Introduction

The harmful use of alcohol is a significant contributor to the global burden of disease. The World Health Organisation (WHO) lists misuse of alcohol as the third leading risk factor for premature death and disability in the world. It is estimated that 2.5 million people worldwide died from alcohol-related causes in 2004, including 320,000 young people between 15 and 29 years of age. 1

Alcohol misuse substantially contributes to social disruption, injury and death. In Australia about half the reported cases of interpersonal violence, domestic violence and sexual assault are related to excessive alcohol consumption. Alcohol-fuelled incidents are also a factor in up to two thirds of police callouts and around half of homicides.

The College has developed its recommendations on reducing alcohol-related harm drawing on scientific evidence and the expertise of our Fellows in Australia and New Zealand, and other members of the medical profession.

Context

Surgeons are dramatically confronted with the effects of alcohol misuse when treating patients with injuries resulting from road traffic trauma, interpersonal violence and personal accidents that are related to excessive alcohol consumption. Alcohol misuse is also a significant contributor to the total burden of disease, including liver failure, GI bleeding, upper GI and oropharyngeal cancer and infections related to malnutrition. 3 Overall, hospitalisations relating to alcohol misuse continue to represent a significant and concerning proportion of the surgical workload.

Alcohol is legal but it is not an ordinary commodity. Public awareness of the extent of alcohol-related harm in Australia and New Zealand is limited. Alcohol has never been more affordable, available or heavily promoted than it is today,4 and a major reason for this is the involvement of the alcohol industry in government decision making, 5 and lax advertising regulation.

Health and wellbeing impacts

Alcohol misuse is a causal factor in more than 200 diseases and injury conditions, including cirrhosis of the liver, inflammation of the gut and pancreas, heart and circulatory problems, sleep disorders, male impotency, and eye disease. 6 Excessive alcohol consumption also raises the overall risk of cancer, including cancer of the mouth, throat and oesophagus, liver cancer, breast cancer and bowel cancer.7

The Australian study ‘The Range and Magnitude of Alcohol’s Harm to Others’ released in 2010 by Laslett et al, was the first of its type in the world to quantify alcohol harm on those directly affected by the drinker. The study has contributed to WHO methodology as part of that agency’s global strategy to reduce the harmful use of alcohol. 8

The study found that an estimated 367 Australians died and nearly 14,000 people were hospitalised because of the drinking of others, in the year studied. In 2005, interpersonal violence resulted in 182 deaths, of which 42% (77 deaths) were estimated to be attributable to another person’s drinking. A total of 277 deaths of people aged 15 years and over were estimated to be due to another’s drinking and driving, with 31 of these being pedestrian deaths. 9

In New Zealand, the prevalence of self-reported harm from others' drinking was higher than harm from own drinking (18% vs. 12% in the past year) and was higher in women and young people. 10 The link between alcohol and family violence in New Zealand has also been recently highlighted in a report from The Glenn Inquiry, which identified alcohol as one of the overwhelming contributors to the severity of domestic abuse. 11

The following statistics further demonstrate the pervasive effects of harmful alcohol use and the significant cost to health services and the community: 

Australia

  • Each week, on average, more than 100 Australians die and more than 3,000 are hospitalised as a result of excessive alcohol consumption. 12
  •  Every year more than 70,000 Australians are the victims of alcohol-related assaults of which 24,000 are victims of domestic violence. In addition, almost 20,000 children across Australia experience substantiated alcohol-related child abuse. 13
  • The total cost to society of alcohol-related problems in 2010 was estimated to be $14.352b. 14
  • The estimated cost of alcohol’s negative impacts on others was estimated at $6.807b. 15 The same year, the Australian Government received an estimated $7.075b in total alcohol tax revenue. 16
  • More than one third (38%) of people aged 14 or older consumed alcohol at least once in 2013 at a level placing them at risk of injury, and one quarter had done so as often as monthly (26%). 17 • 3.5 million Australians drank at levels that placed them at lifetime risk of an alcohol-related disease or injury (down 250,000 from 3.7 million in 2010).
  • Young people are more likely to drink at risky levels and their increased alcohol consumption is linked to an increase in alcohol-caused hospitalisations. 18
  • The rate of alcohol-attributable death among Indigenous Australians is about twice that of the non-Indigenous population, with a particularly strong association apparent between alcohol use and suicide19. From 2000-2006, 87% of intimate partner homicides among Indigenous populations were alcohol related.20

