Ave.ee

Effectiveness of policy Chapter 7 – The effectiveness of alcohol policy
Alcohol policies can be grouped within five headings: (i) policies that reduce drinking and driving; (ii) policies that support education, communication, training and public awareness; (iii) policies that regulate the alcohol market; (iv) policies that support the reduction of harm in drinking and surrounding environments; and (v) policies that support interventions for individuals. Since the 1970s, considerable progress has been made in the scientific understanding of the relationship between alcohol policies, alcohol consumption and alcohol-related harm. The drinking-driving policies that are highly effective include unrestricted (random) breath testing, lowered blood alcohol concentration (BAC) levels, administrative license suspension, and lower BAC levels for young drivers. The limited evidence does not find an impact from designated driver and safe drive programmes. Alcohol locks can be effective as a preventive measure, but as a measure with drink driving offenders only work as long as they are fitted to a vehicle. The World Health Organization has modelled the impact and cost of unrestricted breath testing compared with no testing; applying this to the Union finds an estimated 111,000 years of disability and premature death avoided at an estimated cost of €233 million each year. The impact of policies that support education, communication, training and public awareness is low. Although the reach of school-based educational programs can be high because of the availability of captive audiences in schools, the population impact of these programs is small due to their current limited or lack of effectiveness. Recommendations exist as to how the effectiveness of school-based programmes might be improved. On the other hand, mass media programmes have a particular role to play in reinforcing community awareness of the problems created by alcohol use and to prepare the ground for specific interventions. There is very strong evidence for the effectiveness of policies that regulate the alcohol market in reducing the harm done by alcohol, including taxation and managing the physical availability of alcohol (limiting hours and days of sale and raising the minimum drinking age). Alcohol taxes are particularly important in targeting young people and the harms done by alcohol. If alcohol taxes were used to raise the price of alcohol in the EU15 by 10%, over 9,000 deaths would be prevented during the following year and an approximate estimate suggests that €13bn of additional excise duty revenues would also be gained. The evidence shows that if opening hours for the sale of alcohol are extended more violent harm results. The World Health Organization has modelled the impact of alcohol being less available from retail outlets by a 24 hour period each week; applying this to the Union finds an estimated 123,000 years of disability and premature death avoided at an estimated implementation cost of €98 million each year. Restricting the volume and content of commercial communications of alcohol products is likely to reduce harm. Advertisements have a particular impact in promoting a more positive attitude to drinking amongst young people, and, even in advertisements that do not portray drinking of alcohol, young people perceive the characters as heavy drinkers. Self-regulation of commercial communications by the beverage alcohol industry does not have a good track record for being effective. The World Health Organization has modelled the impact of an advertising ban; applying this to the Union, finds an estimated 202,000 years of disability and premature death avoided, at an estimated implementation cost of €95 million each year. There is growing evidence for the impact of strategies that alter the drinking context in reducing the harm done by alcohol. However, these strategies are primarily applicable to drinking in bars and restaurants, and their effectiveness relies on adequate enforcement. Passing a minimum drinking age law, for instance, will have little effect if it is not backed up with a credible threat to remove the licenses of outlets that repeatedly sell to the under-aged. Such strategies are also more effective when backed up by community based prevention programmes. There is extensive evidence for the impact of brief interventions, particularly in primary care settings, in reducing harmful alcohol consumption. The World Health Organization has modelled the impact and cost of providing primary care based brief interventions to 25% of the at-risk population; applying this to the Union finds an estimated 408,000 years of disability and premature death avoided at an estimated cost of €740 million each year. Using the World Health Organization's models, and compared to no policies at all, a comprehensive European Union wide package of effective policies and programmes that included random breath testing, taxation, restricted access, an advertising ban and brief physician advice, is estimated to cost European governments €1.3billion to implement (about 1% of the total tangible costs of alcohol to society and only about 10% of the estimated income gained from a 10% rise in the price of alcohol due to taxes in the EU15 countries), and is estimated to avoid 1.4 million years of disability and premature death a year, equivalent to 2.3% of all disability and premature death facing the European Union.
INTRODUCTION

Evidence base
Over the last twenty five years, considerable progress has been made in the
scientific understanding of the relationship between alcohol policies, alcohol
consumption and alcohol-related harm (for example, see Bruun et al. 1975; Edwards
et al. 1994; Babor et al. 2003). The evidence base includes time series analyses,
econometric analyses, community studies and randomized controlled trials of
interventions. Alcohol policies can be grouped within five headings: policies that
reduce drinking and driving; policies that support education, communication, training
and public awareness; policies that regulate the alcohol market; policies that support
the reduction of harm in drinking and surrounding environments; and policies that
support interventions for individuals with hazardous and harmful alcohol consumption
and alcohol dependence. Although it is changing, the evidence base is still largely
dominated by studies from North America, northern Europe, and Australia and New
Zealand. Although there is no reason to believe that the results do not have policy
significance for Europe as a whole, there is a need to broaden the evidence base
across countries and cultures, a theme that we return to in Chapter 10. The chapter
gives more space to discussing the evidence in relation to advertising policies, since
this is a policy area of current substantial debate.
Effectiveness of policy Summary sections
Each policy area is summarized with a table of effectiveness ratings. We have done
this by using an updated version of the effectiveness ratings that were provided by
Babor et al (2003), using the classification system of Table 7.1.

Table 7.1
Effectiveness ratings for Drinking-driving countermeasures
Breadth of Research
Cost Efficiency
This criterion refers to the scientific The highest rating was influenced This criterion seeks to estimate evidence demonstrating whether a by the availability of integrative the relative monetary cost to the particular strategy is effective in reducing reviews and meta analyses. state to implement, operate and alcohol consumption, alcohol-related Breadth of research support was sustain this strategy, regardless of problems or their costs to society. The evaluated independent of the effectiveness. For instance, following rating scale was used: rating of effectiveness (i.e., it is increasing alcohol excise duties 0 Evidence indicates a lack of
possible for a strategy to be rated does not cost much to the state low in effectiveness but to also but may be costly to alcohol + Evidence for limited effectiveness.
have a high rating on the breadth consumers. In this criterion, the ++ Evidence for moderate effectiveness.
of research supporting this lowest possible cost is the highest +++ Evidence of a high degree of
evaluation). The following scale standard. Therefore, the higher the rating, the lower the relative ? No studies have been undertaken or
0 No studies of effectiveness cost to implement and sustain this there is insufficient evidence upon which have been undertaken strategy. The following scale was to make a judgment. + Only one well designed study of effectiveness completed. o Very high cost to implement and ++ From 2 to 4 studies of effectiveness have been + Relatively high cost to implement and sustain. +++ 5 or more studies of ++ Moderate cost to implement effectiveness have been +++ Low cost to implement and ? There is insufficient evidence on which to make a judgment. ? There is no information about cost or cost is impossible to estimate. Source: Babor et al (2003).

Estimates and costs of policy impact
Throughout the chapter, we also report the results of the World Health Organization's
CHOICE (CHOosing Interventions that are Cost-Effective) model, which provides
estimates of the impact and cost of implementing policies in reducing Disability
Adjusted Life Years (DALYs) (see Chapter 6) due to harmful alcohol use (Tan Torres
et al, 2003; WHO, 2002; Ezzati et al., 2002; Rehm et al, 2004; Chisholm et al 2004;
Rehm et al, 2003a,b; 2004; Rehm et al, 2001; Stouthard et al, 2000), re-calculated
for the European Union. The CHOICE model determines intervention effectiveness
via a state transition population model (Lauer et al, 2003), taking into account births,
deaths and the impact of alcohol. Two scenarios are modelled over a lifetime (100
years): 1) no interventions available to reduce hazardous and harmful alcohol use
(defined in the CHOICE model as more than 20g alcohol a day for women and more
than 40g alcohol a day for men); and 2) the population-level impact of each specified
intervention, implemented for a period of 10 years. The difference represents the
population-level health gain due to the implementation of the intervention, discounted
at 3% and age-weighted.
Costs covered in the CHOICE model are costs to governments and include
programme-level costs associated with running the intervention, such as
administration, training and media (Adam et al, 2003; Johns et al, 2003), and patient-
level costs
such as primary care visits (Fleming et al, 2000). The costs were
calculated in international dollars (Adam et al, 2003; Johns et al, 2003) and
converted into euros, such that one euro buys the same quantity of health care
resources in England as it does in Hungary. The model does not capture potential
increases in workforce and household productivity among heavy drinkers following
intervention, nor does it incorporate the economic consequences of alcohol-related
crime, violence and harm reduction. Government's receipts from taxes are not
counted.
CHOICE modelled specified interventions, which are described in each section. The
models are used for illustrative purposes to give an indication of the impact and cost
of certain interventions. The fact that a specific intervention is modelled (for example
reducing the availability of alcohol, or banning advertising) does not imply that the
specified intervention is the one recommended for European policy (see Chapter 10).
Rather, since the model compares the intervention of a Europe without the specified
intervention, its prime purpose is to provide comparisons for policy makers between
the impact and costs of different types of interventions. The results are presented for
three regions of the European Union, based on the WHO classification, Table 7.2.
Table 7.2 WHO classification of European Union countries based on mortality rates1.
Europe A
Very low child and very low adult Low child and low adult Low child and high adult mortality
Social welfare and other sectors
Alcohol this is not discussed in detail, alcohol policy should also be embedded in
sound social welfare and fiscal policies. Social and economic policies that seek to
improve conditions for the healthy development of children and youth, reduce
disadvantage, increase equity, and strengthen communities will have a range of
benefits including lower rates of the harm done by alcohol (Blane et al 1996; Marmot
& Wilkinson 1999).
REDUCING DRINKING DRIVING
Policies that regulate the alcohol market

Policies that regulate the alcohol market, including the price of alcohol, the location,
density, and opening hours of sales outlets, controls on the availability of alcohol, and
on the promotion and advertising of alcohol, have an impact in reducing drinking and
driving and related fatalities (see below) (Grube and Stewart 2004).
1 For full listing of countries in the three Europe sub-regions, see World Health Organization 2002. Effectiveness of policy
Lowering blood alcohol concentration (BAC) levels

Lowering BAC levels consistently produces positive results in drink-driving behaviour
at all levels and also to further reductions in alcohol road traffic accidents (Jonah et
al., 2000).

US experience
Although many studies have been published on the effectiveness of the 0.8g/L blood
alcohol concentration (BAC) laws in the US (Johnson and Walz 1994; Hingson et al.
1996; Hingson et al. 2000; Foss et al. 1998; 2001; Apsler et al 1999; Voas and
Tippetts 1999; Villaveces et al 2003), they have varied in the statistical methods and
the type of outcome measure used, so it is difficult to integrate the findings into an
overall estimate of the effectiveness of the law (Beirness and Simpson 2002). A time-
series analysis analyzed the introduction of the 0.8g/L in 19 states from 1982 to
2000, accounting for other key safety laws (administrative license
suspension/revocation and safety belt laws), as well as economic conditions that
might influence the effectiveness of the 0.8g/L law (Tippetts et al 2005). The effect
size combined across all 19 locations showed a 15% decline in the rate of drinking
drivers in fatal crashes after the 0.8g/L laws were introduced. The reduction was
greater in states that had an administrative license suspension/revocation law and
implemented frequent sobriety checkpoints. The introduction of low BACs of 0.2g/L
for young or inexperienced drivers have led to reductions in fatal crashes of from 9%
to 24%. Studies in California demonstrated that publicity doubled the impact of new
laws and new enforcement efforts (Voas and Hause, 1987).
Australian experience
The reduction of the legal BAC limit from 0.8g/L to 0.5g/l in New South Wales found a
7% reduction in all serious crashes, an 8% reduction in fatal crashes, and an 11%
reduction in single vehicle night time crashes (Henstridge et al. 1997). In comparison,
random breath testing was associated with decreases of 19%, 48% and 26%,
respectively. A simple pre-post comparison of the aggregate crash data for the three
years prior to and following the introduction of the lower BAC limit from 0.8g/L to
0.5g/L in Queensland revealed net reductions of 11% for crashes which resulted in a
hospital admission, 15% for injury crashes (but for which no one was admitted), and
12% for property damage crashes (Smith 1987; 1988). However, it does appear that
some of the impact of lowering BAC levels wears off over time because initially
drivers grossly exaggerate the certainty of apprehension in response to the publicity,
but gradually become used to the new law and realize that their chances of detection
are in fact not very high. Making motorists uncertain about the real risk of detection
may paradoxically be the key to cost-effective deterrence (Homel, 1988; Nagin,
1998).
European experience
Lowering the BAC level from 0.5g/L to 0.2g/L level in Sweden in 1990 led to a
reduction of fatal alcohol-related accidents by between 8% and 10% (Ross and Klette
1995; Norström, 1997; Norström and Laurell 1997; Lindgren, 1999; Borschos, 2000).
Denmark reduced its BAC from 0.8g/l to 0.5g/l on 1st March 1998. There was some
evidence for a reduction all motor vehicle injury accidents and in accidents involving
a driver with a BAC of greater than 0.5g/L in 1998, compared with 1997 (Bernhoft
and Behrensdorff 2003), but no change in fatal accidents.
Unrestricted (random) breath testing

Unrestricted or random breath testing
means that motorists are stopped
with no restrictions by police and
Drink driving laws
required to take a breath test, even if The World Health Organization has modelled they are not suspected of having the impact and cost of unrestricted breath committed an offence or been testing compared with no testing; applying this involved in an accident. Any motorist to the Union finds an estimated 111,000 years at any time may be required to take a of disability and premature death avoided at an test, and there is nothing that the estimated cost of €233 million each year.
driver can do to influence the
chances of being tested. Testing
varies from day to day and from week to week, and refusal to submit to a breath test
is equivalent to failing. Twenty three studies of unrestricted breath testing and
selective testing have found a decline of 22% (range 13%-36%) in fatal crashes, with
slightly lower decreases for non-injury and other accidents for such enforcement
strategies (Shults et al., 2001).
Australian experience
Australia is one of the countries with the most experience of random breath testing.
In 1999, 82% of Australian motorists reported having been stopped at some time,
compared with 16% in the UK and 29% in the US (Williams et al., 2000). The result
was that fatal crash levels dropped 22%, while alcohol-involved traffic crashes
dropped 36%, and remained at this level for over four years (Homel, 1988; Arthurson,
1985). A time series analysis for four Australian states found that unrestricted breath
testing was twice as effective as selective checkpoints (Henstridge et al., 1997). For
example, in Queensland, unrestricted breath testing resulted in a 35% reduction in
fatal accidents, compared with 15% for checkpoints. Since their implementation, the
drink driving enforcement and publicity campaigns in Victoria have persisted in their
effectiveness in reducing serious crashes during peak alcohol consumption times
(Tay 2005a; 2005b).
European experience
In the Netherlands, the implementation of experimental random breath testing
resulted in a reduction of drivers with alcohol in their blood, but especially drivers with
BAC levels above 0.5 g/L, the national legal limit (Mathijssen and Wesemann, 1993).
License suspension

Suspending the license of those convicted of impaired driving is only partially
effective as a way to reduce drink driving recidivism and alcohol-related crashes.
Without some form of education, counselling or treatment program, the effects of
suspension upon alcohol-impaired driving last only as long as the driver is
incapacitated by the license suspension, and these periods can be relatively short
(McKnight and Voas, 1991; Ross, 1992). The deterrent effect of any penalty is
benefited by certainty and immediacy (Ross, 1984; Ross, 1992; McKnight and Voas,
2001). A review of 46 studies on license suspension found that suspension was
followed by an average reduction of 5% in alcohol-related accidents and a reduction
of 26% in fatal accidents (Zobeck and Williams, 1994).
There is little evidence that prison sentences or fines have a specific deterrent effect
by promoting avoidance of future offences (Voas, 1986). Nevertheless, the authority
to impose a prison sentence may provide the legal basis for referring offenders to
Effectiveness of policy treatment programs, which have been shown to reduce recidivism of drink driving in
first and multiple offenders (Voas and Tippetts, 1990). A meta-analysis of 215
independent evaluations of remedial programs found them to yield an average
reduction of 8%-9%, both in recurrence of alcohol-impaired driving offences and in
alcohol-related accidents (Wells-Parker et al., 1995).
Alcohol locks

One action to prevent drink driving offenders from driving while impaired is to place
interlocks in the ignition to prevent an impaired driver from operating the vehicle. To
operate a vehicle equipped with an ignition interlock device, the driver must first
provide a breath specimen. If the breath alcohol concentration of the specimen
exceeds the predetermined level, the vehicle will not start. As a measure to reduce
circumvention of the device (i.e. someone else blows into the mouthpiece), random
retests are required while the vehicle is running. Interlocks can also be used as a
preventive measure, by being fitted to public service and heavy goods vehicles.
One review of eight studies of interlock programs conducted under the authority of a
local court or a motor vehicle department found them to be more effective than full
license suspension in preventing recidivism among alcohol-impaired drivers (Voas et
al., 1999). However, seven of the studies found that, once the interlock is removed,
offenders have the same recidivism rate as suspended offenders.
A systematic Cochrane review identified one randomised controlled trial (RCT), ten
controlled trials, and three ongoing trials (Willis et al 2004). In the RCT, recidivism
was lower in the intervention group while the device was still installed in the vehicle,
but the benefit disappeared once the device was removed. In all 13 non-randomised
controlled trials, interlock participants again had lower recurrence of offences than
the controls. However, the favourable results did not extend to the time period after
the interlock was removed.
In 2000, a European research consortium explored the feasibility of alcolock
programs in EU countries and concluded that impaired driving offences were reduced
during interlock program participation and that accident rates were also reduced
(Mathijssen 2005). As a result of the feasibility study, alcolock initiatives are being
implemented in Belgium, Finland, Germany, Netherlands, Norway, Spain and
Sweden. In the Netherlands, the target group will consist of DWI offenders who
undergo a medical/psychiatric assessment and are declared "not unfit to drive",
which represents about 10% of the multiple recidivists or those with a BAC above
1.8g/L, who are assessed. The alcolock program will be mandatory under
administrative law and will have a duration of two years with the possibility of a six-
month extension. It is estimated that the cost per installed alcolock is €2,200. Based
on an estimated 65% reduced crash rate for alcolock users, the estimated benefit of
the program is an annual reduction of 4-5 fatalities, at an annual program cost of €0.9
million.
Alcolock devices and programs were introduced in Sweden in 1999, with two types of
programs (Bjerre 2005). A primary prevention strategy was initiated to prevent
alcohol impaired driving in three commercial transport companies (buses, trucks,
taxis). A secondary prevention trial was begun as a voluntary 2-year program for
drink driving offenders involving strict medical requirements, including counselling
and regular checkups by a medical doctor. Alcolocks in commercial vehicles have
been well accepted by professional drivers, their employers, and their passengers,
and the number of vehicles with alcolocks as a primary prevention measure is rapidly
growing in Sweden. Three of 1000 starts in the primary prevention program were
blocked by the alcolock after measuring a BAC higher than the legal limit and lock
point of 0.2g/L. Only 11% of eligible drink driving offenders took part in the voluntary,
secondary prevention program, of whom 60% had a diagnosis of alcohol
dependence. During the program, alcohol consumption decreased as measured by
five biological alcohol markers, and the rate of drink driving offences fell sharply from
a yearly rate of approximately 5% to almost zero. However, those dismissed from the
program appeared to return to their previous drink driving behaviour.
Restrictions on young or inexperienced drivers

Reviews have found that lower BAC limits for young drivers (for example, 0.1g/L to
0.2g/L) reduce injuries and crashes (Hingson et al., 1991, 1994; Zwerling and Jones,
1999), with reductions of between 9% and 24% for fatal crashes (Shults et al., 2001).
A national study of US states found a net decrease of 24% in the number of young
drivers with positive BACs as a result of lower BAC limits for young drivers (Voas et
al., 1999). A combination of raising the minimum legal drinking age to 21 years and
establishing zero tolerance (<0.2g/L BAC) for drivers younger than age 21 years are
associated with substantial reductions in alcohol-positive involvement in fatal crashes
in drivers younger than age 21 years in the United States from 1982 to 1997 (Voas et
al 2003). Graduated driver licence programmes place restrictions on the
circumstances under which young or novice drivers are allowed to drive, such as
prohibiting driving during certain hours or driving with other young people in the
vehicle. Such programmes, which frequently have BACS of <0.2g/L are effective in
reducing motor vehicle fatalities among 15-17-year-old drivers by up to 19%
(Morrisey et al 2005).
Server training and civil liability

