++

Indu

stryvolun

taryself-regu

latio

ncode

sofpracti

cearein

effectiv

einlimiting

exposureof

youn

gpe

rson

stoalcoh

olm

arketin

g,nordotheypreventobjectio

nableconten

tfrombeing

ai

red.

Educ

ation

and

per

suas

ion

Impa

ctgen

erallyevaluated

inte

rmsofkno

wledg

ean

datti

tude

s;effe

ctonon

seto

fdrink

ing

anddrinking

problem

sisequ

ivocalorminim

al.Targetp

opulati

onisyou

ngdrinkersun

less

othe

rwiseno

ted.

Classroo

medu

catio

n0

+++

++Mayin

crea

sekno

wledg

ean

dchan

geattitude

sbu

thasnolong

-termeffe

ctondrinking

.Co

llegestude

ntnormati

ve

educati

onand

multicom

pone

nt

prog

ram

mes

++

0Individu

alised

multi-compo

nentapp

roache

sthatin

clud

efeed

backonno

rms,expectancies,

moti

ves,orde

cision

albalan

cehaveshort-term

effe

ctson

con

sumpti

onand

problem

s.

Prog

rammesusuallyta

rgeted

heavydrinkersan

dthusm

ayoverlap

with

briefinterven

tions

targeted

ath

ighriskdrinkers.Purelyinform

ation

alapp

roache

smayin

crea

sekno

wledg

ean

dchan

geattitude

s,buthaveno

effe

ctondrinking

.


236

Tabl

e 19

.1. S

umm

ary

of e

ffec

tive

pro

gram

mes

for

the

prev

enti

on a

nd tr

eatm

ent o

f alc

ohol

pro

blem

s (c

onti

nued

)

Stra

tegy

or i

nter

venti

onEff

ectiv

enes

sBr

eadt

h of

re

sear

ch

supp

ort

Cros

s-

natio

nal

testi

ng

Com

men

ts

Briefinterventi

onswith

high-risk

stud

ents

++

0Briefm

otivatio

nalinterventi

onscanim

pactdrink

ingbe

haviou

r.

Massmed

iacam

paigns,including

drink-drivingcampa

igns

0++

+++

Noeviden

ceofimpa

ctofm

essagestoth

edrinkerab

outlim

iting

drink

ing;som

eeviden

ceof

increa

sedeff

ectiv

enessofra

ndom

breathtesting

whe

nmed

iapub

liciseit.

Warning

labe

lsand

signs

0+

0Ra

isepu

blicawaren

ess,butdono

tcha

ngedrinking

beh

aviour.

Socialm

arketin

g0

++0

Raisespub

licawaren

essbu

talcoh

ol-spe

cificcam

paignsdono

tcha

ngebe

haviou

r.Tr

eatm

ent a

nd e

arly

inte

rven

tion

Usuallyevaluated

inte

rmsofdaysorm

onthsofabstin

ence,red

uced

intensity

and

volum

eof

drinking

,and

improvem

entsin

hea

lthand

lifefu

nctio

ning

.Targetp

opulati

onisharmfuland

de

pend

entd

rinkers,unlessothe

rwiseno

ted.

Briefinterventi

onwith

at-risk

drin

kers

+++

+++

+++

Canbe

effe

ctivebutm

ostp

rimarycarepracti

tione

rslacktraining

and

timetocon

duct

screen

ingan

dbriefinterventi

ons.

Mutua

lhelp/self-he

lpatten

dance

++++

++Afe

asible,cost-eff

ectiv

ecomplem

ento

ralternati

veto

form

altreatm

entinman

ycoun

tries.

Man

datorytreatm

ento

fdrink-

drivingrepe

atoffe

nders

+++

0Pu

nitiv

ean

dcoerciveapp

roache

sha

vetime-lim

itedeff

ects,and

som

etimesdistract

atten

tionfrom

moreeff

ectiv

einterven

tions.

Med

icaland

sociald

etoxificatio

n++

+++

++Safeand

effe

ctivefo

rtreatin

gwith

draw

alsym

ptom

s.Red

ucesalcoh

ol-related

harmsthroug

hpreven

tionofm

ortality.Littleeffe

ctonlong

-termalcoh

olcon

sumpti

onunlesscombine

dwith

otherth

erap

ies.

Talk

ther

apie

s++

+++

++Avarietyofthe

oreti

callybased

therap

iestotreatp

ersonswith

alcoh

oldep

ende

ncein

outpati

enta

ndre

side

ntialsetti

ngs.Pop

ulati

onre

achislo

wbecau

sem

ostcou

ntrieshave

limite

dtreatm

entfacilitie

s.Ph

armaceu

ticalth

erap

ies

+++

++Co

nsistentevide

nceforamod

estimprovem

ento

vertalkth

erap

iesan

dclinicalm

anagem

ent

onlyfo

rna

ltrexon

e.


237

Appendix 2: Cost benefits of effective treatments for alcohol misuseAlcohol – No Ordinary Commodity [91] summarisesevidenceon thecosteffectivenessof various interventions using an analysis paper for theWorld HealthOrganization byAnderson[144]whoconductedadetailedcost-benefitanalysisofalcoholpoliciesinthreeregions:theAmericas(e.g.BrazilandMexico),EasternEurope(e.g.RussiaandUkraine),and theWestern Pacific (e.g. China andVietnam).On the basis of this analysis itwasconcluded:

• Two strategies (school-based education and mass-media awareness campaigns)werefoundnottobecost-effectivebecausetheydonotaffectalcoholconsumptionor health outcomes.

• Population-levelalcoholpolicies(e.g.pricingandavailabilitypolicies)aremorecost-effective than individual-level policies, such as brief interventions for hazardousalcohol use.

• Tax increases represent a highly cost-effective response in regions with a highprevalenceofheavydrinking,suchasLatinAmericaandEasternEurope.

• Incountrieswithhighlevelsofunrecordedproductionandconsumption,increasingtheproportionofconsumptionthatistaxedcouldbemoreeffectivethanasimpleincreaseinexcisetaxes.

• The impactof reducingaccess to retailoutlets forspecifiedperiodsof theweekandimplementingacomprehensiveadvertisingbanhavethepotentialtobecost-effectivecountermeasures,butonlyiftheyarefullyenforced.

WhiletheextenttowhichtheseconclusionsapplytoNewZealandisnotcompletelyclear,thefindingsaboveare likelytoprovidesomegeneralguidanceabouttherelativecost-effectivenessofdifferentapproachestoreducingtherisksposedbyalcoholconsumption.

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