New Zealand

  • Each week, on average, 20 New Zealanders die as a result of excessive alcohol consumption. 21
  • Around a third of injury-based emergency department presentations are alcohol-related. 22
  • The latest results from 2013/14 show that one in six adults has a hazardous drinking pattern - one in three of these are 18-24 year olds, and one in three identify as Mäori. 23
  • National drinking surveys consistently show around 25% of drinkers – the equivalent of 700,000 New Zealanders – typically drink large quantities when they drink. 24
  • In 2012, alcohol was a contributing factor in 73 fatal crashes, 331 serious injury crashes and 933 minor injury crashes. These crashes resulted in 93 deaths, 454 serious injuries and 1,331 minor injuries. 25
  • Harmful drug use in 2005/06 caused an estimated $6,525 million of social costs. This is equivalent to the GDP of New Zealand’s agricultural industry ($6,701 million). 26
  • Overall, Mäori have four times the alcohol-related mortality of non-Mäori.27

WHAT CAN BE DONE?

The Royal Australasian College of Surgeons endorses preventative measures as the best way to reduce alcohol-related harm, as well as delivering substantial health, social and economic benefits. The College supports coordinated efforts between governments, health professionals, health services and community organisations to reduce alcohol related harm and injury by the production of evidencebased policy reform. Since the corporate responsibility of the alcohol industry is to its shareholders to increase profit, governments should exercise considerable caution to ensure that harm minimisation remains at the core of legislative objectives, and that public health is prioritised over financial benefit.

Given that the tax revenue received by the Commonwealth Government is not even half of the total estimated cost of alcohol-related harm, an increased proportion of tax revenue could arguably be used to implement strategies aimed at further reducing the social costs associated with alcohol misuse.

 

Recommendations

The College encourages governments to give consideration to the following policy areas as a means to reduce alcohol-related harms.

Restricting the physical availability of alcohol (Hours and Outlets)

The Australian Government’s Preventative Health Taskforce, citing evidence compiled by the National Drug Research Institute, concluded that, ‘Most Australian studies have shown that increased trading hours have been accompanied by significantly increased levels of alcohol consumption and/or harms.’28 The Taskforce highlighted consistent links between the availability of alcohol in a region and the alcohol-related problems experienced there. Many studies have also linked rates of violence to density of alcohol outlets. 29

By regulating the physical availability of alcohol, through reduced trading hours and liquor outlet density restrictions, governments can make a significant contribution to reducing its negative impacts.

Restricting the economic availability of alcohol (Taxes)

International scientific evidence consistently shows that rates of alcohol consumption and resultant harm are influenced by price. 30 Alcohol taxation is one of the most effective policy interventions to reduce the level of alcohol consumption and related problems, including mortality rates, crime and traffic accidents. Even small increases in the price of alcohol can have a significant impact on consumption and harm.31 However, despite its reported effectiveness, taxation as a strategy to reduce alcohol-related harm has been under-utilised in Australia and New Zealand.32

The Henry Review of Australia’s taxation system described Australia's present alcohol tax system as ‘incoherent', and recommended a new approach based on volumetric or alcohol content-based tax. The Australian Government's Preventative Health Taskforce also called for taxes on alcohol to be overhauled. Economic modelling commissioned by the Foundation for Alcohol Research and Education has shown that replacing the Wine Equalisation Tax and rebate with a ten percent increase to all alcohol excise and a volumetric tax on wine and cider would deliver $2.9 billion revenue and reduce alcohol consumption by 9.4 per cent.33

The New Zealand Ministry of Justice has suggested that imposing a minimum price per standard drink of alcohol will reduce harmful alcohol consumption, particularly among young people, who consume the highest quantities of low cost, high alcohol volume products. 34 It estimated a $1-$1.20 minimum price per standard drink would result in net benefits to society ranging from $44 million to $86 million in the first year.