Training programmes for servers and bartenders for preventing impaired driving by
identifying impairment, refusing service and providing transportation have been
evaluated in North America, Australia, and the Netherlands. These have
demonstrated a significant improvement in server knowledge and attitude, as well as
discouraging over-consumption and encouraging alternative beverages. This effect
is particularly strong when coupled with a change in the serving and sales practices
of the licensed place, and with training for managers (Rydon et al., 1996; Saltz,
1997). Although success in reducing the risk of drink-driving has not been found in all
studies, even when mandating the training of servers as a condition of licensing
(Lang et al., 1998), when implemented as part of more comprehensive community
based programmes, responsible server programmes have been found to be effective,
particularly for night time crashes for young people (Holder and Wagenaar, 1994;
Wagenaar et al., 2000).
The civil liability of alcohol retail establishments who serve alcohol to intoxicated
customers has been established particularly in the United States, often based upon
common law, with very limited spread to other countries, but including Australia and
Canada. This liability has been primarily reactive, that is, as a means of legal redress
after service to an intoxicated person resulted in persona loss or injury (Mosher,
1979, 1987). This may for instance occur when an intoxicated driver, served by a
retail establishment, crashes and injures or kills an innocent bystander. However,
server liability can also be a preventive policy to encourage safer beverage serving
practices and to prevent drink driving (Mosher, 1983 and, 1987; Holder et al., 1993).
States within the US that hold bar owners and staff legally liable for damage
Effectiveness of policy attributable to alcohol intoxication have lower rates of traffic fatalities (Chaloupka et al., 1993; Ruhm, 1996; Sloan et al., 1994a) and homicide (Sloan et al., 1994b), compared to states that do not have this liability. When one State deliberately distributed publicity The importance of
about the legal liability of servers, there was a 12% decrease in single-vehicle night-time injury- An enforcement activity in producing traffic crashes (Wagenaar and Holder, which plain clothes officers 1991), mediated by the effects of legal liability on visited licensed establishments the attitudes and behaviour of bar owners and that were serving visibly staff (Holder et al., 1993; Sloan et al., 2000). intoxicated customers showed a three-fold increase in In many jurisdictions, it is illegal to sell an refusals of service to pseudo- alcoholic beverage to purchasers considered to customers simulating signs of be at risk of injury, including the underage and the intoxication and a one-fourth intoxicated. Violations can result in criminal drop in the percentage of actions and fines against sellers and arrested drivers coming from administrative action, such as fines and license bars and restaurants suspensions, against the establishments. (McKnight and Streff, 1994). Enforcement of laws prohibiting service to an The savings in accident costs intoxicated customer is rarer than enforcement of were estimated at €75 for each laws prohibiting sales to an underage customer. Euro cost of enforcement. Most actions against servers appear to occur when the illegal service resulted in some form of harm, rather than from routine enforcement activity. The efficiency of alcohol-control efforts can be enhanced by focusing
enforcement on establishments that are the most persistent violators. Arrested
drivers queried for the sources of their last drink can identify the greatest sources of
trouble.
Designated Driver and safe ride programmes

There is no universal definition of a "designated driver." The most common definition
requires that the designated driver abstain from all alcohol, be assigned before
alcohol consumption, and drive other group members to their homes (see Ditter et al
2005). Other definitions employ a risk and harm reduction strategy, in which the
primary goal is not necessarily abstinence, but to keep the designated driver's blood
alcohol content (BAC) at less than the legal limit.
In practice, it appears that only a minority of designated drivers remain completely
abstinent, and many people may apply the designated driver concept in ways that
are unsafe. In a California survey, only 56% of respondents said that the designated
driver should be chosen before drinking begins, and only 64% expected the driver to
abstain from alcohol for 4 hours before driving (Lange et al 1998). Also in some
cases, the "designated driver" may be chosen based on who in the group is the least
intoxicated (Knight et al 1993; DeJong & Wintsen 1999). Timmerman et al (2003)
found that the mean BAC for 66 designated drivers leaving university bars was
0.6g/L.
A systematic review was conducted to assess the evidence of effectiveness of
designated driver programs for reducing alcohol-impaired driving and alcohol-related
crashes by evaluating population-based campaigns that encourage designated driver
use, and programs conducted in drinking establishments that provide incentives for
people to act as designated drivers (Ditter et al 2005). Only one study of a population
based designated driver promotion campaign was identified. Survey results indicated
a 13% increase in respondents "always" selecting a designated driver, but no significant change in self-reported alcohol-impaired driving or riding with an alcohol impaired driver (Boots & Midford 1999). Seven studies (five of which were reported in the same journal article, and six of which were by the same two principal authors) evaluated the number of patrons who identified themselves as designated drivers before and after programs were implemented, with a mean increase of 0.9 designated drivers per night (Brigham et al 1995; Meier et al 1998; Simons-Morton & Cummings 1997). An eighth study reported a 6% decrease in self-reported driving or riding in a car with an intoxicated driver among respondents exposed to an incentive program (Boots 1994). Interpretation of these results was complicated by the fact that only two of the studies (Brigham et al 1995; Simons-Morton and Cummings 1997) reported the number of patrons or groups of patrons in the bar during each observation period. Thus, although the incentive programs generally found small increases in the number of patrons identifying themselves as designated drivers, the extent to which these changes related to actual designated driver use was unclear. Finally, it was impossible to estimate the public health effects of observed changes in the number of self-identified designated drivers without information on what their behaviour would have been in the absence of a designated driver program. Thus, due to the small effect sizes observed, and the limitations of the outcome measures, the present evidence is insufficient to draw any conclusions about the effectiveness of either type of designated driver promotion program evaluated. Further, no study has evaluated whether the use of designated drivers actually decreases alcohol-related motor vehicle-related injuries. However, some studies of designated drivers have assessed their BACs, which are strongly associated with crash risk. Studies indicate that the BACs of designated drivers are generally lower than those of their passengers and also lower than those of other drivers who are not acting as designated drivers (Lange et al 2000), but still often higher than the legal limit for drinking and riving (Timmerman et al 2003). The potential impact of designated driver programs on alcohol consumption is another important consideration. Several studies indicate an increase in passenger alcohol consumption when a designated driver is available. One study estimated that the mean increase in the BACs of passengers of designated drivers was 0.17 g/L, (Harding et al 2001), with young and high-risk drinkers particularly likely to increase consumption (Knight et al 1993; DeJong and Wintsen 1999; Boots and Midford 1999). Several communities have organizations that provide free rides largely to individuals who drive while being alcohol impaired. A survey of 335 ride services in response to calls from passengers or the drinking places serving them found the biggest obstacle to be the inability of more than 15% of the programs to transport the driver's vehicle (Harding, Apsler and Goldfein, 1998). Drivers were reluctant to leave their vehicles behind or return to the drinking location to collect their vehicles. Ross (1992) suggested that one approach to individuals could be to provide them with free taxi rides to drinking places. This would ensure their inability to drive away and, consequently, a heavy drinker would be forced to find alternative transportation to return home, as the vehicle would not be at the drinking location. One study found that if the safe ride program had not been in place 44% of drinkers would have driven themselves home (Sarkar et al 2005). One third of the drinkers did not feel they had control over their choice to avoid drinking and driving. Effectiveness of policy The Saving Lives Project
The Saving Lives Project conducted in six communities in Massachusetts, USA was designed to reduce alcohol-impaired driving and related problems such as speeding (Hingson et al., 1996). In each community a full time coordinator from the local government organized a task force representing various city departments. Programs were designed locally and involved a host of activities including media campaigns, business information programs, speeding and drunk driving awareness days, speed watch telephone hotlines, police training, high school peer-led education, Students Against Drunk Driving groups, college prevention programs, and other activities. During the five years that the program was in operation, sites that received the Saving Lives intervention produced a 25% greater decline in fatal crashes than the rest of Massachusetts, a 47% reduction in the number of fatally injured drivers who were positive for alcohol as well as a 5% decline in visible crash injuries and an 8% decline in crash injuries affecting 16-25 year olds. In addition, there was a decline in self-reported driving after drinking (specifically among youth) as well as observed speeding. The greatest fatal and injury crash reductions occurred in 16-25 year old age group. School based education courses
A systematic review of the literature to assess the effectiveness of school-based
programs for reducing drinking and driving and riding with drinking drivers identified
thirteen peer reviewed papers or technical reports, which met specified quality criteria
and included evaluation outcomes of interest (Elder et al 2005). The papers
evaluated three classes of interventions: school based instructional programs, peer
organizations, and social norming campaigns. For instructional programs, whereas
the median effects of five studies found no effect on self-reported drinking and driving
(Harre and Field 1998; Klepp et al 1995; Shope et al 1996; D'Amico and Fromme
2002; Sheehan et al 1996), the median effects of four studies found a reduction in
self-reported riding with drinking drivers (Harre and Field 1998; Newman et al 1992;
Wilkins 2000; Sheehan et al 1996). Only one study looked at crashes and found no
effect (Shope et al 2001).Two studies of the effectiveness of peer organization
programmes were unable to provide evidence for effect (Leaf & Preusser 1995;
Klitzner et al 1994). Two studies of social norming programmes appeared to reduce
drink driving, and more frequent use of designated drivers (Cimini et al 2002; Foss et
al 2001).
Community programmes for safe driving

Although commonly used, public information programs that disseminate information
about drinking and driving through the mass media have, by themselves not
demonstrated any benefit in reducing alcohol-related accidents (Haskins, 1985).
However, broad based community prevention programmes that include public
information seem to be effective (Hingson et al., 1996; see below).
Policies to reduce drink-driving

Summary
The drinking-driving policies that are highly effective include lowered blood alcohol
concentration (BAC) levels, unrestricted (random) breath testing, administrative
license suspension, and lower BAC levels and graduated licenses for young drivers
Table 7.3. Whilst alcolocks can be used as a preventive measure, their use for drink
driving offenders lasts for only as long as the device is fitted. There is no evidence for
an effective impact from designated driver and safe drive programmes or from school
based education courses. To be effective drink driving laws must be publicized. If the
public is unaware of a change in the law or an increase in its enforcement, it is
unlikely that it will affect their drinking and driving. When incorporated as part of
community programmes, drink driving measures appear to have increased
effectiveness.

Table 7.3
Effectiveness ratings for Drinking-driving countermeasures
Lowered BAC levels Random breath testing (RBT) License suspension Low BAC for youth Graduated licensing Server training and civil liability Designated drivers and ride School based education courses Community programmes 1For definitions see Table 7.1
Source: Babor et al (2003) (modified).

Impact and costs of drink drive measures
The World Health Organization's CHOICE modelled two independent effects on
alcohol-related traffic injuries: drink-driving laws, estimated to reduce traffic fatalities
by 7% if widely implemented within a region (Shults et al, 2001), adjusted for the
current level of implementation; and enforcement via random breath testing (RBT),
estimated to reduce fatalities by a further 6-10% (Peek-Asa, 1999; Shults et al,
2001). The model found that the full implementation of random breath testing
(compared to no random breath testing) throughout the European Union (EU)
prevents between 161 (EuroB countries) and 460 (EuroC countries) DALYs per
million people per year, at an estimated cost of between €43 (EuroC countries) and
€62 (EuroB countries) per 100 people per year (see Figures 7.11 and 7.12 at end of
chapter). The model estimated that unrestricted breath testing in Europe, compared
with no breath testing, can avoid 111,000 years of disability and premature death at
an estimated cost of €233 million each year (adapted from Chisholm et al 2004).
Effectiveness of policy EDUCATION, COMMUNICATION, TRAINING AND PUBLIC AWARENESS

This section discusses four areas under the heading of education, communication,
training and public awareness: mass media and counter-advertising, low-risk drinking
guidelines, warning labels on alcohol products and school-based education.
Mass Media and Counter-Advertising

Although most media portrayals of alcohol are in the form of commercial
advertisements, public health and safety perspectives are also portrayed in the mass
media. Public service announcements on television or radio, paid counter-
advertisements, billboards, magazine articles, newspaper pieces, and news or
feature stories on television and radio, all attempt to provide information about the
risks and complications associated with drinking.
Public service announcements (PSAs) are messages prepared by
nongovernmental organizations, health agencies or by media organizations for the
purposes of providing important information for the benefit of a particular audience.
In contrast to paid advertising, PSAs depend upon donated time or space for
distribution to the public. When applied to alcohol, PSAs usually deal with
"responsible drinking," the hazards of driving under the influence of alcohol, and
related topics. Despite their good intentions, PSAs are considered an ineffective
antidote to the high-quality pro-drinking messages that appear much more frequently
as paid advertisements in the mass media (see Ludwig 1994; Murray et al. 1996).
In many cases the messages in PSAs are intended to be particularly relevant to
drinking by youth (Connolly et al. 1994; Holder 1994). Reviews point to the limited
impact on alcohol use and alcohol-related problems from mass media interventions
that use a universal strategy (Gorman 1995). Nevertheless, a Canadian study
(Casiro et al. 1994) found that after a T.V. campaign on the dangers of alcohol
consumption during pregnancy, more women concluded that drinking would put their
baby at risk, and attributed this information to television. In general, there is a need
for more research to find out what audiences perceive and understand from mass
media campaigns (Martin 1995). Looking at how media set the public policy agenda
is potentially more fruitful (Casswell 1997). For example, portrayal of alcohol issues in
the news media (print, T.V. and radio) tends to be simplistic, sensational and
dramatic (Gusfield 1995), and focuses on stories about individual people rather than
alcohol in its social perspective. These portrayals raise interesting questions about
the way news reporting may shape public attitudes and policy about alcohol, but this
area has not been extensively researched.
Counter-advertising involves disseminating information about a product, its effects,
or the industry that promotes it, in order to decrease its appeal and use. It is distinct
from other types of informational campaigns in that it directly addresses the fact that
the particular commodity is promoted through advertising (Stewart 1997). Tactics
include health warning labels on product packaging and media literacy efforts to raise
public awareness of the advertising tactics of an industry, as well as prevention
messages in magazines and on television. Counter-advertising may also be a
module in community or school prevention programs (e.g., Giesbrecht et al. 1990;
Greenfield and Zimmerman 1993), and be used as part of the multiple agenda of
government spirits board retail systems (Goodstadt and Flynn 1993).
In most countries, the number of public service announcements and counter-
advertisements on alcohol issues are at best a small fraction of the volume of alcohol
advertisements (see Fedler et al. 1994; Wyllie et al. 1996) and are rarely seen on
television. Moreover, the quality of counter-advertising is often poor. A study of high
school students in the Moselle region in France (Pissochet et al. 1999) found that
respondents considered alcohol risk prevention advertising to be less effective than
alcohol advertising, and daily drinkers were more critical than intermittent and non-
drinkers.
Media advocacy However, mass media marketing can be used to reinforce
community awareness of the problems created by alcohol use and to prepare the
ground for specific interventions (Casswell et al 1990; Holder & Treno 1997).
Education and public information approaches can be used not just to seek to
persuade the individual drinker to change his or her behaviour, but also to mobilise
public support for prevention approaches that have demonstrated effectiveness
(Casswell and Gilmore, 1989), including limiting the availability of alcohol, drinking
driving countermeasures, and regulation and harm reduction in and around drinking
environments. Media advocacy can also be used to support a shift in public opinion
for policy changes (Wallack et al 1993), for example, the introduction of standard
drinks labelling on all Australian alcohol containers (Stockwell & Single 1997).
Low risk drinking guidelines

Epidemiological research on the effects of moderate drinking on cardiovascular
problems (see chapter 5) has created political pressures in some countries to provide
the public with promotional and educational material about the benefits of moderate
alcohol use. Surveys in several countries have noted an increase in the number of
adults who are aware of these health benefits. For example, in New South Wales,
Australia, the proportion identifying health benefits increased from 28% in 1990 to
46% in 1994, with relaxation (54%) and cardiovascular benefits of moderate drinking
(39%) most often mentioned (Hall 1995). In this context, official or semi-official
guidelines have been adopted in a number of countries on "moderate" drinking or
"low-risk drinking" (e.g., Bondy et al. 1999). Given the complex considerations that
underlie any such guidelines, it is not surprising that the guidelines vary considerably
from one country to another (Stockwell 2001). There is at present little research on
the impact of these messages (Walsh et al. 1998). Furthermore, it is unclear whether
such messages should be expected to lead to decreases or increases in alcohol
consumption and problems (Casswell, 1993). In both Denmark (Strunge 1998) and
England (Cabinet Office 2003), sensible drinking messages based on the concept of
unit drinks, whilst having an impact on knowledge, have had very limited impact on
behaviour.
Warning labels on alcohol products

Warning labels on beverage
containers that are required in
US warning labels
Canada and the United States GOVERNMENT WARNING: (1) According typically emphasize the potential for to the Surgeon general, women should not birth defects when alcohol is drink alcoholic beverages during consumed during pregnancy and pregnancy because of the risk of birth the danger of alcohol impairment defects. (2) Consumption of alcoholic when drinking and driving or beverages impairs your ability to drive a operating machinery. Health risks car or operate machinery, and may cause are also mentioned. Some states health problems.
require posted warnings of alcohol Effectiveness of policy risks in establishments that serve or sell alcohol. In the US, the appearance on labels or in advertisements of any positive health-related statement is prohibited (Alcohol and Tobacco Tax and Trade Bureau (2003). Reasons for such a ruling include (1) There are serious health risks associated with alcohol consumption, even moderate consumption; (2) the health benefits of moderate alcohol consumption do not apply universally, but only to a discrete segment of the population; (3) there are many groups of people who should abstain from, or minimize, their consumption of alcohol; (4) allowing health claims would undermine the Government warning label; and (5) explanatory statements are insufficient to clarify a misleading health claim. A fairly extensive amount of research has been conducted in connection French Loi Evin
with mandated warning labels on A health message must be included on
alcoholic beverage containers in the all alcohol advertisements:
United States, (Kaskutas 1995). Studies have found that a significant L'abus d'alcool est dangereux pour la
proportion of the population report having seen warning labels (Hilton, 1993; Graves 1993; Greenfield et al. (Alcohol abuse is dangerous for health)
1993; Kaskutas and Greenfield 1992), and there is some evidence that warning labels may increase knowledge regarding the risks of drinking and driving and drinking during pregnancy
(Kaskutas and Greenfield 1992; Greenfield 1997; Greenfield and Kaskutas 1998;
Greenfield et al. 1999; Kaskutas and Greenfield 1997), with some evidence for a
dose-response relationship between pregnancy-related conversations about drinking
while pregnant and the number of types of messages seen (Kaskutas et al. 1998).
No direct impacts of warning labels on consumption or alcohol-related problems have
been reported (MacKinnon et al., 2000; Grube & Nygaard, 2001; Agostinali & Grube,
2002). However, where there is a risk to health in consuming alcoholic beverages,
and in particular during pregnancy, when taking medication or when driving or
operating machinery, consumers should be informed about the risks, even if the
evidence is limited for the impact of warning labels.
Although there is limited evidence for the impact of warning labels on alcoholic
products in reducing the harm done by alcohol, European consumers should still
receive accurate and consistent information on the potential of the harms done by
alcohol.
School based education

The goal of most school-based alcohol education programs is to change the
adolescent's drinking beliefs, attitudes, and drinking behaviours, or to modify factors
such as general social skills and self-esteem that are assumed to underlie
adolescent drinking.
Informational approaches Earlier school-based interventions relied solely on
informational approaches and taught students about the effects and the dangers of
alcohol use. Such programs have not been found to be effective (Botvin et al. 1995a
1995b; Hansen 1994; Tobler 1992). Although they can increase knowledge and
change attitudes toward alcohol use, actual use remained largely unaffected. In
addition, there is some evidence that simply providing information about the dangers
of different substances may, in some cases, actually increase use (Hansen 1980,
1982).
Resistance and normative
education approaches
Scientific
School based education
evaluations of school and Despite many years of research, the effect university based resistance and sizes for most school based programmes normative education interventions are small and program failures are common. have produced mixed results with This suggests that, until there is more regard to alcohol, with some evidence for effectiveness, it is not a good evidence for effectiveness use of scarce resources to invest heavily in (Dielman 1995; Botvin and Botvin school based education programmes. 1992; Hansen 1992, 1993, 1994; Ellickson, 2003), including those aimed at reducing harmful alcohol consumption in university students Baer et al., 1992, Marlatt et al., 1995, Marlatt et al., 2002, some of which are screening and intervention programs (Marlatt et al., 1998, Baer et al., 2001) (see below), and educational programmes based on the social norm concept (e.g. the need to conform to what is acceptable to their peers) (Mattern & Neighbors, 2004; Kypri & Langley, 2003, Perkins, 2002); but also criticisms of the methodology discounting the effectiveness (Brown and Kreft 1998; Foxcroft et al. 1997; Gorman 1996, 1998; Paglia and Room 1999). Project Northland
Project Northland, was a school and community intervention designed to prevent or delay the onset of drinking among young adolescents in 10 communities in north-eastern Minnesota (Perry et al. 1993, 1996). The primary intervention was a series of school-based resistance-skills, media literacy, and normative education sessions. The program also provided parents with information on adolescent alcohol use. Task forces in some communities were involved in local policy actions such as the passage of local laws requiring responsible beverage service training. Evaluation of the project found that although it had a positive influence on alcohol knowledge and family communication about alcohol, it had no sustained impact on alcohol use (Williams et al. 1995; Perry et al. 1996; Perry et al. 1998). The Alcohol Misuse and Prevention Study (AMPS) is typical of school-based education programs that focus on pressures to use alcohol, risks of alcohol use, and ways to resist pressures to drink (Shope et al. 1996a, 1996b). The AMPS program had positive effects on alcohol knowledge (Shope et al. 1992), but few effects on drinking behaviour (Shope et al. 1996a). Other school-based alcohol resistance skills programs have produced similar results (Botvin et al. 1995a; Klepp et al. 1995). A good example of a well-designed study is the School Health and Alcohol Harm Reduction Project (SHAHRP study) from Australia, which aimed to reduce alcohol-related harm in secondary school students (McBride et al 2004). The study found that the intervention group (which received eight to ten 40 to 60 minute lessons on skill-based activities to minimize harm at age 13 years, and twelve further skills based activities delivered over 5-7 weeks at age 14 years) consumed significantly less alcohol at 8-month follow-up, after the first phase of the intervention (31% difference). However, at final follow-up, 17 months after the intervention, the total amount of alcohol consumed by intervention and comparison had lessened to a 9% difference. After the first phase of the programme at 8-month follow-up, intervention students were less likely to consume to risky levels (26% difference), but by seventeen months Effectiveness of policy after programme completion, the difference was only 4%, Figure 7.1. There was a significant difference between the study groups in the harm they reported associated with their own use of alcohol after both phases of the intervention, which was maintained 17 months after the intervention (23% difference). 20 months
32 months

Figure 7.1 The impact of 2 education sessions (after baseline and one year later) in the
intervention group compared to the control group (no education sessions) on binge drinking in
13-15 year olds. Source: McBride et al (2004).

Media literacy
Other school based initiatives have used media literacy efforts to
teach young people to resist persuasive appeals of alcohol advertising, with some
small positive effects (Austin and Johnson 1997) on resistance to such advertising
(Slater et al. 1996) and reductions in drinking and in the number of times young
people went to high-risk social environments where alcohol consumption was likely
(Canzer 1996).
Family and community interventions Some programs include both individual-level
education and family or community-level interventions (Werck et al., 2003; Bauman
et al., 2002; Turrisi et al., 2001). Well-designed evaluations suggest that even
comprehensive school-based prevention programs may not be sufficient to delay the
initiation of drinking, or to sustain a small reduction in drinking beyond the operation
of the program. (Perry et al. 1993, 1996, 1998; Williams et al. 1995; MacKinnon et al.
1991; Pentz et al. 1989; Johnson et al. 1990).
Midwestern Prevention Project
The Midwestern Prevention Project was implemented in 50 public schools in 15 communities in the State of Kansas (USA). A replication was conducted in 57 schools and 11 communities in another state. The intervention consisted of five components: (a) a 10-13-session school-based program with 5 booster sessions, (b) a mass media program, (c) a parent education and organization program, (d) training of community leaders, and (e) local policy changes initiated by the community organization. Differences between program and comparison schools in self-reported prevalence of monthly drinking were significant after one year (MacKinnon et al. 1991; Pentz et al. 1989) but they did not differ after 3 years (Johnson et al. 1990). Over the longer term (more than 3 years), the Strengthening Families Programme (SFP), showed promise as an effective prevention intervention, with a number needed to treat (NNT) for three alcohol initiation behaviours (alcohol use, alcohol use without permission and first drunkenness) of 9 (Spoth et al 2001a; 2001b), Figure 7.2. This means that nine students have to receive the programme for one to benefit. One other study also highlighted the potential value of culturally focused skills training over the longer-term (NNT = 17 over 3.5 years for 4 + drinks in the last week) (Schinke et al. 2000). This means that 17 students have to receive the programme for one to benefit. Ever been Drunk

Figure 7.2
The impact of the Strengthening Families Programme on ever having been drunk.
Source: Spoth et al 2001a, 2001b).
A Cochrane review of long term prevention for the primary prevention in young
people found that 23 of 56 studies reviewed were ineffective in the short term, Table
7.4 (Foxcroft et al 2003). The review was unable to make any firm conclusions about
the effectiveness of prevention interventions in the short- and medium term.
Table 7.4 Effectiveness of primary prevention programmes for young people in the short,
medium and long term. Source: Foxcroft et al 2004.
(1 year or less)
Can the success of education programmes be improved? A number of
suggestions have been made as to how the impact of school based education
programmes might be improved (Marlatt et al., 2002, Hawks et al., 2002, (McBride
Effectiveness of policy 2002; 2003; 2005). Based on the evidence of effective programmes, it is suggested that programs can be improved by: ƒ adopting adequate research design; ƒ encouraging program planners to adopt a formative phase of development that involves talking to young people and testing the intervention with young people and teachers; ƒ providing the program at relevant periods in young people's development; ensuring programs are interactive and based on skill development; ƒ setting behaviour change goals that are relevant and inclusive of all young ƒ including booster sessions in later years; ƒ including information that is of immediate practical use to young people; ƒ including appropriate teacher training for interactive delivery of the program; ƒ making effective programs widely available; and ƒ adopting marketing strategies that increase the exposure of effective These improvements to school education research and program development cannot occur in isolation to the practical implementation of programs at the school level. Identification of barriers and strategies that lead to effective alcohol education are important. Evidence based implementation and practice research will enhance this development and reinforce school alcohol education as an important strategy in a community approach for dealing with youth alcohol issues. Public investment in school alcohol education should be accompanied with both research expenditure to improve practice and with adequate training to ensure quality standards are met. Policies to support Education, Communication, Training and Public Awareness

Summary
Public service announcements, public education campaigns, and particularly those
that focus on low risk drinking guidelines have limited evidence for effectiveness,
although media advocacy approaches are important to gain public support for policy
changes, Table 7.5. Although there is limited evidence for the impact of warning
labels, there is an argument for their use in relation to consumer protection and
consumer rights. Although there are individual examples of the beneficial impact of
school-based education, systematic reviews and meta-analyses find that the majority
of well-evaluated studies show no impact even in the short-term. A policy that fails
more often than not cannot be considered an effective policy option. One family-
based programme may show some promise, but has only been evaluated in a
particular US context and needs a large amount of further research. There is
considerable experience of what might be best practice in school-based education
programmes, but currently unconvincing evidence for their effectiveness. This is not
to imply that education programmes should not be delivered, since all people do
need to be informed about the use of alcohol and the harm done by it, but school
based education should not be seen as the only and simple answer to reduce the
harm done by alcohol.
Table 7.5 Effectiveness ratings for education and public awareness
Effectiveness1
Public service messages Alcohol education in schools
1For definitions see Table7.1
Source: Babor et al (2003) (modified).

Impact and costs of drink drive measures
Due to lack of convincing evidence, the
CHOICE model did not assess the impact or costs of education based interventions.
REGULATION OF THE ALCOHOL MARKET

This section considers the impact of three different measures to regulate the alcohol
market; price and tax measures; restrictions on availability; and advertising,
promotion and sponsorship. Although each is considered in turn, these policy
measures do not act in isolation.
Price and tax measures to reduce the harm done by alcohol

The impact of price changes on alcohol
Box 7.1: Price elasticities
consumption and the harm done by alcohol has been more extensively investigated Economists and econometric studies use than any other potential alcohol policy the term elasticity to measure how much
measure (Ornstein 1980; Ornstein & Levy alcohol consumption or alcohol-related 1983; Godfrey 1988; Leung & Phelps 1991; harm changes when the price of alcohol Österberg 1995; USDHHS 1997; Österberg Price elastic Alcohol is described as price
Econometric studies are available at least elastic when the percent change in the
from the following European countries: amount of alcohol consumed is greater
Austria, Belgium, Denmark, Germany, than the percent change in price. Finland, France, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Price inelastic Alcohol is described as
Spain, Sweden, and the United Kingdom price inelastic when the percent change
(Ahtola et al 1986; Huitfeldt & Jorner 1972; in the amount of alcohol consumed is less
Lau 1975; Ornstein 1980; Ornstein & Levy than the percent change in price. 1983; Olsson 1991; Edwards et al. 1994; Österberg 1995; 2000). The price- For example, an elasticity of -2 would elasticities for alcoholic beverages mean that a 10% rise in the price of estimated in different studies have shown alcohol would lead to a 20% fall in that when other factors remain unchanged, consumption, and would be described as an increase in price has generally led to a ‘price elastic'. decrease in alcohol consumption, and that a decrease in price has usually led to an Price inelastic does not mean that
increase in alcohol consumption, with the consumption is not responsive to the price. size of the elasticities sometimes It only means that the proportional change dependent on the relative presence or is less. absence of other alcohol policy measures Effectiveness of policy (Farrell et al 2003; Trolldal and Ponicki 2005). An analysis of annual data from Australia, Canada, Finland, New Alcohol taxes
Zealand, Norway, Sweden, and the If alcohol taxes were used to raise the price United Kingdom from the mid 1950's of alcohol in the EU15 by 10%, over 9,000 to the mid 1980's found price deaths would be prevented during the elasticities of -0.35 for beer, -0.68 for following year and around €13bn of wine, and -0.98 for spirits (Clements additional excise duty revenues would be et al. 1997). This means that if the price of beer is raised by 10%, beer consumption would fall by 3.5%; if the price of wine was increased by 10%, wine consumption would fall by 6.8%; and if the price of spirits increased by 10%, spirits consumption would fall by 9.8%. There are differences between countries and within countries over time, in the way that alcohol consumers react to changes in the price of alcoholic beverages. This is reflected in the diversity of price elasticity values cited across studies from any given country (Österberg 1995; Chaloupka, Grossman & Saffer 2002). Reviews of demand models from 1989 and 1990 in the United Kingdom found that the demand for beer, wine, and spirits was generally price-inelastic, with the demand for wines and distilled spirits being more responsive to prices than the demand for beer (Godfrey 1989, 1990). More recent estimates found price elasticities of -0.48 for beer consumed on premises, -1.03 for beer purchased and consumed off premises, -0.75 for wine, and -1.31 for spirits (Huang, 2003). Changes in alcohol consumption are not only determined by changes in price, but also by changes in income. The European Comparative Alcohol Study analyzed price and income (as measured by expenditure) elasticities for alcohol during the period 1960s to 1990s for 14 European countries, Table 7.6 (Lepannen et al 2000). The price elasticities indicate that demand for alcoholic beverages is more easily controllable by excise taxes in the northern European countries than elsewhere. Demand appears to be least sensitive to prices in the southern European countries. Although in the northern European countries the prices of alcoholic beverages are set at a relatively high level by taxes, the estimated value of the price elasticities indicated that the taxes were not set at their tax revenue-maximizing level even in these countries. That is, taxes could be set higher further to generate further tax intakes for the governments. Between the 1960s and 1990s, the price elasticities converged separately across the northern European countries and across the southern European countries. The similar values of the income elasticities indicate that consumers view alcoholic beverages as normal goods, and not luxuries. Between the 1960s and 1990s, the expenditure elasticities converged across all the European countries. The price of alcohol and consumer expenditure on alcohol accounted for over half (56%) of the variation in alcohol consumption between the countries (Lepannen et al 2004). However, when taking into account the different cultural characteristics of the countries themselves, price and expenditure were responsible for 11% of the variation in alcohol consumption between the countries. Finally, the variation in alcohol consumption levels decreased when prices were set at an equal level between the countries, but appeared to increase slightly when real expenditures were equalized between the countries. This shows that price is more important than expenditure in bringing about a convergence of alcohol consumption between
countries.
Table 7.6 Mean elasticities of alcohol demand for selected European countries, averaged for
the years 1980-1995.
Price of alcohol Income (measured as expenditure on alcohol adjusted for consumer purchasing power) Source: Lepannen et al (2000).

Price and beverage preferences
Examining a series of purposeful price
adjustments by Systembolaget (the Swedish alcohol monopoly) throughout the years
1984 to 1993, the responses of consumers to changes in patterns of prices could be
examined (Ponicki et al., 1997; Gruenewald et al., 2000a). Beverages were classified
into "low", "medium" and "high" quality groups by beverage type (beer, wine and
spirits, based on 1990 real prices) and the impacts of changes in the real prices of
these beverages within quality classes upon consumption within and between quality
classes were examined. Increasing the prices within quality classes decreased sales
within classes, increased sales in lower quality classes within beverage types, and
increased sales in lower quality classes between beverage types. A flat price
increase across all beverages led to a 1.7% drop in sales, a price increase that
resulted in higher prices for higher quality beverages led to a 2.8% increase in sales,
and a price increase that resulted in higher prices for lower quality beverages led to a
4.2% drop in alcohol sales.
Another natural experiment occurred in Switzerland with its reform of spirits taxes,
which came into effect on 1 July 1999. Previously, the tax rate per litre of pure
Effectiveness of policy alcohol for domestic spirits was Swiss francs 26.00 and for foreign spirits between
Swiss francs 32.00 and 58.00, according to the type of beverage and its alcohol
content. The fiscal reform also liberalized the import of spirits. The result was a
reduction of between 30% and 50% in the retail price of foreign spirits. Prices of
domestic spirits, however, did not change. Spirits consumption increased significantly
(by 28.6%) in the total sample, and specifically in young males and in individuals who
were low-volume drinkers at baseline (Heeb et al 2003). Consumption of alcohol
overall, or of wine or beer, did not change significantly. No indication of effects of
substitution was found. Alcohol-related problems also increased significantly; the
significance disappeared, however, after controlling for spirits consumption,
indicating that the increase of alcohol-related problems at follow-up was mainly
mediated through the increased consumption of spirits.

Price effects in young people and heavy drinkers:
Studies, have found that
increases in the price of alcohol reduce the alcohol consumption of young people,
with a greater impact on more frequent and heavier drinkers than on less frequent
and lighter drinkers (Grossman et al. 1987; Coate and Grossman 1988; Laixuthai &
Chaloupka 1993; Chaloupka & Wechsler 1996; Cook and Moore 2002). Beyond
levels of drinking, price has also been found to influence drinking to intoxication. One
large survey in the US found that a 10% increase in price would decrease the
number of intoxication episodes per month by 8% (defined as consuming 5+ drinks
on one occasion; Sloan et al. 1995). The impact of alcohol taxes differs with age,
with the impact of increasing age in youth possibly swamping the impact of price
(Gius 2005).
Although alcoholic beverages appear to behave in the market like most other
consumer goods, the demand for alcoholic beverages in some consumers may differ
from other products because of the addictive nature of alcohol. The addictive nature
of alcohol implies that an increase in the past consumption of alcohol would raise the
current consumption; and thus the price elasticity in the short-term, which holds past
consumption constant, would be smaller in absolute value than the price elasticity in
the long-term, which allows past consumption to vary. For example, a price increase
in 2004 would reduce consumption in 2004, with consumption in previous years held
constant. Because of the addictive nature of alcohol, it would be expected that
consumption in 2005 and in all future years would also fall. Consequently, the
reduction in consumption observed over several years (i.e., in the long term) after the
price increase would exceed the reduction observed in 2004 (i.e., in the short term).
Studying the relationship between price and alcohol consumption by young adults
ages 17 to 29 has found this to be the case (Grossman et al 1998). Ignoring previous
years' consumption (and thus the addictive aspects of alcohol) the price elasticity of
demand for alcohol was -0.29. However, when previous years' consumption (and
thus the addictive aspects of alcohol) was taken into account, the estimated long-
term price elasticity of demand was more than twice as high at -0.65, indicating that
price had a much greater influence on alcohol consumption. This also means that
about one half of the reason that heavy drinking young adults do not reduce their
consumption is the difficulty (costs) of overcoming the addictive nature of alcohol.
Price of alcohol and use of other drugs It is also important to know the impact of
price changes of alcohol on the use of other substances. An English study of 43
polysubstance users investigated the influence of price upon hypothetical purchases
of alcohol, amphetamine, cocaine and ecstasy. As the price of alcohol rose, it was
found that amphetamine to some extent substituted the use of alcohol, more cocaine
was used in addition to alcohol, and the use of ecstasy remained independent
(Sumnall et al 2004). How this translates to the real world and amongst non-poly-
substance users is not known.

Effects of price on dependence and frequency of drinking Increasing the price of
alcohol reduces heavier drinking (Coate and Grossman, 1988; Kenkel, 1993, 1996;
Manning et al., 1995), as well as alcohol dependence (Farrell et al 2003).
Effects of price on the harm done by alcohol A wide range of studies have found
that increasing the price of alcohol and beer reduces road traffic accidents and
fatalities among people of all ages, but particularly for younger drivers (Saffer and
Grossman (1987a,b; Kenkel 1993; Ruhm 1996 Chaloupka and Laixuthai 1997 Dee
1999; Mast et al. 1999; Dee and Evans 2001; Chaloupka et al 2002 Saffer and
Chaloupka, 1989; Evans et al., 1991; Chaloupka et al., 1993; Sloan et al., 1994a;
Mullahy and Sindelar, 1994a). For example, a policy adjusting the US beer tax for the
inflation rate since 1951 to the mid- 1980s would have reduced total road traffic
fatalities by 11.5 percent and fatalities among 18- to 20-year-olds by 32.1 percent
(Chaloupka et al 1993).
Increases in alcohol prices reduce cirrhosis death rates (Grossman 1993; Cook &
Tauchen 1982), intentional and unintentional injuries (Sloan et al 1994; Grossman
and Markowitz, 1999), workplace injuries (Ohsfeldt & Morrisey 1997) and sexually
transmitted disease rates (Chesson et al 2000). In the United Kingdom, it has been
estimated that a 10% rise in the prices of alcoholic beverages would lead to a drop of
7.0% in male and 8.3% in female cirrhosis mortality, a drop of 5.0% for male victims
and 7.1% for female victims of homicide, and a drop of 28.8% for male and 37.4% for
female deaths from explicitly alcohol-involved causes (alcohol dependence,
poisoning, etc.) (Academy of Medical Sciences 2004). Higher beer prices have been
shown to lead to reductions in rapes and robberies (Cook and Moore 1993),
homicides (Sloan et al. 1994), crime (Saffer 2001), child abuse (Markowitz and
Grossman 1998; Markowitz and Grossman 2000), wife abuse (Markowitz 2000)
violence at universities (Grossman and Markowitz 2001), and violent related injuries
(Matthews et al 2005).
Impact and costs of tax measures Using the elasticities of the ECAS project
(Leppänen, Sullström, and Suoniemi 2001), it is possible to estimate the effect of a
tax rise that would raise the price of alcohol by 10% in each country. It should be
stressed that this takes no account of any rise in smuggling or cross-border shopping
due to a lack of data; in practice, policy decisions will take account of anticipated
changes in these areas. Using the ECAS report analysis, it can be predicted that
countries in Southern Europe would experience a drop in consumption of 2%, while
the fall in Central Europe would be 5% and that in Northern Europe 8%. If these
estimates are combined with the ECAS analysis of the effect of changes in
consumption on health outcomes (Norström et al 2001), it can be estimated that a
10% price rise would save over 9,000 deaths in the EU15 each year. This would
include over 4% fewer deaths from liver disease for men (and 3% for women), 1%
fewer deaths among men and women from accidents, and 5% fewer deaths among
men due to homicide. Furthermore, in Finland, Sweden and Norway – where the
effects of both price (on consumption) and consumption (on harm) are stronger – it is
estimated there would be a 6-7% fall in suicide deaths and accidents, together with a
20% decrease in directly alcohol-related deaths for men and a 40% fall in women.
When looked at from the public accounts view, it can be roughly estimated that a
10% price rise would also give around €13bn of additional excise duty revenues
within the EU.2 This is likely to be something of an overestimation, given that it takes
2 The tax rise from a 10% change in price is estimated from data on the share of tax in price given in the WHO Global Status Report on Alcohol 2004 (WHO 2004). The changed tax take is then calculated for Effectiveness of policy no account of smuggling/cross-border shopping or the effect of price rises on all beverages at the same time (compared to individual beverage elasticities). Even accounting for the former and only looking at one beverage though,3 a detailed official UK analysis shows that spirits duties could be raised by 40% before the maximum revenue is achieved (Huang 2003). The potential for increased tax revenues even in a relatively high-tax country such as the UK was further demonstrated when beer and wine were examined – the current duties were so much lower than the maximum revenue point that it proved impossible to say exactly where this would be. Price measures

Summary
An increase in the price of alcohol reduces alcohol consumption, hazardous and
harmful alcohol consumption, alcohol dependence, the harm done by alcohol, and
the harm done by alcohol to others than the drinker, Table 7.7. The exact size of the
effect will vary from country to country and from beverage to beverage. There is very
strong evidence for the effectiveness of alcohol taxes in targeting young people and
the harms done by alcohol.