Reduce exposure

Analysis of national drinking survey data from New Zealand indicates young people’s drinking patterns have changed in recent years towards increased consumption per occasion, 35 and the New Zealand Ministerial Forum on Alcohol Advertising and Sponsorship has made recommendations to the Government about restricting the exposure of minors to alcohol advertising and sponsorship. 36 

A 2013 survey commissioned by the Salvation Army found that nearly three-quarters of Australians believed that alcohol and sport were too closely related. Two thirds of the survey respondents believed that alcohol sponsorship should be phased out of sport, and 70 per cent said that the amount of alcohol advertising that people under 25 see encourages them to drink more. 37

Australian studies have shown that exposure to alcohol advertisements among Australian adolescents is strongly associated with increased drinking patterns. 38 The National Health and Medical Research Council recommends that parents of adolescents delay the age of drinking initiation as long as possible to protect the health and wellbeing of young Australians.39 Given current high levels of drinking among Australian and New Zealand youth, the College supports efforts to reduce young people's exposure to alcohol advertising through policy reforms aimed at reducing the proliferation of alcohol advertising.

Data collection

Government agencies monitor and report incidents of alcohol-related harm and some of the costs associated with alcohol abuse, however, agencies do not monitor or report the total costs to the community through alcohol related trauma and law enforcement, meaning we do not have a complete picture of the harm caused by alcohol in terms of its costs and effects on society.

Despite the evidence supporting the effectiveness of Screening and Brief Intervention (SBI) programs very few patients are asked about their alcohol use in the past year. A structured SBI program is inexpensive, takes little time to implement (5-10 minutes), and can be undertaken by a wide range of health and welfare professionals.

The College supports further investigation of how a suitable SBI program could be implemented in Australia and New Zealand, in particular the mandatory collection of data on whether alcohol use is a factor in emergency department presentations, either by the patient or another individual. Since data is essential for good public policy, the College also supports the mandatory collection of alcohol sales data. 40

Resources

As below

References

1 World Health Organisation (2010) Global strategy to reduce harmful use of alcohol. Available from: http://www.who.int/substance_abuse/activities/gsrhua/en/

2 Dearden J & Payne J 2009. Alcohol and homicide in Australia. Trends & issues in crime and criminal justice no. 372. Canberra: Australian Institute of Criminology. http://www.aic.gov.au/publications/current series/tandi/361- 380/tandi372.aspx

Key issues in alcohol-related violence. Research in practice no. 4 Anthony Morgan and Amanda McAtamney ISSN 1836-9111, Canberra: Australian Institute of Criminology, December 2009

Briscoe S & Donnelly N, 2001. Temporal and regional aspects of alcohol-related violence and disorder. Alcohol studies bulletin no. 1. http://www.bocsar.nsw.gov.au/agdbasev7wr/bocsar/documents/pdf/ab01.pdf 

Doherty SJ & Roche AM 2003. Alcohol and licensed premises: best practice in policing. A monograph for police and policy makers. Adelaide: Australasian Centre for Policing Research. http://nceta.flinders.edu.au/files/7312/5548/1448/EN34.pd

Poynton S et al 2005. The role of alcohol in injuries presenting to St Vincent’s Hospital Emergency Department and the associated short-term costs. Alcohol studies bulletin no. 6. http://www.bocsar.nsw.gov.au/agdbasev7wr/bocsar/documents/pdf/ab06.pdf

3 Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. The Lancet 373(9682): 2223-2233. 2009

4 FARE (2013) The Foundation for Alcohol Research and Education’s 2013 Election Platform: 10 ways to reduce alcohol harms. Available from: www.fare.org.au

5 Saitz R. Alcohol: No ordinary health risk. Addiction. 2015 Jul 14;110(8):1228–9

6 World Health Organisation (2015) Alcohol Fact Sheet. Available from: http://www.who.int/mediacentre/factsheets/fs349/en/

7 IARC Working Group on the Evaluation of Carcinogenic Risks to Humans (2007: Lyon, France) Alcohol consumption and ethyl carbamate

8 World Health Organisation (2010) Global strategy to reduce harmful use of alcohol. Available from: http://www.who.int/substance_abuse/activities/gsrhua/en