Table 7.7
Effectiveness ratings for pricing and taxation
Effectiveness1

1For definitions see Table 7.1
Source: Babor et al (2003).
Impact and costs
The World Health Organization's CHOICE modelled the impact of a tax on alcohol
set at the current level increased by 25%, compared with no tax at all, and adjusted
for the observed or expected level of unrecorded use (taken as a close proxy
measure for untaxed consumption) due to illicit production and smuggling, using
published price elasticities (Ornstein and Levy, 1983; Babor et al., 2003). The model
estimated that the current level of taxation plus a 25% increase can prevent between
503 (EuroB countries) and 1576 (EuroA countries) DALYs per million people per
year, at a cost of between €18 (EuroC countries) and €38 (EuroA countries) per 100
people per year (see Figures 7.11 and 7.12 at the end of the chapter). The model
estimated that the current level of tax with a 25% increase in the tax rate throughout
Europe, compared with no tax on alcohol, can prevent an estimated 656,000 years of
disability and premature death at an estimated cost of €159 million each year
(adapted from Chisholm et al 2004).
each beverage separately from the tax rate per litre of pure alcohol (taken from the spirits industry
organisation CEPS), changes in consumption from tax rises (above), adult per capita consumption, and
adult population (both from the WHO's HFA database).
3 The UK estimate for spirits includes the effect of spirits price changes on beer and wine consumption (known as ‘cross-price elasticities'). This has the effect of lowering the tax rate at which the maximum tax revenue is obtained in this case. However, it is extremely difficult to model the effect of simultaneous price rises in multiple beverage types, which is why the effects of beverage-specific rises are given here.
Restrictions on the availability of alcohol

Total or partial bans on the sale of alcohol It is clear from historical evaluations of
the prohibition periods in North American and the Nordic countries (Aaron & Musto
1981; Paulson 1973) and from studies of current more limited prohibitions, that total
bans on alcohol production and sales can reduce alcohol-related problems (Chiu et
al. 1997; Bowerman 1997). However, where there has been a substantial demand for
illicit alcohol, it has been be filled partly by illegal operators, often with associated
violence in the enforcement of the illegal market (Johansen1994; Österberg and
Haavisto 1997).
For Europe, total prohibition is not a politically acceptable option even if the potential
for reducing alcohol problems does exist. However, that is not to say that bans on
alcohol sales for specific persons in the population (e.g., children and adolescents,
see below), or in specific circumstances (d'Abbs and Togni 2000) cannot be applied
with demonstrated success.
Restrictions on eligibility to purchase and sell alcohol During the mid twentieth
century, broad restrictions on who could purchase alcohol were fairly common. The
most elaborate example of such controls was the Bratt system in Sweden, where a
rationing scheme assigned a limit to each adult on how much spirits could be
purchased (Tigerstedt 2000). Other types of schemes included those where drinkers
convicted of violent assaults could be banned from bars and cafés.
Whilst rationing is clearly politically unacceptable in contemporary Europe, there is no
doubt that general alcohol rationing schemes, such as the Bratt system in effect in
Sweden until 1955 (Norström 1987) and the system in effect in Greenland from 1979
to 1982 (Schechter 1986) were responsible for reducing liver cirrhosis mortality,
violence, and other consequences of heavy drinking. In Poland during the early
1980s, when alcohol rationing limited each adult to half a litre of spirits per month,
episodic heavy drinking was reduced, mental hospital admissions for alcoholic
psychosis fell by 60%, deaths from liver diseases dropped by 25%, and deaths from
injuries by 15% (Moskalewicz & Swiatkiewicz 2000).

Sales to minors
For young people, laws that lower the minimum legal drinking age
reduce alcohol sales and problems among young drinkers (Grube and Nygaard
2001; Babor et al 2003).
Although legal restrictions on the age at which young people may purchase alcohol
vary widely from country to country, ranging typically from 16 to 21 years of age,
almost all countries legally restrict these sales. A review of 132 studies published
between 1960 and 1999 found very strong evidence that changes in minimum
drinking age laws can have substantial effects on youth drinking and alcohol-related
harm, particularly road traffic accidents, often for well after young people reached the
legal drinking age (Waagenar & Toomey 2000). Many studies have found that raising
the minimum legal drinking age from 18 to 21 years decreased single vehicle night
time crashes involving young drivers by 11% to 16% at all levels of crash severity
(Klepp et al. 1996; Saffer and Grossman 1987a,b; Wagenaar 1981, 1986; Wagenaar
and Maybee 1986; O'Malley and Wagenaar 1991; Voas and Tippett 1999), Changes
in the minimum drinking age are related to changes in other alcohol-related injury
admissions to hospitals (Smith 1988) and injury fatalities (Jones et al. 1992). One
study from Denmark, where a minimum 15-year age limit was introduced for off-
premise purchases, found that there was an effect in reducing teenagers' drinking,
Effectiveness of policy but that the drinking of those above as well as below the age limit was affected
(Møller 2002).
The importance of enforcement The full benefits of a higher drinking age are only
realized if the law is enforced. Despite higher minimum drinking age laws, young
people do succeed in purchasing alcohol (e.g., Forster et al. 1994, 1995; Preusser
and Williams 1992; Grube 1997). In most EU countries in the ESPAD study (see
chapter 4), a majority of 15-16 year old students thought that getting any type of
alcoholic beverage was fairly easy or very easy, rising to 70-95% for beer and wine
(Hibell et al 2004). Such sales result from low and inconsistent levels of enforcement,
especially when there is little community support for underage alcohol sales
enforcement (Wagenaar and Wolfson 1994, 1995). Even moderate increases in
enforcement can reduce sales to minors by as much as 35% to 40%, especially
when combined with media and other community activities (Grube 1997; Wagenaar
et al. 2000).

Regulating retail outlets for alcohol
Alcohol can be purchased through "off-
premise" or "on-premise" sales. For off-premise sales, where alcohol is consumed
elsewhere, regulations can be made on the type, strength and packaging of the
alcoholic beverage and the time, costs and location of alcohol sales. For on-premise
sales, where alcohol is consumed in the bar or café, regulations can specify drink
sizes, disallow discount drink promotions or require on-premise staff to receive
training in responsible beverage service. They may also regulate the design of the
bar or café, and include specifications on such matters as food service, availability of
entertainment, and other non-alcohol-related matters (see section on reducing harm
in drinking and surrounding environments below).
A licence issued by a local or central administration is required in many countries
before some types of alcoholic drinks can be sold, either on licensed premises or
from off-licences. In some countries the licensing of outlets selling spirits is much
stricter than regulations on the retail sale of beer and wine. There are many reasons
and benefits for licensing retail sales (Lehto 1995). One is to make sure that outlets
observe other regulations such as age limits and opening times. Another is to ensure
that tax is collected on every drop of alcohol sold. When the system is used to restrict
the number of outlets, most often the aim is to prevent health and public order
problems by limiting the alcohol supply. Licensing systems have also been used to
control the standard of licensed premises, for instance to deny licences to places that
are perceived to encourage harmful drinking and to grant licences to outlets that
appear to encourage less harmful drinking.
One means to regulate sales of alcohol is through government-owned alcohol
outlets, retail monopolies, which still operate in parts of the US and much of
Canada, as well as in the Nordic countries. Off-premise monopoly systems reduce
alcohol consumption and alcohol-related problems. Studies of privatisation of sales of
alcoholic beverages in the United States show substantial variations in increases in
consumption (cf, Mulford, Ledolter and Fitzgerald, 1992; Wagenaar and Holder,
1991), with increases observed ranging between 13% and 150% (Wagenaar and
Holder, 1995). When Finland changed from selling beer only in government
monopoly stores to selling it also in grocery stores in 1968, alcohol consumption rose
by 46% in the following year, alcohol problem rates increased (Mäkelä et al. 2004),
and drinking among 13 to 17-year-olds increased (Valli 1998). Noval and Nilsson
(1984) found that total alcohol consumption in Sweden was substantially higher when
medium-strength beer could be purchased in grocery stores between 1965 and 1977,
rather than only in state monopoly stores.
Number of retail outlets/outlet density Outlet density refers to the number of
outlets available for the retail purchase of alcohol. The smaller the number of outlets
for alcoholic beverages, the greater the difficulty in obtaining alcohol, a situation that
is likely to deter alcohol use and problems (Gruenewald et al. 1993). This can be
seen in practice in Finland, Sweden, Britain and North America.
Finnish studies have found an overall impact on alcohol consumption from changes
in the number of outlets (Kuusi 1957; Lehtonen 1978; Mäkinen 1978). The most
dramatic change was observed in 1969, when beer up to 4.7% alcohol was allowed
to be sold by grocery stores, and it also became easier to get a restaurant license.
The number of off-premise sales points increased from 132 to about 17,600, and on-
premise sales points grew from 940 to over 4000 (Österberg 1979). In the following
year, alcohol consumption increased by 46%. In the following five years, mortality
from liver cirrhosis increased by 50%, hospital admissions for alcoholic psychosis
increased by 110% for men and 130% for women, and arrests for drunkenness
increased by 80% for men and 160% for women (Poikolainen 1980).
Swedish studies have also found an overall impact on alcohol consumption and
alcohol-related harm from changes in the number of outlets (Noval and Nilsson 1984;
Hibell 1984). A time-series analysis found that motor vehicle accidents were
significantly reduced in three of four age groups when the right to sell 4.5% beer in
groceries was retracted; there was a significant fall in hospital admissions for alcohol-
specific diagnoses among those aged under 20 years, but no effect on assaults,
suicides and falls (Ramstedt 2002).
However, Norwegian studies of the effects of opening wine and spirit outlets in
places where beer was already available found a shift away from other beer and
home produced spirits, with little effect on overall consumption. This suggests that,
where there is already some availability of alcohol, the effects on total consumption
of changes in the number of off-sale stores selling one or another type of beverage
are minor (Mäkelä et al. 2002).
Recent years have seen the transformation of the night-time economy in British cities
and towns (Hobbs et al., 2003; Chatterton and Hollands, 2003), with older pubs being
replaced by large branded drinking warehouses run by national or international
chains. In Manchester City Centre, for example, the capacity of licensed premises
increased by 240% between 1998 and 2001, whilst the number of assaults reported
to the police increased by 225% between 1997 and 2001 (Hobbs et al., 2003).
North American studies have looked at the association of outlet density with rates of
drinking driving collisions (Blose and Holder 1987; Gruenewald et al. 1993). Four
studies report no impact of outlet density on drinking-driving or collision measures
(Gruenewald and Ponicki, 1995; Kelleher et al., 1996; Meliker et al., 2004; Lapham et
al., 2004). However, a larger number of studies (eight) have reported a significant
impact of outlet density on alcohol consumption and drinking driving collision
(Scribner, MacKinnon and Dwyer, 1994; Gruenewald et al., 1996; Gruenewald et al.,
1999; Gruenewald, Johnson and Treno, Jewell & Brown 1995; 2002; LaScala et al.,
2001; Treno, Grube and Martin, 2003; Escobedo and Ortiz, 2002; Cohen, Mason and
Scribner., 2002), and assaults, particularly in high population density areas
(Gruenewald et al., 1996). On balance, the research indicates that increasing
numbers of outlets will increase alcohol-related collisions and fatalities (see Mann et
al., 2005 for a more detailed description). Outlet density has also been associated
with an increased risk of pedestrian injury collisions (LaScala et al. 2000), and violent
assaults (Alaniz et al. 1998; Stevenson et al. 1998; Zhu et al 2004).
Effectiveness of policy The distribution of alcohol-related crashes (single-vehicle night-time crashes) is also related to the distribution of on-premise outlets and rates of these crashes decrease with greater distance from concentrated areas (Gruenewald et al., 1996). Further, greater outlet concentrations have a greater impact on alcohol-related crashes in areas with greater amounts of highway traffic (Gruenewald & Johnson 2000), and in lower income areas (LaScala, Gruenewald & Gerber, 2000). Research has examined the associations between outlet density and measures of student and underage drinking. Outlet density has been found to be closely related to heavy drinking and drinking related problems among college students (Weitzman et al., 2003); other associations were found for the number of commercial sources of alcohol and binge drinking and drinking in inappropriate places for students age 16 to 17 years (Dent et al., 2005). The impact of changes in availability will depend on local circumstances (Abbey, Scott & Smith, 1993). Thus, whereas changes occurring across a country have an impact (Gruenewald, Ponicki & Holder, 1993; Wagenaar & Holder, 1996), when changes in availability are more local, there may be no impact (Gruenewald et al., 2000b). In the first case, it is difficult to avoid the effects of reduced availability. In the local case, it is possible to travel outside the local geographic area to obtain alcohol. Further, equivalent reductions in local areas can have different effects. A 10% reduction in the number of outlets in high density areas will have negligible effects on the distances between people and outlets. A 10% reduction in the number of outlets in low density areas may result in the elimination of the only outlets easily accessible by drinkers. In sum, outlet density is in general positively associated with alcohol consumption and alcohol related problems: the higher the density, the higher consumption and problems will likely be, (Her et al. 1998; 1999), Figure 7.3, although the extent to which changes in densities over time affect rates of problem outcomes is not always certain (Gorman et al 2001). Figure 7. 3 Illustration of the relationship between volume of drinking as a function of
outlet density (Source: Her et al., 1999a) Hours and days of retail sale A number of studies have indicated that although
changing either hours or days of alcohol sale can redistribute the times at which
many alcohol related crashes and violent events related to alcohol take place (e.g.,
Smith 1988; Nordlund 1985), it does so at the cost of an overall increase in problems.
Around-the-clock opening in Reykjavik, for instance, produced net increases in police
work, in emergency room admissions and in drink driving cases. The police work was
spread more evenly throughout the night, but this necessitated a change in police
shift to accommodate the new work (Ragnarsdottir et al. 2002). A study in Western
Australia showed that extending opening hours from midnight to 1.00am increased
violent incidents at the later night venues by 70% (Chikritzhs, Stockwell & Masters,
1997; Chikritzhs & Stockwell 2002), Figure 7.4. The increased problems associated
with the late trading venues appeared to result from increased alcohol consumption
rather than increased opportunity for crime to occur, since there was no apparent
difference between the two groups after alcohol sales were controlled for. The blood
alcohol levels (BALs) of drivers in road crashes, who had been drinking at the
extended trading premises, were significantly higher than those drinking at the
control premises. Similar studies have also found that assaults at licensed premises
are much more likely to occur during extended trading periods, with the most
frequent time being midnight to 3am (Briscoe & Donnelly, 2003a).
Extended
Extended Trading Figure 7.4 Assault rates for hotels that closed at 1 am []] and those that closed at midnight)
[W] Perth, WA. Source: Chikritzhs & Stockwell (2002)
A study in Sweden (Norström and Skog 2001, 2002, 2005) found a net 3.6%
increase in alcohol sales with Saturday opening of government alcohol stores,
although the changes in harm were not big enough to be significant. The Saturday
opening occurred at a time when alcohol was more readily available from other
sources, including restaurants and bars, groceries (up to 3.5% alcohol concentration)
and travellers' imports.
There is also evidence that restricting days and hours of sale reduces problems. In
the 1980s Sweden re-instituted Saturday closing for spirits and wine off-premise
sales after studies showed that Saturday sales were associated with increased rates
of domestic violence and public drunkenness (Olsson and Wikström 1982). In 1984,
Effectiveness of policy Norway reintroduced Saturday closing, with a resultant decrease in domestic violence and disruptive intoxication (Nordlund 1985). Restricting availability

Summary
Raising and implementing a minimum age of purchase for alcohol, and reducing the
availability of alcohol through restrictions on the number and density of outlets and
the days and hours of sale all reduce alcohol related harm, Table 7.8.
Table 7.8 Effectiveness ratings for restrictions on the availability of alcohol
Effectiveness1
Minimum drinking age Government retail outlets Number of outlets Density of outlets Hours and days of sale 1For definitions see Table 7.1
Source: Babor et al (2003) (modified)
Impact and costs
The World Health Organization's CHOICE modelled reduced access to and
availability of alcohol through estimating what would happen if alcohol could not be
purchased for a 24-hour period at the week-end (although not politically acceptable
across contemporary Europe, this option was chosen by the WHO team, based on
Scandinavian data, which has been shown to reduce consumption and alcohol-
related harm (Leppanen, 1979; Nordlund, 1984; Norström and Skog, 2003)). Based
on these studies, a modest reduction of 1.5-3.0% in the incidence of hazardous
drinking and 1.5-4.0% in alcohol-related traffic fatalities was modelled. If
implemented throughout the European Union, the model estimated that such an
intervention can prevent between 251 (EuroA countries) and 689 (EuroC countries)
DALYs per million people per year, at a cost of between €12 (EuroC countries) and
€23 (EuroA countries) per 100 people per year (see Figures 7.11 and 7.12 at the end
of the chapter). Although it is not known for how long the effects might last, the model
estimated that such an intervention throughout Europe can prevent an estimated
123,000 years of disability and premature death at an estimated cost of €98 million
each year (adapted from Chisholm et al 2004).
Alcohol advertising, promotion and sponsorship.

Introduction
Beverage alcohol is prominent among the many branded consumer goods that young
people in particular increasingly use as a way of signalling their identity and place in
the world. The producers and marketers of beverage alcohol, many of whom are
global players (Babor et al., 2003, Jernigan, 1997), use sophisticated promotional
practices to target specific groups such as those starting to drink, regular young
drinkers and established young drinkers (Academy of Medical Sciences, 2004). This
marketing utilizes multiple channels (youth radio, television, events, websites, mobile
phones) and diverse modalities (advertising, sponsorship, branding) (Jernigan and
O'Hara, 2005). Such marketing of alcohol to young people is at the forefront of what
is termed post-modern marketing (Cooke et al 2004; Jernigan & O'Hara 2005).
Advertising and branding are crafted to mirror and express dominant representations
of youth culture and lifestyles (Klein 1999; Jackson et al. 2000). Promotion is never
static, even in established markets, as new cohorts of young people become
available as targets for marketing activity on a continual basis as they mature (Saffer,
2002).
A total marketing strategy has five steps: product development, pricing, physical
availability, market segmentation and targeting, and advertising and promotion
campaigns (Cowan and Mosher, 1985; Kotler, 1992). This section will consider the
impact of each of the five marketing steps on alcohol consumption, with the greater
discussion on the impact of advertising and promotion campaigns, and will discuss
some aspects of regulating marketing practices, and in particular self-regulation.
New product development
New product development has been particularly active since the 1990s (Jackson et
al., 2000; Mosher and Johnsson 2005), and started with designer drinks
characterised by brightly coloured and innovative packaging, delivering the product
benefits of strength, flavour and portability, such as bottled ciders and fortified fruit
wines. The boom in designer drinks lasted until the mid-1990s, when a new range of
alcoholic soft drinks, which became known as ‘alcopops', emerged. Alcopops were
then superseded by ‘pre-mix cocktails' (blends of spirits, soft drinks and other unique
flavourings that are not readily concocted by consumers themselves), and a trend
towards mixing high energy soft drinks (such as Red Bull) with spirits (such as
vodka). A development of this trend has been the introduction of ‘ready-to-drink'
alcoholic energy drinks that are sold on the basis of their stimulant properties. These
drinks contain a blend of vodka, caffeine, glucose and taurine and have an average
alcohol content of 5.4%. Another type of product – strong spirits designed to be
consumed in one mouthful from small ‘shot' glasses - is becoming increasingly
popular. Brands include ‘Aftershock' and ‘Goldshlager', and are chosen by young
drinkers because their strength gives an immediate hit, and their strong flavours (for
example cinnamon), brand names and packaging have created associations with
daring behaviour (see Hastings et al 2005).
Whether they be wine coolers, (Goldberg et al 1994) designer drinks (McKeganey et
al 1996), or alcopops, (Barnard and Forsyth 1998) studies of young people's
attitudes and behaviour in several countries have documented that such new
products are the drinks of choice of young people and can contribute both to heavier
drinking and to lowering the age of onset of drinking. In some instances, these
products seem to be competing directly with the youth market for illegal drugs
(Jackson et al 2000).
The brand imagery of designer drinks - in contrast to that of more mainstream drinks
- matched many 14 and 15 year olds' perceptions and expectations of drinking, with
consumption of designer drinks tending to be in less controlled circumstances and
associated with heavier alcohol intake and greater drunkenness (Hughes et al 1997).
Data from the Health Behaviour in School-aged Children study found that in Wales
alcopops consumption matched the entire increase in weekly drinking of alcohol
between 1994 and 1996 among 11 and 12 year olds, half the increase for 13 and 14
year-olds, and most of the increase for 15 and 16 year old girls (Roberts et al.,
1999). Swedish surveys have found that alcopops and sweet ciders accounted for
more than half the recorded increase in alcohol consumption among 15 and 16 year
Effectiveness of policy old boys between 1996 and 1999, and two-thirds of the increase in consumption
among girls, at a time when alcohol consumption among Swedish adults remained
stable while youth consumption was increasing (Romanus, 2000).
Industry representatives do not deny the importance of new products designed to
reach ‘‘new drinkers'' or ‘‘entry-level drinkers'' or some similar term: ‘‘No matter
where in the world they are drunk, and at what kind of occasion, there is no doubt
that FABs (flavoured alcoholic beverages) are consumed by younger drinkers. The
combination of packaging, taste and alcoholic content gives them little appeal to
older drinkers
'' (Euromonitor 2004; 6, Section 22.15).
Pricing
The impact of price on consumption has been discussed above. There has been a
considerable trend towards popular drinking venues offering promotional deals and
‘happy hours' (temporary price-cuts) on products regularly consumed by young
drinkers (se Hastings et al 2005). Examples include: a never ending vodka glass
(purchase one glass of vodka and refill it as often as you like); buy one drink and get
one free happy hours, and cheap deals on popular drinks on particular nights of the
week. Alcohol price promotions are associated with increased binge drinking (Kuo et
al 2003)
Availability
The impact of availability on consumption has been discussed above. Alcohol
advertising can also take place at the point of purchase, including exterior and
interior advertisements for alcoholic beverages; alcohol-branded functional objects
provided free to retailers (e.g., counter change mats with an alcohol company logo);
beer placement (e.g., single cans or bottles chilled in buckets near checkout
locations); and the presence of low-height advertisements (i.e., advertisements
placed in the sight line of children and adolescents as opposed to adults) (CDC
2003). For non-drinkers aged 12-13 years, exposure to in-store beer displays are
predictive of drinking onset by age 14-15 years (Ellickson et al 2005).
Market segmentation and targeting
Research in the United States shows that alcohol companies have placed significant
amounts of advertising where youth are more likely per capita to be exposed to it
than adults (Jernigan et al 2005). In 2002 in the US, underage youth saw 45% more
beer and ale advertising, 12% more distilled spirits advertising, 65% more low-
alcohol refresher advertising, and 69% less advertising for wine than persons 21
years and older (Jernigan et al 2004). Girls aged 12 to 20 years were more likely to
be exposed to beer, ale, and low-alcohol refresher advertising than women in the
group aged 21 to 34. Girls' exposure to low-alcohol refresher advertising increased
by 216% from 2001 to 2002, while boys' exposure increased 46%.
Magazines are the most tightly targeted of the measured media. Two studies to date
have looked at alcohol advertising in this medium. Following on research suggesting
that cigarette brands popular among youth ages 12 to 17 were more likely than other
brands to be advertised in magazines (King et al., 1998), Sanchez et al. (2000)
selected a convenience sample of 15 magazines, 11 with the highest youth
readership (greater than 1.9 million readers) and 4 with the lowest youth readership
(less than 0.8 million), and assessed the volume of influence by counting advertising
pages for alcohol and tobacco in each magazine. The authors found a relationship
between the size of youth readership and alcohol and tobacco advertisements, with
magazines with more youth readers containing more alcohol and tobacco
advertisements. Similar findings were made by Garfield et al (2003), who found that
after adjustment for other magazine characteristics, the advertisement rate ratio was
1.6 more times for beer and spirits for every additional one million adolescent readers. Wine industry advertising was not associated with adolescent readership, Figure 7.5. Rate rati
Figure 7.5 Magazine readership and alcohol advertisements. The advertisement rate ratio for
every additional 1 million adolescent readers. For example, a US magazine that has 1 million
more readers aged 12-19 years than another US magazine will have 1.6 times the number of
beer and spirits advertisements. Source: Garfield et al (2003).
Advertising and promotion campaigns
Television portrayal
of alcohol use has been given a lot of attention. When people
are seen drinking on television they seem to be drinking alcohol most of the time
(Brown and Witherspoon, 2002). Pendleton et al. (1991), for example, found that
every 6.5 min a reference to alcohol was made in their sample of 50 programmes on
British television. Especially in fictional series the consumption of alcohol was
prominently present. Furnham et al. (1997) concentrated on the portrayal of alcohol
and drinking in six British soap operas and concluded that 86% of all programmes
contained visual or verbal references to alcoholic beverages. More alcohol was
consumed than any other kind of drink, but the sample of programmes almost never
referred to the hazards of alcohol consumption.
Content analyses of portrayals of alcohol use on television suggest that incidences of
drinking occur frequently and that these portrayals present drinking as a relatively
consequence-free activity (Christen-son et al. 2000; Grube 1993; Mathios & Avery &
Shanahan & Bisogini 1998; Wallack & Grube & Madden & Breed 1990). Television
characters who drink tend to be "high status" characters who are wealthy, successful,
attractive, and in senior-level occupations. Their drinking is often associated with
happiness, social achievement, relaxation, and camaraderie (Hundley 1995; Wallack
et al. 1990).
Content analyses of the appeals used in alcohol advertisements suggest that
drinking is portrayed as being an important part of sociability, physical attractiveness,
masculinity, romance, relaxation and adventure (Grube 1993; Finn & Strickland 1982;
Effectiveness of policy Madden & Grube 1994). Many alcohol advertisements use rock music, animation,
image appeals, and celebrity endorsers, which increase their popularity with
underage television viewers (Aitken 1989; Grube 1993; Jones & Donovan 2001;
Martin et al. 2002; Waiters & Treno, & Grube 2001). Not surprisingly, then, alcohol
commercials are among the most likely to be remembered by teenagers and the
most frequently mentioned as their favourites (Aitken 1989; Aitken et al. 1988; Aitken
& Leathar & Scott 1988; Grube 1993).
A number of studies have attempted to understand the process by which exposure to
alcohol advertising and incidental portrayals of drinking on television and music
videos (DuRant & Rome & Rich et al. 1997; Robinson & Chen & Killen 1998)
influence alcohol-related beliefs and behaviours in children and adolescents. Aas and
Klepp (1992), Atkin (1990), and Austin and Meili (1994) have argued that alcohol use
is a learned behaviour, part of the adolescent socialization process. They contend
that adolescents, particularly those who have not yet begun to experiment personally
with alcohol, actively and deliberately seek information about alcohol from cultural
sources as well as family and peers. One of the primary sources is television, which
may present only a distorted view of the realities of alcohol use (Atkin 1990; Austin &
Nach-Ferguson 1995; Christen-son & Henrikson & Roberts 2000; Grube 1993; Kelly
& Donohew 1999; Mirazee & Kingery & Pruitt 1989; Wallack et al 1990).
High school boys who are heavier television viewers drink more than lighter viewers
(Tucker 1985; Atkin 1990), although this is not the case for all programme viewing
(Klein et al 1993). Heavier viewers are more likely than lighter viewers to agree that
‘‘people who drink are happy'' and ‘‘you have to drink to have fun at a sporting event''
(Neuendorf 1985). More recently, it was found that television viewing was related to
initiation of drinking over an 18-month period (Robinson et al 1998) Each 1-hour
increase in television viewing at baseline was associated with a 9% increased risk for
initiating drinking during the following 18 months.
Music and music videos An analysis of music that is popular with youth found that
17% of lyrics across all of the genres contained references to alcohol (Roberts et al
1999). Alcohol was mentioned more frequently in rap music (47%) than in other
genres, such as country-western (13%), top 40 (12%), alternative rock (10%), and
heavy metal (3%). A common theme is getting intoxicated or high, although drinking
also is associated with wealth and luxury, sexual activity, and crime or violence. As
with television and film, consequences of drinking are mentioned in few songs and
antiuse messages occur rarely. Product placements or brand name mentions
occurred in approximately 30% of songs with alcohol mentions and are especially
common in rap music (48%). From 1979 to 1997, rap music song lyrics with
references to alcohol increased fivefold (from 8% to 44%); those exhibiting positive
attitudes rose from 43% to 73%; and brand name mentions increased from 46% to
71%(Herd 2005). There were also significant increases in songs mentioning
champagne and liquor (mainly expensive brand names) when comparing songs
released after 1994 with those from previous years. In addition, there were significant
increases in references to alcohol to signify glamour and wealth, and using alcohol
with drugs and for recreational purposes. The findings also showed that alcohol use
in rap music was much more likely to result in positive than negative consequences.
A similar pattern is found for music videos. DuRant et al (1997) found that rap music
videos contained the highest percentage of depictions of alcohol use, whereas
rhythm and blues videos showed the least alcohol use. Additionally, alcohol use was
found in a higher proportion of music videos that had any sexual content than in
videos that had no sexual content. Both the content, which has been shown to
glamourize the use of alcohol, and the advertisements surrounding the music videos
have a potential to make drinking alcohol more enticing to young viewers.
Use of alcohol by adolescents has been associated with higher levels of music video
exposure (Robinson et al., 1998; Durant et al. 1997; Brown and Witherspoon 2002).
Robinson et al (1998) found a 31% increased risk of drinking initiation over 18
months for each 1-hour increase in watching music videos. Another study of the
effects of popular music videos on adolescent risk behaviour found a positive
association between exposure to rap music videos and an increased likelihood of
alcohol use among African American female adolescents (Wingood et al 2003).
Results of a 12-month follow-up showed that adolescents with a greater exposure to
rap music videos were 1.5 times more likely to have used alcohol than were
adolescents with less exposure to rap music videos. A Dutch study examined the
association between music video viewing and the amount of drinking in adolescents
(Van Den Bluck, & Beullens 2005). The results showed that the quantity of alcohol
consumed while going out in February 2004 was related to the adolescents' overall
TV viewing and their music video exposure a year earlier. Even after controlling for
gender, school year, and drinking in 2003, these results remained significant.
Films Content analyses indicate that alcohol is shown or consumed in most films.
Thus, 92% (185) of the 200 most popular US movies for 1996–1997 contained
images of drinking (Roberts et al 1999). Underage use of alcohol occurred in
approximately 9% of these films. In general, drinking was associated with wealth or
luxury in 34% of films that contained alcohol references and pro-use statements or
overt advocacy of use occurred in 20% of these films. Statements that advocated
against drinking appeared in only 9% of the films with alcohol references. In all, 57%
of films with alcohol references portrayed no consequences to the user at all. Similar
findings have emerged from other content analyses (Everett et al 1998). Surprisingly,
an analysis of children's animated feature films found that 47% of them depicted
alcohol or drinking (Thompson and Yokota 2001). None of these animated films
contained an overt health warning about alcohol use and good or neutral characters
accounted for most of the drinking portrayals.
In terms of images of drinkers, a content analysis of 100 films from 1940 to 1989
compared drinkers with non-drinkers; drinkers were depicted more positively than
non-drinkers (McIntosh et al 1999). Specifically, drinkers were rated as having a
higher socio-economic status, being more attractive, having more romantic and
sexual involvements, and being more aggressive than non-drinkers. These films,
however, presented negative consequences associated with drinking, such as death
and loss of loved ones, on an equal basis with positive consequences, such as
wealth and romance. A similar analysis of films produced from 1906 to 2001 found
alcohol use to be portrayed predominantly in a normalized fashion, compared with
demonized portrayals of illicit drugs, such as cannabis (Cape 2003).
Studies of the effects of exposure to depictions of drinking in films on youth are rare
Thompson (2005). In one study, college students were exposed to one of two
versions of A Star is Born; one depicted the negative consequences of drinking for
the lead character, whereas the other version had the negative consequences
deleted (Bahk 1997; 2001). Viewing the version that had deleted scenes led to more
favourable attitudes toward drinking and to stronger intentions to drink. In a similar
study, college students were exposed to a series of film clips that depicted negative
consequences of spirits consumption, positive consequences, or a control condition
with no drinking (Kulick and Rosenberg 2001). Results indicated that participants
who viewed the clips that showed positive consequences of drinking had significantly
higher positive alcohol expectancies compared with controls. The control group and
Effectiveness of policy the group that viewed the clips that showed negative consequences did not differ in
their intentions to drink spirits in the next week. Other research showed a positive
correlation between parental restrictions on non-childhood movies and a decreased
likelihood of adolescent drinking. Dalton et al (2002), for example, found that the
prevalence of drinking among middle school students was decreased as parental
restrictions that were placed on viewing films increased. The prevalence of having
tried alcohol was 46% for youth with no parental viewing restrictions, 16% for youth
with partial restrictions, and 4% for those with complete restrictions. These
prevalence rates held constant, even after controlling for other variables, such as
student and parenting characteristics.
Paid placements Paid placements of products in films, television, books, and video
games is another way to embed alcoholic beverages in the daily lives of young
people. Media placement decisions are the result of extensive market research and
the use of standard market research databases to assess the demographic profiles
of the audiences for various media vehicles, as well as the effectiveness of such
vehicles in delivering target audiences to firms interested in placing advertising in
them (Jernigan & O'Hara 2005).
Internet The rapid rise of information technology and, in particular, the Internet has
given manufacturers a new promotional opportunity. Sophisticated web sites have
been created using technology to produce interactive arenas with impressive
graphics and eye-catching animation. Research on alcohol portrayals on the Internet
has focused on youth access, exposure to alcohol marketing, and the potential
attractiveness of commercial alcohol web sites to youth. Research has not addressed
the content of non-commercial web sites that focus on alcohol products or drinking
cultures. Similarly, no study has addressed the potential effects on consumption by
youth of exposure to alcohol portrayals and promotion on the Internet. The Center for
Media Education (Quoted in Grube and Waiters 2005) found that commercial alcohol
web sites are easily accessible to youth, and often are accessed from search
engines through nonrelated key word searches for games, entertainment, music,
contests, and free screensavers. Content analyses of web sites that are registered to
large alcohol companies revealed that young drinkers are targeted through a
glorification of youth culture that offers humour, hip language, interactive games and
contests, audio downloads of rock music, and community-building chat rooms and
message boards. Overall, these sites were found to promote alcohol use. Only a
handful of them included any information on the harm done by alcohol.
Grass roots and viral Grass-roots level marketing has also increased during the
1990s through the use of technologies such as the Internet; the adoption of racial,
ethnic, and other holidays and celebrations and the expansion of sponsorship from
sporting events to popular music concerts as alcohol marketing opportunities
(McBride and Mosher, 1985:143; Alaniz and Wilkes, 1998), to events in which
alcohol is often a central part of the activities, thereby embedding products in young
people's lifestyles and daily practices (Aaker, 1996; Fleming and Zwiebach, 1999).
Viral marketing techniques are also popular to encourage users to bring their friends
to Internet sites, including features that permit users to send e-mail and mobile phone
text messages to friends (Cooke et al., 2002). Little research has been done to date
on the impact of such marketing on young people.
Sports sponsorship Commercial sponsorship has expanded greatly since the
1980's, led by the tobacco industry, but with the alcohol industry in second place
(Meenaghan 1991, Meerabeau et al 1991). As a result, alcohol sponsorship has
become common across the world in all the key areas of youth culture: music, sport,
dance, film and television (see Table 7.9).

Sponsorship brings a number of potential benefits to the sponsor. It can provide a
means of avoiding regulations on direct advertising (Meerabeau et al 1991). It is an
inexpensive form of advertising which can easily reach favoured market segments
(young men are both the keenest sports fans and the heaviest drinkers), and these
consumers are less critical of it than traditional forms of advertising. Further,
sponsorship of large international sports events can allow a company's brand to
cross borders into countries where direct alcohol marketing may be severely
restricted or even banned.
Table 7.9 Examples of alcohol sponsorship activity
Athinaiki Zithopiia Athens 2004 Olympic Games (Athenian Brewery S.A.) Steinlager UEFA Champion's League Football events and teams, and the Derby ‘Sex and the City' Olympic Games and the United States' three Olympic Training Centres (Van Komen 2000) Night-club events and linked radio shows which are branded as ‘The Smirnoff Experience' (http://www.smirnoffexperience.com/intro.htm) Source: Cooke et al (2002)
Research on the effects of sponsorship is limited, and much more is needed.
Sponsorship produces higher levels of awareness than advertising amongst both
users and non-users of the brand being examined (Hoek et al 1997). For non-
drinkers aged 12-13 years, exposure to beer concession stands at sporting events
displays is predictive of drinking onset by age 14-15 years (Ellickson et al 2005).
Further, attendance at family entertainment venues associated with sporting events
is predictive of alcohol consumption amongst 12-13 year olds (Thomsen et al 2004).
Changing expectancies, beliefs, and attitudes
Social norms
reflect one's beliefs about both the normality and appropriateness of
particular beliefs and behaviours and, as a result, often create pressure to conform
and behave in a particular way (Aas & Klepp 1992; Austin & Johnson 1997a; 1997b;
Austin & Knaus 2000; Austin & Meili 1994; Austin & Nach-Ferguson 1995; Thomsen
& Rekve 2004). In most cases, this pressure is internal and reflects what we think
others will expect of us in particular situations. As suggested by social cognitive
theory, social norms are often learned through observation and vicarious
Effectiveness of policy experiences. Teenagers, for example, who see other teenagers drink – on television
or in a real-life setting – may come to believe that all teenagers drink, in turn creating
pressure to conform to this normative standard (Aas & Klepp 1992). The problem is
that teenagers tend to overestimate the frequency of drinking by other teenagers,
thus creating beliefs and related pressures that are not consistent with reality (Aas &
Klepp 1992).
For children and adolescents who have not yet begun to drink, expectancies are
influenced by normative assumptions about teenage drinking as well as through the
observation of drinking by parents, peers, and models in the mass media (Aas 1993;
Ary & Tildesley & Hops & Andrews 1993; Cumsille & Sayer & Graham 2000; Curran
& Stice & Chassin 1997; Grube & Wallack 1994; Jackson & Henriksen & Dickinson
1999; Webb & Baer & Getz & McKelvey 1996). A growing body of research has
linked exposure to portrayals of alcohol use in the mass media with the development
of positive drinking expectancies by children and adolescents (Andsager & Austin &
Pinkleton 2002; Austin & Johnson 1997a; 1997b; Austin & Knaus 2000; Austin &
Meili 1994; Aitken 1989; Aitken & Eadie & Leathar & McNeill & Scott 1988; Austin &
Knaus 2000; Austin & Meili 1994; Austin & Nach-Ferguson 1995; Austin & Pinkleton
& Fujioka 2000; Dunn & Yniguez 1999; Grube & Wallack 1994; Kelly & Edwards
1988; Kotch & Coulter & Lipsitz 1986; Martin et al. 2002; Hill & Caswell 2001).
Many studies suggest that portrayals of incidental drinking in entertainment media
and messages and images in advertising influence beliefs and behaviours in those
who are under the legal drinking age (Aitken 1989; Atkin 1990; Connolly & Casswell
& Zhang & Silva 1994; Jones & Donovan 2001; Martin et al. 2002; Waiters & Treno &
Grube 2001; Wyllie & Zhang, & Caswell 1998). Positive alcohol expectancies, in turn,
have also been linked to current adolescent alcohol use (Aas 1993 & Aas & Klepp &
Laberg & Aarø 1995; Aas & Leigh Anderssen, & Jacobsen 1998; Austin & Johnson
1997a; 1997b; Brown et al. 1987; Connelly et al. 1994; Grube & Wallack 1994; Kotch
et al. 1986). Some of these studies, however, have been criticized in that they have
not provided sufficient empirical support to assert a causal link between media
exposure and attitudes and behaviours (Kohn & Smart 1984; Smart 1988), and also
because some have reported very small effect sizes (Beccaria 2001; Grimm 2002;
Nelson 1999; Strickland 1983).
Content analysis suggest that many alcohol advertisements link drinking with valued
personal attributes (e.g., sociability, elegance, physical attractiveness) and with
desirable outcomes (e.g., success, relaxation, romance, adventure) (Strickland et al
1982). In general, children and adolescents find alcohol advertising with celebrity
endorsers, humour, animation, and popular music to be particularly appealing (Chen
and Grube 2002; Atkin and Block 1983). Adolescent boys are especially attracted to
alcohol advertisements that depict sports (Slater et al 1996; 1997).
One relatively large study looked into connections between children's awareness of
alcohol advertising and their knowledge and beliefs about drinking (Grube 1995;
Grube and Wallack 1994). The students' awareness of alcohol advertising was
ascertained through presentations of a series of still photographs taken from
television commercials for beer, with all references to the product or brand deleted.
The children were asked if they had seen each advertisement and, if so, to identify
the product being advertised. Children who were more aware of advertising had
increased knowledge of beer brands and slogans as well as more positive beliefs
about drinking, which was maintained with statistical accounting for the possibility
that prior beliefs and knowledge could affect the children's awareness of the
advertising.
Thus, a recent study found that young people with more positive affective
responses
to alcohol advertising held more favourable drinking expectancies,
perceived greater social approval for drinking, believed drinking was more common
among peers and adults, intended to drink more as adults, and drank with higher
frequency and in greater quantities (Chen and Grube 2002). These results were
maintained, even though the reciprocal effects of alcohol consumption, intentions,
and beliefs on positive affect toward alcohol advertising were controlled statistically.