9 Laslett, A-M., Catalano, P., Chikritzhs, Y., Dale, C., Doran, C., Ferris, J., Jainullabudeen, T., Livingston, M, Matthews, S., Mugavin, J., Room, R., Schlotterlein, M. and Wilkinson, C. (2010) The Range and Magnitude of Alcohol’s Harm to Others. Fitzroy, Victoria: AER Centre for Alcohol Policy Research, Turning Point Alcohol and Drug Centre, Eastern Healt

10 Connor, J., Casswell, S. (2012) Alcohol-related harm to others in New Zealand: evidence of the burden and gaps in knowledge. NZMJ Vol 125 No 1360; ISSN 1175 8716 p11 Available at: http://www.nzma.org.nz/journal/125-1360/5308/

11 The Glenn Inquiry (2014) The People’s Blueprint: Transforming the way we deal with child abuse and domestic violence in New Zealand. Available from: https://glenninquiry.org.nz/uploads/files/The_Peoples_Blueprint_Electronic_Final.pdf

12 Gao, C.*, Ogeil, R.P.*, & Lloyd, B. (2014). Alcohol’s burden of disease in Australia. Canberra: FARE and VicHealth in collaboration with Turning Point.

13 Laslett, A-M., Catalano, P., Chikritzhs, Y., Dale, C., Doran, C., Ferris, J., Jainullabudeen, T., Livingston, M, Matthews, S., Mugavin, J., Room, R., Schlotterlein, M. and Wilkinson, C. (2010) The Range and Magnitude of Alcohol’s Harm to Others. Fitzroy, Victoria: AER Centre for Alcohol Policy Research, Turning Point Alcohol and Drug Centre, Eastern Health.

14 Manning, M., Smith, C. and Mazerolle, P. (2013) Trends & issues in crime and criminal justice series: The societal costs of alcohol misuse in Australia No. 454, Australian Institute of Criminology

15 Laslett, A-M., Catalano, P., Chikritzhs, Y., Dale, C., Doran, C., Ferris, J., Jainullabudeen, T., Livingston, M, Matthews, S., Mugavin, J., Room, R., Schlotterlein, M. and Wilkinson, C. (2010) The Range and Magnitude of Alcohol’s Harm to Others. Fitzroy, Victoria: AER Centre for Alcohol Policy Research, Turning Point Alcohol and Drug Centre, Eastern Health. 16 Manning M, Smith C, Mazerolle P. Australian Institute of Criminology. Canberra: Australian Institute of Criminology. The societal costs of alcohol misuse in Australia; 2013 Apr 2. Available from: http://www.aic.gov.au/publications/current%20series/tandi/441-460/tandi454.html

17 AIHW 2014. National Drug Strategy Household Survey detailed report 2013. Drug statistics series no. 28. Cat. no. PHE 183. Canberra: AIHW. http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129549848

18 Chikritzhs, T., Catalano, P., Stockwell, T. et al. (2003). Australian alcohol indicators 1990-2001: Patterns of alcohol use and related harms for Australian States and Territories. National Drug Research Institute, Curtin University of Technology, Perth.

19 National Health and Medical Research Council (2009) Australian Guidelines to Reduce Health Risks from Drinking Alcohol

20 Dearden J & Payne J 2009. Alcohol and homicide in Australia. Trends & issues in crime and criminal justice no. 372. Canberra: Australian Institute of Criminology

21 Connor, J., Broad, J., Jackson, R., Vander Hoorn, S., Rehm, J. (2004) The burden of death, disease and disability due to alcohol in New Zealand

22 Humphrey, G., Casswell, S., and Yeo Han, D. Alcohol and injury among attendees at a New Zealand emergency department. NZMJ 24 January 2003, Vol 116 No 1168. Available at: http://www.nzma.org.nz/__data/assets/pdf_file/0005/17987/Vol-116-No-1168-24-January-2003.pdf

23 Ministry of Health (2014) Annual Update of Key Results 2013/14: New Zealand Health Survey. Available from: http://www.health.govt.nz/publication/annual-update-key-results-2013-14-new-zealand-health-survey

24 New Zealand Law Commission (2010) Alcohol in our lives: Curbing the harm - A Report on the review of the Regulatory Framework for the sale and Supply of Liquor. Available from: http://www.lawcom.govt.nz/project/review-regulatory-framework-sale-and-supply-liquor

25 Health Promotion Agency. Alcohol Facts. Available from: http://www.alcohol.org.nz/research-resources/nzstatistics/alcohol-facts

26 Business and Economic Research Limited (2009) Costs of Harmful Alcohol and Other Drug Use. Report to Ministry of Health and Accident Compensation Commission

27 Connor, J., Broad, J., Jackson, R., Vander Hoorn, S., Rehm, J. (2004) The burden of death, disease and disability due to alcohol in New Zealand

28 Australian Government Department of Health. Technical Report No 3, Preventing alcohol–related harm in Australia: a window of opportunity (including addendum for October 2008 to June 2009). Available from: http://www.health.gov.au/internet/preventativehealth/publishing.nsf/Content/09C94C0F1B9799F5CA2574DD0081E77 0/$File/alcohol-jul09.doc

29 Donnelly N, Poynton S, Weatherburn D, Bamford E and Nottage J. Liquor outlet concentrations and alcoholrelated neighbourhood problems. Alcohol Studies Bulletin. Sydney: NSW Bureau of Crime Statistics and Research, 2006. Available from: http://www.bocsar.nsw.gov.au/agdbasev7wr/bocsar/documents/pdf/ab08.pdf 

Livingston M. Alcohol outlet density and assault: a spatial analysis. Addiction. 2008; 103:619−28. Available from: www3.interscience.wiley.com/journal/119411938/abstract

30 Babor, T, et al. Alcohol: No Ordinary Commodity. Second Edition. New York: Oxford University Press. 2010. Available from: http://www.ndphs.org///documents/2253/Babor_alc%20no%20ordinary%20comm%20second%20edition.pdf

31 Chikritzhs T, Stockwell T, Pascal R. The impact of the Northern Territory’s Living With Alcohol program, 1992- 2002: revisiting the evaluation. Addiction. 2005; 100(11):1625-36. 

32 Stockwell T. Australian alcohol policy and the public interest: a brief report card. Drug and Alcohol Review. 2004; 23:377–9. Available from: http://onlinelibrary.wiley.com/doi/10.1080/09595230412331324491/pdf

33 The Allen Consulting Group (2011) Alcohol taxation reform starting with the Wine Equalisation Tax. Canberra: Foundation for Alcohol Research and Education (FARE).

34 White, J., Lynn, R., Ong, S., Whittington, P. (2014) The Effectiveness of Alcohol Pricing Policies: Reducing harmful alcohol consumption and alcohol-related harm. Available from: http://www.justice.govt.nz/publications/global-publications/e/the-effectiveness-of-alcohol-pricing-policies

35 New Zealand Law Commission (2010) Alcohol in our lives: Curbing the harm - A Report on the review of the Regulatory Framework for the sale and Supply of Liquor, p66. Available from: http://www.lawcom.govt.nz/project/review-regulatory-framework-sale-and-supply-liquor

36 NZ Ministry of Health. Ministerial Forum on Alcohol Advertising and Sponsorship (2014) Ministerial Forum on Alcohol Advertising and Sponsorship: Recommendations on alcohol advertising and sponsorship. Available at: http://www.health.govt.nz/publication/ministerial-forum-alcohol-advertising

37 Salvation Army media release (2013) The Salvation Army releases national research highlighting the need for an urgent review of alcohol advertising and promotion. Available at: http://salvos.org.au/blog/?p=80

38 Jones, S. C. & Magee, C. A. (2011). Exposure to alcohol advertising and alcohol consumption among Australian adolescents. Alcohol and Alcoholism, 46 (5), 630-637. Available at: http://ro.uow.edu.au/cgi/viewcontent.cgi?article=2848&context=hbspapers

39 Australian Government National Health and Medical Research Council (2009) Australian Guidelines to reduce health risks from drinking alcohol. Available from: https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/ds10-alcohol.pdf

40 Hall W, Chikritzhs T, d’Abbs P and Room R. Alcohol sales data are essential for good public policies towards alcohol. MJA, 2008; 189:188−9. Available from: www.mja.com.au/public/issues/189_04_180808/hal10593_fm.html