Amongst 15 to 20 year olds, alcohol advertising is influential in shaping young
people's attitudes and perceptions about alcohol advertising messages, which are in
turn predictive of both positive expectancies and intentions to drink, suggesting that
the effects of alcohol advertising on intentions to drink are mediated by cognitive
responses to advertising messages and positive expectancies (Fleming et al 2004).
Fourteen year olds with greater exposure to advertisements in magazines, at
sporting and music events and on television are more advertisement aware than
those with less exposure, as were teens who watch more TV, pay attention to beer
advertisements and know adults who drink (Collins et al 2003). Amongst 10-17 year
olds, the perceived likeability of beer advertisements is a function of the positive
affective responses evoked by the specific elements featured in the advertisements.
Liking of specific elements featured in beer advertisements significantly contributed
to the overall likeability of these advertisements and subsequently to advertising
effectiveness indicated by purchase intent of product and brand promoted by these
advertisements (Chen et al 2005).

Changing behaviour
The impact of alcohol advertisements in changing behaviour can be measured by
both consumer studies and population based (largely econometric) studies.
Consumer studies
The impact that advertising can have on young people's
behaviour is well illustrated by smoking, where it has been accepted that advertising
is associated with cigarette use. A systematic review of nine longitudinal studies that
followed up a total of over 12,000 baseline non-smokers found that exposure to
tobacco advertising and promotion was associated with the likelihood that
adolescents will start to smoke (Lovato et al 2003). Based on the strength of this
association, the consistency of findings across numerous observational studies, the
temporality of exposure and smoking behaviours observed, as well as the theoretical
plausibility regarding the impact of advertising, the review concluded that tobacco
advertising and promotion increases the likelihood that adolescents will start to
smoke.
Effectiveness of policy Heavy drinking when it is not there
The importance of how young people perceive advertisements is illustrated by a study in which three groups of US college students (two-thirds of whom were aged 20 years or below) were exposed to the same set of two beer advertisements (Proctor et al 2005). In these advertisements, the codes stipulate that the actors are not to be younger than 25 years of age and are not supposed to appear to be younger than 21 years of age. The results showed that while all actors were perceived to be, on average, older than the legal purchase age (21 years), the actors in one of the advertisements appeared younger than the minimum (real) age requirement of 25 years. All characters in the advertisements were perceived as attractive, with the female character being rated the highest. Although neither of the commercials depicted the physical act of drinking, the student raters nevertheless perceived the characters to be binge drinkers, in one advertisement perceived as consuming more than 5 drinks on normal occasions and more than 10 drinks on celebratory occasions. These data suggest that the information content of some advertisements, reflected perhaps in the actors' behaviour, appearance, language and situational context, conveys the message t that the characters are heavy episodic drinkers, something that is not easily captured by advertising codes.

Similar results have been found for food preferences, where a systematic review
found: reasonably strong evidence, from 14 studies, that exposure to food promotion
influences children's food preferences; strong and consistent evidence, from 7
studies, that exposure to food promotion influences children's purchasing and
purchase-related behaviour; modest evidence, from 11 studies, that exposure to food
promotion influences children's food consumption behaviour; evidence from 6 studies
of a significant relationship between television viewing and diet, obesity and
cholesterol; evidence from one study that greater exposure to food adverts was
associated with higher snacking and calorific consumption; evidence, from 8 studies,
that food promotion exerts an influence on children's food behaviour and diet
independently of other influences such as parents' behaviour or price; and,
importantly, evidence, from 13 studies that food promotion influences children's
brand preferences and their category preferences (Hastings et al 2003).

Early survey research of children and adolescents, provided some evidence of links
between alcohol advertising and a greater likelihood of drinking (Aitken et al. 1988;
Atkin and Block 1980; Atkin et al. 1983, 1984; Austin and Meili 1994; Austin and
Nach-Ferguson 1995; Grube 1995; Grube and Wallack 1994; Wyllie et al. 1998a,b).
The effects were small, however, and a few studies found no significant relationships
(Adlaf and Kohn 1989; Strickland 1982, 1983). Further, the survey study designs
were unable to establish whether, for example, the advertisements caused the
behaviours, or whether pre-existing behaviours led to an increased awareness of the
advertisements.
A number of studies have attempted to find out whether children and adolescents
who like alcohol advertisements have different drinking behaviours than those who
do not like the advertisements. In one study of 213 children aged 7 to 12 years, the
more the children liked alcohol advertisements, the more likely they were to have
experimented with alcohol (Austin and Nach-Ferguson 1995).

New Zealand studies
One New Zealand study that tracked a random sample of 677
teenagers over several years found that young men who, at age 15 years, could
recall more alcohol commercials (mostly beer advertisements) drank greater
quantities of beer when they were 18 than did those who could recall fewer
commercials at age 15 (Connolly et al. 1994). However, opposite results were found
for women.
A more recent study of 500 New Zealand children aged between 10 and 17 years
found that the degree to which the children liked a set of beer advertisements
influenced how much they expected to drink at age 20 years (Wyllie et al. 1998a).
Statistical analysis concluded that, while liking alcohol advertising influences current
drinking status and intentions, the reverse does not seem to be true. In a similar
study of an older age group, stronger results were reported in 1,012 randomly
selected 18- to 29-year-olds (Wyllie et al. 1998b). In this case, the more the
respondents liked the alcohol advertisements, the more likely they were to drink at
greater rates and to agree with positive belief statements such as "Drinking is a good
way to escape from the hassles of everyday life." Most important, the more they liked
the advertisements, the more they reported drinking problems such as getting into a
physical fight because of drinking. Statistical modelling concluded that alcohol
advertising and responses to alcohol advertising influence drinking beliefs,
behaviours, and problems rather than the other way around.

US studies
In 1998, the US National Institute on Alcohol Abuse and Alcoholism
funded three longitudinal studies. Ellickson et al. (2005) followed over 3,000 13–15-
year-olds for three years. Comparing drinkers and non-drinkers at baseline, they
found that exposure to in-store beer displays predicted drinking onset for non-
drinkers after 2 years, and exposure to advertising in magazines and beer
concession stands at sports or music events predicted frequency of drinking after two
years. They found no significant predictive effect of exposure to television advertising
for either drinkers or non-drinkers. However, Stacy et al. (2004) did find effects for
television advertising. They began with a cohort of 2,250 12–13-year-olds and, using
a combination of exposure and recall variables, found that an increase in viewing
television programmes containing alcohol commercials was associated with a 44%
increased risk of beer use, a 34% increased risk of wine or liquor use and a 26%
increased risk of engaging in three-drink episodes a year later. Finally, the third study
that used longitudinal data showed that market-level alcohol advertising expenditures
were related positively to self-reported exposure to alcohol advertising and to
individual-level alcohol consumption among youth and young adults, although the
effects were small (Snyder et al 2002).
Population studies
There have been mixed findings from population based studies, Table 7.10 (see
Calfee and Scheraga 1994; Saffer 1995, 1996). A UK study suggested that a 1-
percent decrease in alcohol advertising would be associated, at most, with a 0.1-
percent decrease in consumption (Godfrey 1994). U.S. data from 1970 through 1990
has also been analyzed to investigate changes in per capita consumption as a
function of changes in advertising. Although the years with higher total wine and
spirits advertising had higher relative levels of consumption, a model that accounted
for changes over time found no evidence that changes in advertising were related to
changes in consumption (Fisher and Cook 1995). The results did indicate that
increased advertising of spirits was linked to a drop in the market share for wine,
suggesting that such advertising may realign market share.
Effectiveness of policy
Table 7.10 Results of econometric studies of advertising on alcohol use and harm variables
TIME SERIES
STUDIES
Blake and Nied (1997)
Small positive effect
of advertising

Bourgeois and Barnes No effect of
advertising
Calfee and Scheraga No effect of
Netherlands Sweden advertising
No effect of
advertising

1963-1985 quarterly No effect of
advertising

1963-1988 quarterly No effect of
advertising

1964-1996 quarterly No effect of
advertising

Franke and Wilcox 1964-1984 quarterly Small positive effect
of beer and wine
advertising

Grabowski (1976) No effect of
advertising

Lee and Trembley No effect of
advertising
McGuiness (1980) Small positive effect
of spirits advertising

McGuiness (1983) Small positive effect
of beer advertising

No effect of
advertising

Nelson and Moran No effect of
advertising
Selvanathan (1989) Small positive effect
of beer advertising

STUDIES
Goel and Morey (1995) US
Positive effect of
advertising

1986-1989 quarterly Positive effect of
advertising

BAN STUDIES
Interrupted Time
Series
Makowsky and
No effect of
Whitehead (1991) advertising
Ogborne and Smart No effect of
advertising
Smart and Cutler British Columbia No effect of
advertising
Ornstein and Hanssens Positive effect of
price advertising
Negative effect of
bans

Nelson and Young Positive effect of bans
(2001) Saffer and Dave (2002) OECD Negative effect of
bans

Source: Saffer and Dave (2003). Later studies have suggested significant effects of alcohol advertising on alcohol-
related problems (Saffer 1991, 1997; Saffer & Dave 2004). Countries with partial
restrictions had 16% lower alcohol consumption rates and 10% lower motor vehicle
fatality rates than did countries with no restrictions, and countries with complete bans
on television alcohol advertisements had 11% lower consumption rates and 23%
lower motor vehicle fatalities rates than did countries with partial restrictions (Saffer
1991, 1993b). After accounting for regional price differences and population variables
such as income and religion, increases in alcohol advertising were found to be
significantly related to increases in total and night time vehicle fatalities across US
states (Saffer 1997). It was estimated that a total ban on alcohol advertising might
reduce motor vehicle fatalities by as much as 5,000 to 10,000 lives per year.
Amongst US 12 to 16 years, the elasticity of advertising expenditure with respect to
past month alcohol use was estimated at about 0.08 and with respect to past month
binge participation at about 0.14 (Saffer and Dave 2003). The data suggested that
the compete elimination of alcohol advertising could reduce adolescent monthly
alcohol use by about 24% and binge participation by about 42%. The size of the
effect was similar to a doubling of the price of alcohol, which was estimated to reduce
adolescent monthly alcohol use by 28%, and binge drinking by 51%.
Econometric studies of the impact of advertising have a number of weaknesses
that stem from the fact that they are dependent on the construction of complex
equations to model an extremely sophisticated social phenomenon (Smart 1988;
Godfrey 1989; Harrison and Godfrey 1989; Saffer 1996): data on key variables, most
notably advertising expenditure, are often missing; advertising spending is assumed
to be an accurate marker of advertising effectiveness, whereas content is also
important (Strickland 1982); models do not account for consumers active involvement
in the communication process (Casswell 1995), leading to more effective
advertisements (Casswell and Zhang 1998); complications such as feedback, the
potential reciprocity of advertising and consumption levels, and advertising wear-out
are frequently ignored; and they focus
on advertising and ignore the integrated
nature of marketing.
Not surprisingly, therefore, other
studies have concluded that a total ban
on broadcast alcohol advertising has no
measurable effects on alcohol
consumption, probably and largely due
to substitution effects (Nelson 2003).
A physiological basis for marketing
Cue reactivity studies in alcohol-
dependent adults have shown atypical
physiological, cognitive, and neural
responses to alcohol-related stimuli that Figure 7.6 Blood oxygen level-
differ from the responses of light drinkers. dependent response signal contrast
Adolescents aged 14 to 17 years with in the right precuneus/posterior
alcohol use disorders showed substantially
cingulated region during exposure greater brain activation to alcoholic to alcoholic beverage pictures relative to non-alcoholic beverage beverage pictures than control youths, pictures plotted as a function of predominantly in brain areas linked to drinks consumed per month for reward, desire, positive affect (Tapert et al adolescents with alcohol use 2003). The degree of brain response to the disorders. Source: Tapert et al alcohol pictures was highest in youths who Effectiveness of policy consumed more drinks per month and reported greater desires to drink, Figure 7.6.


Self-regulation of alcohol marketing
Regulation has three components: legislation (defining appropriate rules);
enforcement (initiating actions against violators); and adjudication (deciding whether
a violation has taken place and imposing an appropriate sanction) (Swire 1997). The
term ‘self-regulation' means that the industry rather than the government is doing
the regulation. However, it is not necessarily the case that government involvement is
entirely lacking. Instead of taking over all three components of regulation, industry
may be involved in only one or two. For example, an industry may be involved at the
legislation stage by developing a code of practice, while leaving enforcement to the
government, or the government may establish regulations, but delegate enforcement
to the private sector. Sometimes government will mandate that an industry adopt and
enforce a code of self-regulation. Frequently an industry will engage in self-regulation
in an attempt to stave off government regulation. Alternatively, self-regulation may be
undertaken to implement or supplement legislation (Kuitenbrower 1997). The term
‘co-regulation' is sometimes used when the rules are developed, administered and
enforced by a combination of government agencies and industry bodies (see Caswell
and Maxwell 2005). In the United Kingdom for example, broadcast advertising is co-
regulated by Ofcom, the statutory body overseeing content and structure of the
communications sector with responsibility for auditing, and the industry body, the
Advertising Standards Authority, which has become a ‘‘one-stop shop'' for all
advertising standards and consumer complaints.
The claimed advantages of self-regulation over governmental regulation include
efficiency, increased flexibility, increased incentives for compliance, and reduced
cost. For example, it is argued that industry participants are likely to have superior
knowledge of the subject compared to a government agency (Michael 1995). This
factor may be particularly important where technical knowledge is needed to develop
appropriate rules and determine whether they have been violated. Second, it is
argued that self-regulation is more flexible than government regulation (Michael
1995). It is easier for a trade association to modify rules in response to changing
circumstances than for a government agency to amend its rules. Moreover, self-
regulation can be more tailored to the particular industry than government regulation.
Another argument in support of self-regulation is that it provides greater incentives for
compliance (Swire 1997). It is thought that if rules are developed by the industry,
industry participants are more likely to perceive them as reasonable. Companies may
be more willing to comply with rules developed by their peers rather than those
coming from the outside. Fourth, it is argued that self-regulation is less costly to the
government because it shifts the cost of developing and enforcing rules to the
industry (Campbell 1999).
Critics of self-regulation question the basis for the arguments in favour of self-
regulation. For example, while acknowledging that industry may possess greater
technical expertise than government, it has been questioned whether companies will
use that expertise to the benefit of the public, suggesting instead that they are more
likely to employ their expertise to maximize the industry's profits (Swire 1997).
Similarly, the idea that industry will comply more willingly with its own regulations
than those imposed from the outside might seem somewhat weak where industry is
actively involved in developing regulations. Leaving regulation to the industry can
create the possibility that industry may subvert regulatory goals to its own business
goals (Baker & Miller 1997). Self-regulatory groups may be more subject to industry
pressure than government agencies. Moreover, the private nature of self regulation
may fail to give adequate attention to the needs of the public or the views of affected
parties outside the industry. Many question the adequacy of enforcement in self-
regulatory regimes, recognizing that industry may be unwilling to commit the
resources needed for vigorous self-enforcement (Balkam 1997). It is also unclear
whether industry has the power to enforce adequate sanctions. At most, a trade
association may punish non-compliance with expulsion. Whether expulsion is an
effective deterrent depends on whether the benefits of membership are important
(Perrit 1997). Where a company can make greater profit by ignoring self-regulation
than complying, it is likely to do so, especially where non-compliance is not easily
detected by the consumer or likely to harm the particular company's reputation (Swire
1997).
Codes of content typically include commitments not to couple alcohol with social
and sexual success, and not to show intoxication or link alcohol with younger people
or with driving. Research has consistently shown that the interpretation of these
provisions varies depending on whether the review is being conducted by an industry
appointed body, representatives of the public or the specific target audience involved.
For example, an Australian study reported that representatives of the general public
found a large sample of advertisements in violation of the relevant voluntary code,
while the industry review board did not (Saunders and Yap 1991). As noted above,
the content of contemporary marketing is increasingly sophisticated, subtle and
interactive. This presents an increased challenge for monitoring and control of
content. Brown (1995) identifies increasing use of post-modern elements in modern
advertising – scepticism, subversiveness, irony, anarchy, playfulness and paradox.
The fact that viewers are ‘‘active recipients'' of advertising creates another major
difficulty for the application of codes of content. Advertising messages are received
and understood in the context of the recipients' lived experience. For example,
advertisements that contain cues to indicate intoxication, without expressly showing
it, can reinforce the norms supportive of heavy drinking. Research has documented
that young people interpret advertisements as indicating drinking to intoxication
(Wyllie et al 1997; 1998) but these advertisements would not necessarily be
perceived as such by all viewers. Similarly, while many codes restrict the use of
young people in advertisements, having them present is not necessary for an
advertisement to be appealing to under-age drinkers – it is enough to show the
lifestyles to which young adults aspire (Hill and Caswell 2001). Thus, much alcohol
marketing is likely to be effective in appealing to underage young people without
violating the codes
US self-regulation
An example of the fragility of self-regulatory systems comes from
the advertising of spirits on US television, as reported by Campbell (1999): "The
broadcast advertising of spirits was prohibited by the "Code of Good Practice" of the
Distilled Spirits Council of the United States (DISCUS 1995), the national trade
association of producers and marketers of distilled spirits. In March 1996, Seagram,
the second largest marketer of distilled spirits, violated the Code of Practice by airing
a spirits advertisement on a small sports cable network. A few months later, it
violated the ban again by airing an advertisement on an ABC affiliate in Corpus
Christi, Texas. Instead of imposing sanctions, however, DISCUS voted in November
1996 to repeal the voluntary prohibition (see Campbell 1999). According to DISCUS's
President, the association saw no basis for allowing the broadcast advertising of beer
and wine and not other alcoholic beverages. The members of DISCUS were
undoubtedly aware of the Supreme Court's decision in 44 Liquormart, Inc. v. Rhode
Island announced in May 1996, which struck down a state law prohibiting the
advertisement of spirits prices. This decision effectively removed the credible threat
of government regulation. Although DISCUS repealed the ban on broadcast
advertising, other provisions of the DISCUS Code of Practice remained in effect. For
example, the Code cautioned that distilled spirits should be portrayed ‘in a

Effectiveness of policy responsible manner' and ‘should not be advertised or marketed in any manner
directed or primarily intended to appeal to persons below the legal purchase age
.'"
The Federal Trade Commission (FTC) (1999) questioned the efficacy of self-
regulatory provisions. In August 1998, the FTC began an inquiry into the advertising
practices of eight of the nation's top marketers of beer, wine, and spirits. It
specifically sought information about how the companies had implemented Code
provisions that prohibited advertising intended to appeal to or reach persons below
the legal drinking age. At the same time, the FTC (1998) filed a complaint against a
beer advertisement that depicted young adults partying and drinking beer on a sail
boat were "unfair acts or practices" in violation of section 5(a) of the Federal Trade
Commission Act. The complaint noted that the advertisements were inconsistent with
the Beer Institute's Code because they portrayed boating passengers drinking beer
"while engaged in activities that require a high degree of alertness and coordination
to avoid falling overboard." These recent actions by the FTC suggest that the self-
regulatory codes of the alcoholic beverages industry are not being effectively
enforced.

In 2003, the Federal Trade Commission commented that self-regulation practices ha
d improved since the 1999 Report, although it expressed concern "that unless care is
taken, alcohol advertisements targeted to young legal drinkers also may appeal to
those under the legal age
"; the reliability of its conclusions have been questioned
(Mosher and Johnsson 2005).
Australian self –regulation In its 2003 report, the National Committee for the
Review of Alcohol Advertising (NCRAA) found that approximately 5% of all
complaints received by the Advertising Standards Board (ASB) relate to alcohol
advertising. None of the 361 complaints about a total of 48 different alcohol
advertisements has been upheld.
Adjudicating advertisements in Australia

Between May 1998 and April 1999, 11 alcohol advertising complaints (relating to
9 separate advertisements) were lodged with the Advertising Standards Board
(ASB) by members of the general public. Marketing experts and advertising
students were asked, without knowing the ASB's rulings, to judge whether the
advertisement(s) breached any of the clauses of the Australian Association of
National Advertisers' Code of Ethics or Alcoholic Beverages Advertising Code
(Jones and Donovan 2002). A majority of the expert judges perceived breaches of
the Codes for seven of the nine advertisements. For all nine of the
advertisements, a majority of the university students felt that each of the ads was
in breach of one or more of the Codes of Practice. The ASB had ruled that none
of the ads breached any of the Codes.
The alcohol advertising code, the Alcohol Beverages Advertising Code (ABAC), was established by the alcohol beverage industry and deals with alcohol-specific advertising issues, such as appeal to young people and alcohol consumption being linked to sporting or sexual success. The industry has established an Adjudication Panel to hear complaints which fall under the ABAC Code. Since its establishment in 1998, the ABAC Adjudication Panel has heard a total of 20 complaints. Of this total, five were upheld and thirteen were dismissed. During its review, NCRAA concluded that the current system does not address public health concerns about alcohol
advertising and use. In particular: the general public is largely unaware of the
complaint resolution system and, in particular, how to make complaints; there is
insufficient reporting of how complaints are adjudicated and the outcomes of those
complaints; the current system does not apply to all forms of advertising, for example,
internet advertising and promotions; and the effectiveness of the current system is
compromised by the amount of time taken to resolve complaints.
Advertising controls

Summary
There is evidence that new product development is attractive to and readily
consumed by underage drinkers. Price promotions increase binge drinking and
exposure to point of purchase advertising predicts onset of youth drinking. There is
evidence for targeting of alcohol advertisements to underage drinkers, and
consistent evidence that exposure to television, music videos and sponsorship
which contain alcohol advertisements predicts onset of youth drinking and increased
drinking. Consumer studies have shown that alcohol advertisements lead to
positive expectancies and attitudes about alcohol. Consumer studies also show that
exposure to tobacco advertising increases smoking initiation amongst young
people, exposure to food advertising changes children's food consumption
behaviour
, and there is increasing evidence that exposure to alcohol advertisements
increase initiation of alcohol use amongst adolescents. Despite the difficulties of
population based studies, there is a range of evidence with some econometric
studies
finding a relationship between the volume of advertising and drinking
behaviour and outcomes, and others not. There is some evidence that advertising
affects brain activity linked to rewards and desires. In conclusion, restricting the
volume of commercial communications of alcohol products is likely to reduce harm,
Table 7.11. Since advertisements have a particular impact in promoting a more
positive attitude to drinking amongst young people, and, even in advertisements that
do not portray drinking of alcohol, young people perceive the characters as heavy
drinkers, it is likely that restricting the content of advertisements will reduce harm,
although this has not been specifically evaluated. To date, self-regulation of
commercial communications by the beverage alcohol industry does not have a good
track record for being effective.

Table 7.11
Effectiveness ratings for advertising controls
Effectiveness1
Reducing the volume of advertising Advertising content controls 1For definitions see Table 7.1
Source: Babor et al (2003) (modified).
Impact and costs
The World Health Organization's CHOICE modelled the impact of advertising
controls based on a 2%-4% reduction in the incidence of hazardous alcohol use,
derived from international time-series analyses of the impact of an advertising ban
(Grube and Agostinelli, 2000; Saffer, 2000; Saffer and Dave, 2002). Although not
politically acceptable in contemporary Europe, were an advertising ban to be
implemented throughout the Union, the model estimated that it can prevent between
Effectiveness of policy 300 (EuroB countries) and 616 (EuroC countries) DALYs per million people per year,
at a cost of between €12 (EuroC countries) and €23 (EuroA countries) per 100
people per year (see Figures 7.11 and 7.12 at the end of the chapter). The model
estimated than a ban on advertising implemented throughout the Union, can prevent
202,000 years of disability and premature death, at an estimated cost of €95 million
each year (adapted from Chisholm et al 2004).

POLICIES THAT REDUCE HARM IN DRINKING AND SURROUNDING
ENVIRONMENTS

Licensed drinking environments

Licensed drinking environments are associated with drunkenness (Snow and
Landrum 1986), drink-driving (Fahrenkrug and Rehm 1994; Gruenewald et al. 1996;
O'Donnell 1985; Single and McKenzie 1992) and problem behaviours such as
aggression and violence (Ireland and Thommeny 1993; Rossow 1996; Stockwell et
al. 1993), with some licensed premises being associated with a disproportionate
amount of harm (Sherman 1992; Stockwell 1997; Briscoe & Donnelly, 2003a).
Aspects of the bar environment that increase the likelihood of alcohol-related
problems (Graham and Homel 1997), include serving practices that promote
intoxication, an aggressive approach taken to closing time by bar staff and local
police (Tomsen 1997), the inability of bar staff to manage problem behaviour (Homel
et al. 1992; Wells et al. 1998), general characteristics of the environment such as
crowding and permissiveness of bar staff (Homel and Clark 1994), the general type
of bar (Gruenewald et al. 1999; Stockwell et al. 1992), and physical comfort, the
degree of overall ‘permissiveness' in the bar, the availability of public transport, and
aspects of the ethnic mix of customers (Homel et al 2004).
Responsible beverage service Nearly all evaluations in training bar staff in
responsible beverage service when backed up with enforcement have demonstrated
improved knowledge and attitudes among participants (Graham 2000; Graham et al.
2002; Hauritz et al. 1998a; Homel et al. 1997), although this wears off over time
(Hauritz et al. 1998b). These studies have also shown some effects on serving
practices (Johnsson and Berglund 2003), but not always (Donnelly and Briscoe
2003). Whilst servers are usually willing to intervene with customers who are visibly
intoxicated (Gliksman et al. 1993), they generally will not intervene with individuals
solely on the basis of the customer's estimated blood alcohol concentration (BAC) or
number of drinks consumed (Howard-Pitney et al. 1991; Saltz and Stanghetta 1997;
Gliksman et al. 1993; McKnight 1991), In addition, training tends to decrease bad
serving practices such as "pushing" drinks and increase "soft" interventions such as
suggesting food or slowing service. In terms of the effects on customer intoxication,
several studies have found that server training results in lower BAC levels of
customers generally (Geller et al. 1987; Russ and Geller 1987) and fewer customers
with high BAC levels (Lang et al. 1998; Saltz 1987; Stockwell et al. 1993). Moreover,
time series analyses of mandatory server training suggest that training is associated
with fewer visibly intoxicated customers (Dresser 2000) and fewer single-vehicle
night-time injury-producing crashes (Holder and Wagenaar 1994). Studies of the
impact of adhering to bar policies for avoiding intoxication (Stockwell 2001) have also
found modest effects in reducing heavy consumption and high risk drinking (Howard-
Pitney et al. 1991; Lang et al. 1998; Wallin et al. 1999; Toomey et al. 2001), but not
as successful as originally expected (Stockwell 2001). Responsible beverage service
programs are frequently included in broad-based interventions (Homel et al., 2001)
that have shown reductions in violence, (Homel et al., 1997; Wallin et al 2003; Felson
et al., 1997; Putnam, Rockett & Campbell, 1993; Maguire et al., 2003).
Community action in holiday resorts
The goal of the Surfers Paradise project was to reduce violence and disorder associated with the high concentration of licensed establishments in the resort town of Surfers Paradise in Queensland, Australia (Homel et al. 1997). The project involved three major strategies: (1) the creation of a Community Forum including the development of task groups and a safety audit; (2) the implementation of risk assessments, Model House Policies, and a Code of Practice; (3) regulation of licensed premises by police and spirits licensing inspectors. This project and its replications in three North Queensland cities (Cairns, Townsville and Mackay) (Hauritz et al. 1998a) resulted in significant improvements in alcohol policy enforcement, in the bar environment, in bar staff practices, and in the frequency of violence. Following the intervention, the number of incidents per 100 hours of observation dropped from 9.8 at pre-test to 4.7 in Surfers Paradise and from 12.2 at pre-test to 3.0 in the replication sites. However, the initial impact of the project was not sustained. Two years following the intervention in Surfers Paradise, the rate had increased to 8.3, highlighting the need to find ways to maintain gains achieved from community action projects.
Active enforcement The impact of responsible beverage service is greatly
enhanced when there is active, but ongoing enforcement of laws prohibiting sale of
alcohol to intoxicated customers (Jeffs and Saunders 1983; McKnight and Streff
1994; Saltz & Stanghetta, 1997; Homel et al. 2001). Increasing the perceived risk of
apprehension for an offence can deter individuals from future violations of the law
(e.g. Homel, 1988; Nagin, 1998; Sherman et al., 1998). This is a cost effective
intervention in which the benefits greatly exceed the costs (Levy and Miller 1995).
Enforcement also seems to be a necessary component for voluntary codes of
responsible beverage service to be successful (Lang and Rumbold 1997; Homel et
al. 1997). One study found that a programme combining stricter enforcement of
alcohol sales laws and training in responsible beverage service had a significant
effect in reducing the rate of violent crimes between 10 pm and 6 am (Wallin et al.,
2003). There is some evidence that enforcement checks prevent alcohol sales to
minors (Wagenaar et al 2005), restricted to the specific establishments checked and
with limited diffusion to the whole community; most of the enforcement effect
decayed within three months, suggesting that a regular schedule of enforcement is
necessary to maintain deterrence. Further, there is some evidence that enforcement
activity focuses more on breaches committed by patrons or minors, rather than
licensees or vendors who are in breach of the intoxication provisions of the liquor
laws (Donnelly & Briscoe, 2003; Briscoe & Donnelly, 2003b).
Legal liability Holding servers legally liable for the consequences of providing more
alcohol to persons who are already intoxicated or those under age has shown
consistent benefits as a policy measure in the US (Holder et al. 1993; Sloan et al.
2000), with lower rates of traffic fatalities (Chaloupka et al. 1993; Ruhm 1996; Sloan
et al. 1994a; Wagenaar and Holder 1991) and homicide in states with such liability
(Sloan et al. 1994b), compared to states that do not have the liability. Such use of
legal liability is uncommon outside of the United States (with the exception of some
cases in Australia and Canada).
Geographical analysis (Wilson and Dufour 2000) can be used to identified specific
drinking localities and problems related to alcohol, particularly motor vehicle crashes,
Effectiveness of policy pedestrian injuries, and violence (Gruenewald et al 2002). This allows targeted public health and law enforcement approaches, as shown in Figure 7.7.
Figure 7.7 Illustration of the use of maps and mapping in alcohol policy. These tools can be
used to study the locations of alcohol outlets and alcohol-related problems. Figure A shows all
the alcohol outlets in a given geographic area. Outlets that sold alcohol to underage decoys
are shown in figure B, and assaults in figure C. Source: Gruenewald et al (2002).
Other harm reduction approaches The risks of aggression, violence and injury
(Stockwell, Lang & Rydon 1993) vary according to the physical bar-room
environment (Graham et al. 1980; Stockwell et al. 1993; Homel & Clark 1994) and
the behaviour and communication skills of bar staff (Hauritz et al. 1998a; Wells et al.
1998). Accordingly, interventions that focus on changing the barroom environment
(e.g. changes in rules or policies related to games, management of queues and re-
The Safer Bars programme
The Safer Bars program developed in Canada includes a risk assessment (Graham 1999) and a training component (Braun et al. 2000) for owners, managers and all staff. The program is designed to increase early intervention by staff, improve teamwork and staff abilities in managing problem behaviour, and reduce the risk of injury to patrons. The Safer Bars training has been shown to be highly valued by bar staff and managers and has demonstrated a significant impact on knowledge and attitudes (Graham et al. 2002). There was also a significant effect in reducing both moderate (e.g. pushing and holding) and severe (e.g. punching and kicking) aggression (Graham et al 2004). The effects were lessened when there was high turnover of managers and door and security staff. entry to the bar, modifications of the social or physical environment and improvement
in staff communication and intervention skills) have been shown to be effective in
reducing harms from drinking in these settings without necessarily altering overall
consumption levels (Homel et al. 1997; Graham et al. 2004; see also review by
Graham 2000).
Interventions focused on public transportation. Various studies using a variety of
methodologies have identified public transport availability as a key issue (d'Abbs,
Forner & Thomsen, 1994; Homel et al., 1997; Homel et al., 1991; Engineer et al.,
2003) moderating the incidence of alcohol-related violence around licensed
premises. Where there is a high concentration of licensed premises, a lack of public
transport has the effect of retaining large groups of intoxicated and frustrated people
in a small area. No direct evaluations of the impact of strategies to improve transport
have been identified, although such interventions have been part of larger multi-
component interventions that demonstrated reductions in violence (Homel et al.,
1997; Hauritz et al., 1998) as well as interventions that did not show a reduction in
violence (d'Abbs & Forner, 1995).

Safer drink containers. It is well-established that intentional and unintentional
injuries from broken drinking vessels are relatively common in licensed premises.
This relationship led to the logical suggestion that replacing conventional glass
vessels with tempered glass should reduce injuries. However, a randomised
controlled trial comparing conventional glassware with tempered (toughened)
glassware (Warburton & Shepherd, 2000) reported increased injuries to staff from
accidental breakage of tempered glassware. As yet, there is no research on the
impact of tempered glass on intentional injuries to patrons.
Reducing harm in drinking environments

Summary
There is growing evidence for the impact of strategies that alter the drinking context
in reducing the harm done by alcohol, Table 7.12. However, these strategies are
Effectiveness of policy primarily applicable to drinking in bars and restaurants, and their effectiveness relies
on adequate enforcement. Passing a minimum drinking age law, for instance, will
have little effect if it is not backed up with a credible threat to remove the licenses of
outlets that repeatedly sell to the under-aged. Such strategies are also more effective
when backed up by community based prevention programmes (see below).
Table 7.12 Effectiveness ratings for drinking environments
Effectiveness1
Responsible beverage service Active enforcement Server liability Enforcement of on-premise regulations Public transport environment/containers 1For definitions see Table 7.1
Source: Babor et al (2003) (modified).
Community mobilization approaches

Community based prevention programmes can be effective in reducing drinking and
driving, alcohol related traffic fatalities and assault injuries (Giesbrecht 2003;
Stockwell and Gruenewald 2001; Holmila 1997; Holder 1998; Hingson et al 2005;
Clapp et al 2005). Community mobilization has been used to raise awareness of
problems associated with on-premise drinking, develop specific solutions to
problems, and pressure bar owners to recognize that they have a responsibility to the
community in terms of such bar-related issues as noise level and customer behaviour
(Hauritz et al. 1998; Homel et al. 1992; Putnam et al. 1993). Evaluation results from
community mobilization approaches as well as documentation from grassroots
projects (Arnold and Laidler 1994; Cusenza 1997) suggest that community
mobilization can be successful at reducing aggression and other problems related to
drinking in licensed premises.
A review of ten community-based prevention trials which have sought to reduce harm
from alcohol (Aguirre-Molina & Gorman 1996; Chou et al. 1998; Douglas et al. 1990;
in press; Gliksman et al. 1995, 1999; Grube 1997; Hingson et al. 1996; Holder et al.
1997a, 2000; Holder & Treno 1997; Johnson et al. 1990; Pentz et al. 1989a; Perry et
al. 1993, 1996; Voas 1997; Wagenaar et al. 1994; 2000) found that strategies
included education and information campaigns, media advocacy, counter-advertising
and health promotion, controls on selling and consumption venues and other
regulations reduced access to alcohol, enhanced law enforcement and surveillance,
and community organizing and coalition development (Giesbrecht et al 2003).
Interventions which showed promise were those that paid particular attention to
controls on access, included the environmental contexts of where the products are
sold and distributed, and involved enforcement of public health polices (see also
(Holder, 1998a; Holder1998b).
Community and neighbourhood characteristics are important in moderating the pricing and promotion of beer (Harwood et al 2003), as well as reducing binge drinking (Nelson et al 2005). Communities with higher enforcement of minimum purchase ages have lower rates of alcohol use and binge drinking (Dent et al 2005). Community action projects can mobilize awareness and concern about alcohol-related harm (Allamani et al 1997; 2003; Holmila 2003). Social capital as measured by aggregate reports of student volunteerism is associated with a decreased risk of binge drinking, drunkenness and alcohol-related harm (Weitzman & Chen 2005), and as measured by high trust is related to a reduced risk of illegally produced and purchased alcohol (Lindstrom 2005). Since 1996, a multi-component program based on community mobilization, training in responsible beverage service for servers and stricter enforcement of existing alcohol laws has been conducted in Stockholm, Sweden, leading to a 29% reduction in violent crimes in the intervention area, compared with the control area (Wallin et al 2003), Figure 7.8. The Community Trials Project (Holder et al. 1997) was a five-component community-level intervention to reduce alcohol-related harm among all residents Figure 7.8 Police-reported violence in
of three communities. The project experimental area (filled circles) and in included a media and mobilization control area (triangles) component, a responsible beverage service component, a sales to youth component to reduce underage access to alcohol, a drinking and driving component, and an access component to reduce the availability of alcohol. The project led to reduction in drink driving accidents, assault injuries, and harmful alcohol use (Holder et al. 2000). Finally, cost-benefit analyses estimated that the trial resulted in savings of €2.9 for every €1 spent on program implementation based upon reductions in automobile crashes alone (Holder et al. 1997). A community intervention project in the Northern Territories in Australia aimed to reduce levels of alcohol consumption and related harm down to national levels by 2002 (d'Abbs 2004) by using a range of strategies including education, increased controls on alcohol availability, and expanded treatment and rehabilitation services (Stockwell et al . 2001; d'Abbs 2004). The Living With Alcohol (LWA) program was originally funded by a specific alcoholic beverage Levy on the sale of alcohol products with more than 3% alcohol by volume until 1997, when a federal ruling prohibited states and territories from raising licence fees and additional taxes on alcoholic beverages, tobacco and petrol. As a direct result, the LWA Levy was removed in August 1997 which in turn resulted in a fall in the real price of alcoholic beverages with more than 3% alcohol by volume (O'Reilly 1998). The Federal government continued to fund the LWA program at the same level until the year 2000. After this time, LWA funds were dispersed directly to the existing programs and services (d'Abbs 2004). The programme was effective in reducing acute (by 4.6 per 100,000 adults) and most likely chronic (by 3 per 100,000 adults) alcohol related deaths in the Northern Territories, Figures 7.9 and 7.10, compared with reductions of 1.6 per 100,000 acute and 1.7 per 100,000 chronic alcohol related deaths in the control area (Chikritzhs et al 2005). Effectiveness of policy
Figure 7.9 Trends in acute death rates per 10,000 adults in NT [W] and Control region [W]
1985-2002. Source: Chikritzhs et al (2005).

Figure 7.10 Trends in chronic death rates per 10,000 adults in NT [W] and Control region
[W]1985-2002. Source: Chikritzhs et al (2005).
Reducing harm through community mobilization

Summary
Community mobilization and intervention projects are effective in reducing the harm
done by alcohol, Table 7.13.
Table 7.13 Effectiveness ratings for community mobilization
Effectiveness1
Community mobilization 1For definitions see Table 7.1
Source: Babor et al (2003).
POLICIES THAT SUPPORT INTERVENTIONS FOR HAZARDOUS AND
HARMFUL ALCOHOL CONSUMPTION AND ALCOHOL DEPENDENCE

Whilst the management of alcohol problems has clear benefit at the level of the
individual, there is some limited evidence for its impact at the level of the population
(Smart & Mann 1993; Smart and Mann 2000; Smart et al. 1989; Smart & Mann 1990;
Mann et al. 1991). There is some evidence that declining liver cirrhosis rates might
be associated with the increased treatment for alcohol problems in Ontario, Canada
(Mann et al. 1988; Mann et al 2005), Sweden (Romelsjo 1987) and North Carolina
(Holder & Parker 1992).
The impact of home visiting
OIds et al. (1997; 1998; 1999) evaluated a program involving regular home visiting by a nurse from late pregnancy until the child's second birthday for low income, unmarried and adolescent women having their first babies. The program focused upon supporting the mother, promoting positive attachment with the child and teaching parenting skills. Follow-up associated the program with reduced rates of alcohol use for the mothers during pregnancy, leading to reductions in alcohol-related cognitive impairment in the children as pre-schoolers. The children have been followed up to age 15 years, documenting reductions in their early initiation of alcohol use. Social welfare based programmes Programs of structured home visits to support
mothers, before and in the first two years after birth, have evidence supporting their
effectiveness and cost effectiveness when targeted to vulnerable families (Mitchell et
al 2001; Loxley et al 2004). These programs offer basic advice, practical assistance
with nursing, and advocacy for access to services. They show evidence of positive
outcomes for maternal alcohol use and infant health.
There is evidence for the value of both universal and selective parenting programs
for pre-primary school age children to reduce child behaviour problems that predict
the emergence of harmful alcohol use (Serketich & Dumas 1995). There is evidence
for positive outcomes (school adjustment and academic attainment) and good cost-
benefit ratios from targeted programs to prepare children from high-risk families for
primary school. Outcomes from these studies have been documented by following
children through to adolescence, and have found reduced alcohol use (Schweinhart
et al 1993).
Effectiveness of policy The importance of pre-school
The Perry pre-school project in the United States found long-term program effects up to age 27, including a lower incidence of alcohol use and teenage pregnancy, lower risk of school drop out, increased likelihood of employment and reduced reliance on welfare (Schweinhart et al 1993). Cost benefit analyses suggested savings of up to €6 for every €1 invested in the programme for a one year programme.
Interventions to reduce alcohol use during pregnancy Of three good-quality
behavioural counselling interventions in primary care settings that targeted pregnant
women making prenatal visits, two found no evidence for an effect on alcohol
consumption (Handmaker et al 1999; Chang et al 1999) and one a possible effect
which just failed to reach statistical significance (Reynolds et al 1995). There is
evidence for the impact of home visits for women with harmful alcohol use during an
index pregnancy (Grant et al 2005); home visits that assisted women in obtaining
alcohol treatment and staying abstinent, and linking them with comprehensive
community resources led to improved attendance at treatment, better treatment
outcomes, and a greater likelihood of subsequent pregnancies being alcohol free.
Workplace The workplace provides several opportunities for implementing
prevention strategies, since the majority of adults are employed, spending a
significant proportion of their time at work. The workplace can also be a risk factor for
harmful alcohol use. A systematic review and meta-analysis of 485 studies with a
combined sample size of 267,995 individuals found that job dissatisfaction was a
powerful predictor for burnout, low self-esteem, depression, and anxiety (Faragher et
al 2005). Many studies have found significant associations between stress in the
workplace and elevated levels of alcohol consumption (Martin and Roman 1996;
Lehman et al 1995; Parker and Farmer 1990; Greenberg and Grunberg 1995), the
risk of problem drinking (Bobak et al 2005) and alcohol dependence (Head et al
2004), and between alienation (an employee's broader sense of identity and control)
and drinking behaviours (Seeman and Anderson 1983; Seeman et al. 1988; Lehman
et al 1995; Rospenda et al 2000).
A series of evaluation studies have indicated that the workplace programs succeeded
in returning substantial proportions of employees with alcohol problems to effective
performance (Asma et al. 1980; Edwards et al. 1973; McAllister 1993; Spickard and
Tucker 1984; Walsh et al. 1991, 1992; Blum and Roman 1995). Supervisory training
significantly increased positive attitudes toward workplace based employee
assistance programmes, increased the perceived likelihood of utilizing the service,
and led to greater service utilization. (Googins and Kurtz 1981; Hoffman and Roman
1984). A workplace prevention training programme for stress management has been
shown to reduce problem drinking from 20% to 11% and missing work because of a
hangover from 16% to 6% (Bennett et al 2004).

Brief interventions for hazardous and harmful alcohol use
Table 7.14, from the
Mesa Grande study, an ongoing updated systematic review of the effectiveness of
different treatments for hazardous and harmful alcohol consumption, ranks the
effectiveness of 48 different treatment modalities (Miller & Wilbourne 2002). Mesa
Grande summarizes the evidence after weighting the findings of studies by their
methodological quality score; the higher the score, the better is the quality of the
study. Study ratings also resulted in the assignment of an outcome logic score for
each treatment modality for which specific efficacy could be inferred from the design.
A positive outcome logic score is assigned when a study design permitted strong
inference of a specific effect (e.g. comparison of the treatment with an untreated
control), and a beneficial effect was reflected as a statistically significant difference. A
negative outcome logic score is assigned when a study has a design logic that
should clearly show a treatment effect if one were present (e.g. comparison with a
no-treatment or placebo control). The Cumulative Evidence Score (CES) is the
methodological quality score multiplied by the outcome logic score, summed across
all studies, with positive trials adding points and negative trials deducting points from
the total. Treatment modalities are listed in Table 7.14 ranked by the CES.
Table 7.14 Effectiveness of treatments for hazardous and harmful alcohol consumption
Treatment modality
26. Marital Therapy – Non- 30. Self-Monitoring (e.g.naltrexone) 33. Antidipsotropic - Calcium Social Skills Training 36. Treatment as Usual 37. Twelve Step Facilitation 11. Aversion Therapy, Nausea 41. Antidipsotropic 42. Antidepressant 15. Aversion Therapy, Apnoeic 43. Videotape Self Confrontation 45. Confrontational Counselling 18. Client-Centred 46. Psychotherapy 19. Aversion Therapy, Electrical 48. Education (tapes, lectures or 22. Antidipsotropic - Disulfiram 23. Antidepresssant - SSRI CES = Cumulative Evidence Score. N = Total number of studies evaluating this
Source: Miller and Wilbourne (2002)
Brief interventions head the list of evidence-based treatment methods. There is a
very large body of research evidence on alcohol brief interventions, including at least
56 controlled trials of effectiveness (Moyer et al., 2002). There have been at least 14
meta-analyses and/or systematic reviews, using somewhat different aims and
methods, of research on effectiveness of brief interventions (Bien, Tonigan & Miller,
1993; Freemantle et al., 1993; Kahan, Wilson & Becker, 1995; Wilk, Jensen &
Havighurst, 1997; Poikolainen, 1999; Irvin, Wyer and Gerson, 2000; Moyer et al.,
Effectiveness of policy 2002; D'Onofrio & Degutis 2002; Berglund, Thelander & Jonsson, 2003; Emmen et
al., 2004; Ballesteros et al., 2004a, 2004b; Whitlock et al. 2004; Cuijpers, Riper &
Lemmens, 2004; Bertholet et al., in press). All these have reached conclusions, in
one form or another, favouring the effectiveness of brief interventions in reducing
alcohol consumption to low-risk levels among hazardous and harmful drinkers. The
number needed to treat is about 8 for both hazardous and harmful alcohol
consumption and for alcohol-related harm (Anderson 2003). This means that 8
patients at risk need to be offered advice for one to benefit.
There is mixed evidence of longer-term effects of brief interventions. A trial based in
family medicine in Wisconsin, USA reported continuing benefits for alcohol use,
binge drinking episodes and frequency of excessive drinking among recipients of
brief intervention compared with controls 4 years after intervention (Fleming et al.,
2002). An Australian study reported that the benefits of receiving brief intervention
had disappeared after 10 years (Wutzke et al., 2002) and it was suggested that
booster sessions would be necessary to maintain the effect over Brief interventions
this period of time. The World Health Organization has modelled the impact and cost of providing primary care There is some evidence that brief based brief interventions to 25% of the at-risk interventions reduce alcohol-
population; applying this to the Union finds an related mortality (Cuijpers, Riper &
estimated 408,000 years of disability and Lemmens, 2004), albeit from a small premature death avoided at an estimated cost number of studies. Moyer et al. of €740 million each year. (2002) also reported that brief interventions were effective on a composite of various drinking-related outcomes, including measures of alcohol-
related problems. There is also direct evidence from an Australian study in general
practice that brief interventions are effective in reducing alcohol-related problems
among those who receive them (Richmond et al., 1995). In a controlled study of
mass screening and brief intervention with follow-up, for men in Malmo, Sweden,
there was a significant decline in hospital admissions and mortality in the treated
group over a four year follow-up period, an 80% reduction in absenteeism in the four
years following the study, a 60% reduction in total hospital days over five years, and
a 50% reduction in all cause mortality over six years, which was maintained at 10-16
years follow-up (Kristenson et al., 2002).
There has been considerable concern about the ability to engage health care
providers
in delivering brief intervention programmes (see Anderson et al 2003).
However, results from international trials (Anderson et al 2004; Funk et al 2005), and
a meta-analysis (Anderson et al 2004) have found that education and support
programmes are effective and cost effective in increasing the involvement of primary
care providers in delivering brief intervention programmes.
After brief interventions, behavioural skill training and pharmacotherapies dominate
the remainder of the top 10 list of treatment methods supported by controlled trials
(Table 7.14). It is also important to identify what has strong negative evidence for
effect (i.e. does not work). Here one finds methods such as twelve-step facilitation,
group psychotherapy, educational lectures and films, mandatory attendance at A.A.
meetings, and relatively unspecified general alcoholism counselling, often of a
confrontational nature.
Accident and emergency departments Brief interventions delivered in emergency
departments and trauma centres have been shown to be effective in reducing alcohol
consumption (D'Onofrio & Degutis, 2002; D'Onofrio et al., 1998; Longabaugh et al.,
2001; Gentilello et al., 1999; Spirito et al., 2004; Mello et al., 2005) and alcohol-
related harm (Monti et al., 1999; Gentilello et al., 1999; Longabaugh et al., 2001;
Mello et al., 2005). A systematic review of 23 studies found evidence for reduced
motor-vehicle crashes and related injuries, falls, suicide attempts, domestic violence,
assaults and child abuse, alcohol-related injuries and injury emergency visits,
hospitalizations and deaths, with reductions ranging from 27% to 65% (Dinh-Zarr et
al 2004).
Interventions for hazardous and harmful alcohol consumption and alcohol
dependence

Summary
There is extensive evidence for the impact of brief interventions, particularly in
primary care settings, in reducing harmful alcohol consumption, Table 7.15.
Table 7.15 Effectiveness ratings for interventions
Effectiveness1
Social welfare based programmes Pregnancy based programmes Work based programmes Brief interventions in primary care Brief interventions in accident and emergency departments 1For definitions see Table 7.1
Source: Babor et al (2003) (modified).

Impact and cost
In the CHOICE model brief interventions such as physician advice provided in
primary health care, which involve a small number of education sessions and
psychosocial counselling, were modelled to influence the prevalence of hazardous
drinking by increasing remission and reducing disability (Higgins-Biddle and Babor,
1996; Moyer et al., 2002; Babor et al., 2003), which would have the effect of shifting
the entire distribution of hazardous drinking downwards if applied to the total
population at risk (a reduction in overall prevalence of 35-50%, equivalent to a 14-
18% improvement in the rate of recovery over no treatment at all). The estimates
were adjusted for treatment adherence (70%) and target coverage in the population
(25% of hazardous drinkers). If implemented throughout the European Union, the
model estimated that a brief intervention programme reaching 25% of the at risk
population can prevent between 512 (EuroB countries) and 1056 (EuroC countries)
DALYs per million people per year, at a cost of between €26 (EuroB countries) and
€185 (EuroA countries) per 100 people per year (see Figures 7.11 and 7.12 at the
end of the chapter). The model estimated that the provision of primary care based
brief interventions to 25% of the at-risk population throughout the Union can prevent
an estimated 408,000 years of disability and premature death at an estimated cost of
€740 million each year (adapted from Chisholm et al 2004).


Effectiveness of policy COST EFFECTIVENESS OF DIFFERENT POLICY OPTIONS

A summary of the estimated impact of different interventions, (DALYs prevented per
million people per year) compared to a Europe with none of these policies is shown
in Figure 7.11, and the estimated costs (Euro per 100 people per year) in Figure
7.12, for the three regions of the European Union, based on the WHO classification,
Table 7.2.
Brief interventions Drink drive measures Current tax + 25% Figure 7.11 The impact of different policy options (DALYs prevented per million people per
year) in the three sub-regions of EU25. Source: Chisholm et al (2004) (adapted).
In all three regions, taxation (current tax levels with a 25% increase in tax, compared
to no tax) has the greatest impact in reducing the harm done by alcohol, followed by
brief interventions delivered by primary providers to 25% of the at risk population.
Brief interventions Drink drive measures Current tax + 25% t per 100 people per y Figure 7.12 The cost of different policy options (per 100 people per year (€)) in the three sub-
regions of EU25. Source: Chisholm et al (2004) (adapted).


The three regulatory measures, (taxation, restricted sales and advertising controls)
are the cheapest in terms of cost to implement, with drink driving measures and brief
interventions being the most expensive. Although brief interventions are the most
expensive to implement, it should be noted that within health service expenditure,
brief interventions for hazardous and harmful alcohol consumption are one of the
most cost effective of all health service interventions in leading to health gain
(Anderson et al 2005).
Cost effectiveness

Figures 7.13 to 7.15 show the cost effectiveness of the different interventions, singly
and in combination. The vertical axis (log scale) is the cost (€) per 100m people per
year and the horizontal axis (log scale) is the number of DALYs prevented per million
people per year. The blue diagonal lines (also on a log scale moving from right to left)
show the cost effectiveness in Euros per DALY prevented, ranging from €100 per
DALY (bottom right) to €10,000 per DALY (top left). So, for example, in Figure 7.13, it
is estimated that a policy setting the tax at the current level plus 25% (♦) at a cost of
€38 per 100 people per year could prevent 1576 DALYs per million people per year
with a cost effectiveness ratio of €241 per DALY prevented. It should be emphasized
that all the interventions for reducing hazardous and harmful alcohol use show a
highly favourable ratio of cost to effect. Each DALY averted by these efficient
strategies costs considerably less than average annual income per capita, a
threshold proposed by the Commission on Macroeconomics and Health for an
intervention to be considered very cost-effective (WHO, 2001, WHO 2002:108).
It is clear in all three sub-regions of the European Union, that taxation (½and ♦),
restricted access (+), and advertising bans (-) are the most cost-effective policy
options. But, it should also be noted that, compared with other health service
Effectiveness of policy interventions, brief interventions (♦) are also highly cost effective, with a cost effectiveness ratio of between €493 (EuroC countries) and €1959 (EuroA countries). Implementing all five options is also extraordinarily cheap, compared to the social cost of alcohol (see chapter 5). Compared with no programme at all, a programme that included brief physician advice, random breath testing, current taxation plus 25%, restricted access and an advertising ban (ƒ) would cost only €1.3 billion, and avert 1.4 million alcohol related DALYs a year. DALYs prevented per million people per year Figure 7.13 Cost effectiveness of different policy options for EU25 A countries (log scales).
Diagonal lines show cost effectiveness in € per DALY prevented. (Legend, see below).
Source: Chisholm et al (2004) (adapted).
A. Brief physician adv ice (25% cov erage)
F4. Brief advice+Tax
B. Random Breath Testing
F5. Tax+Ad Ban+Restrict access
C1. Current tax
F6. Brief advice+Tax+RBT
C2. Current tax + 25%
F7. Brief advice+Tax+Ad Ban
D. Restricted access (sales)
F8. Brief advice+Tax+Ad Ban+Restrict access
E. Adv ertising ban
F9. Brief advice+Tax+Ad Ban+RBT
F1. Brief advice+RBT
F10. Tax+Ad ban+Restrict access+RBT
F2. Tax+Ad Ban
F11. Brief advice+Tax+Ad ban+RBT+Restrict access
F3. Tax+RBT
DA LYs prevented per millio n peo ple per year DALYs prevented per mil ion people per year Figure 7.14 Cost effectiveness of different policy options for EU25 B countries (log scales).
Diagonal lines show cost effectiveness in € per DALY prevented. (Legend, see Figure 7.13).
Source: Chisholm et al (2004) (adapted).
DALYs prevented per mil ion people per year
Figure 7.15 Cost effectiveness of different policy options for EU25 C countries (log scales).
Diagonal lines show cost effectiveness in € per DALY prevented. (Legend, see Figure 7.13).
Source: Chisholm et al (2004) (adapted).
Effectiveness of policy CONCLUSION

There is a wealth of evidence to advise what alcohol policies and programmes work
and what do not work in reducing the harm done by alcohol. Although there is a
dominance of North American literature in testing the effectiveness of alcohol policy
options, nevertheless, the robustness of the evidence is strengthened by a
consistency of evidence over time and in different jurisdictions, countries and
cultures. What is particularly striking is that the policies that work are those that foster
a supportive environment in which individuals are enabled to make healthy choices.
Programmes and policies that are directed to the individual, such as school based
educational programmes are the least effective. This is not to say that such
programmes should be abandoned; rather, it is not a good use of scarce resources to
invest heavily in such programmes, recognizing at the same time that mass media
programmes have a particular role to play in reinforcing community awareness of the
problems created by alcohol use and to prepare the ground for specific interventions.
The exception to the lack of effectiveness of individually based programmes is where
problems or risk of problems is already occurring; there is strong evidence that brief
interventions based in health care settings for individuals with existing hazardous and
harmful alcohol consumption are effective in reducing the harm done by alcohol.
What is also clear is that both enforcement and comprehensive approaches are
important. For example, the impact of responsible beverage service is much
enhanced when there is active enforcement and the support of community based
prevention programmes.
The other striking conclusion is that alcohol policy is not only effective, but it is also
cheap. Compared with no programme at all, a comprehensive programme that is
modelled to reduce the burden of alcohol to the Union by nearly one third would only
cost the governments of the Union as a whole an estimated €1.3 billion a year, about
1% of the total tangible costs of alcohol to society and only about 10% of an estimate
of the income gained from a 10% rise in the price of alcohol due to taxes in the EU15
countries.
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Source: http://www.ave.ee/download/Chapter_7.pdf

Method-sheet-decentralized_s3

Important note for reporting results (for professional users). Um die Grenze zwischen dem ganzzahligen Teil und dem gebrochenen Teil einer Zahl anzugeben, wird in diesem According to the regulations from the German Medical Association for quality assurance of medical laboratory analyses Die Teststreifen sind gebrauchsfertig. Methodenblatt immer ein Punkt als Dezimaltrennzeichen verwendet. Tausendertrennzeichen werden nicht verwendet.

Design of the hiv prevention trials network (hptn) protocol 054: a cluster randomized crossover trial to evaluate combined access to nevirapine in developing countries

Design of the HIV Prevention Trials Network (HPTN) Protocol 054: A cluster randomized crossover trial to evaluate combined access to Nevirapine in developing countriesJim HughesUniversity of Washington, jphughes@u.washington.edu Robert L. GoldenbergUniversity of Alabama, Robert.Goldenberg@ccc.uab.edu Catherine M. WilfertElizabeth Glaser Pediatric AIDS Foundation/Duke University, wilfe001@mc.duke.edu