Alcohol Harm Minimisation Policy is a Fudge

Hal Swerissen

Alcohol policy has a chequered history in Australia. We’ve had prohibition, the six o’clock swill, the European drinking culture reforms and now harm minimisation. But still we drink way too much for our own good, and poorly constructed harm minimisation policies are contributing to the problem.

Alcohol is bad for you

As anyone who has experimented with alcohol and nerve cells in the lab knows, alcohol is a neurotoxin. True, when we drink, the alcohol levels in the human body are generally lower than in the lab, but the research is now clear. Unfortunately, no level of alcohol consumption is completely safe. Amongst other things, it causes cancer, liver disease, heart disease and weakens the immune system and impairs reaction time, judgement and muscle control. Sadly, the idea that a glass or two of red wine is good for you turns out to be based on a misinterpretation of the data.

Beyond the straightforward biological effects, past a couple of standard drinks, alcohol rapidly becomes socially and behaviourally disruptive and lethal when driving, flying, using dangerous equipment and performing other risky tasks. Reaction times, judgement and control over emotions like anger all become problematic. The more you drink the greater the risk.

Policy swings and roundabouts 

We have tried a range of policy options to manage the risks. Following World War I, Temperance movements forced tight restrictions on alcohol in a number of areas, alcohol sales were prohibited after 6pm and on Sundays. In Australia, the Capital Territory banned liquor licenses in the 1920s. A number of other jurisdictions had local ‘dry’ areas.

But, while alcohol consumption fell during the interwar period, prohibition had a range of problems. It led to black markets, crime, corruption, low quality and dangerous alcohol production and risky and unsociable consumption. Community demand for alcohol persisted and eventually public sentiment turned and prohibition was largely dropped, although it is still in place in some indigenous communities.

Nevertheless, following prohibiltion, tight restrictions on liquor licenses remained in place across Australia until the last decades of the 20th century. Licenses were mainly restricted to hotels and hotel hours were tightly controlled, leading to the infamous heavy drinking known as the six o’clock swill in the hour before hotels were required to close at 6 pm.

Much of the male-focussed, working-class pub culture that dominated this period was focused on getting drunk and behaving badly. Being drunk was socially acceptable and often a badge of honour. Drunk men were carried to their cars from the front bar by their mates and made off into the night to cause carnage on the road or with their families if they made it home. Construction workers downed a couple of beers with lunch and went back to work with heavy machinery, sometimes killing themselves or their work-mates. By the mid 1970s alcohol consumption spiked to a 50 year high of 13.4 of pure litres per person per year.

In the last two decades of the 20th century the disasterous effects of alcohol on road deaths, injuries at work and domestic violence saw the emphasis shift from the hotel drinking culture to a greater emphasis on civilised or responsible drinking. This meant combining alcohol with food. Wine with a meal in restaurants and cafes became popular.

At the same time, much more emphasis was placed on drinking responsibly. Drink-driving laws and work-place safety rules were introduced and drinking alcohol during pregnancy became frowned upon. Being blind drunk became less socially acceptable. But at the same time, liquor licensing laws were relaxed and many more venues served alcohol. Paradoxically, civilised drinking has now spread far and wide and the overall level of alcohol consumption in Australia remains high.

Alcohol is still the life of the party. Close to 70 per cent of Australian adults consumed alcohol in the last year. Alcohol is everywhere: parties, dinners, lunches, sporting events, cultural events, in front of the TV and so on. It is rusted on to the Australian culture, from bogan ‘piss ups’ to toffy-nosed wine appreciation classes, pre-loading before clubbing and under-age teenagers raiding the parents’ booze cupboard. Despite, civilised and responsible drinking, it’s still common to celebrate major achievements, including graduations and sporting wins, by going out and getting plastered. Alcohol remains the drug of choice.

Alcohol remains a major problem

As a result, we still drink way more than we should. The National Health and Medical Council guidelines recommend that children under the age of 18 and pregnant and breast-feeding women should not consume alcohol. Adults should consume no more than 10 standard drinks per week and no more than four standard drinks a day. The guidelines are based on research indicating that healthy adults drinking within the guidelines have a less than a 1 in 100 chance of dying from an alcohol-related condition. Drink more and the risk goes up to more than 1 in 100.

Drinking within the guidelines also minimises the risk of short term harm including violence, accidents, injuries, deaths and social disruption and longer term risks of alcohol-related family breakdown, unemployment and homelessness. So drinking within the NHMRC guidelines a sensible national target to aim for if we want to minimise alcohol related harm.

Sadly we are a long way from the target. If we all stuck to the NHMRC guidelines that would mean average consumption per person of no more than 6.5 litres of pure alcohol per year. But average consumption is 9.5 litres per year – way over the recommended level. True, this is lower than the high point of the 1970s, but it is well over the OECD average and about the same level as the 1960s. In reality, despite the emphasis on responsible drinking, consumption has been relatively resistant to any decline for 30 years.

Critics will argue that this measure of apparent consumption is flawed (e.g. alcohol use in cooking, tourists, spillage etc). But the consumption data is backed up by survey results showing massive levels of consumption in excess of the NHMRC guidelines.

Over a quarter of Australian adults regularly drink more than 10 standard drinks a week and more than 4 standard drinks at a single sitting. That wouldn’t matter if the results were trivial, but they aren’t. There are about 150,000 alcohol-related hospital admissions and 1800 alcohol related deaths a year in Australia. Add to this that alcohol is a factor in about a third of domestic violence incidents, a third of road deaths and about two-thirds of police call-outs. Best estimates of the direct costs associated with alcohol harm are around $20 billion a year. That doesn’t include the costs of the loss of life, violence, family breakdown and homelessness – estimated at another $40 billion or so. Altogether the costs of alcohol consumption in 2018 are around $67 billion.

The bads outweigh the goods

But what about the benefits? The alcohol industry generates employment and economic activity. This includes agricultural producers, alcohol manufacturers, wholesale and retail sales and hospitality venues. Estimates suggest 238,000 people have jobs in the industry, there are about 70,000 liquor licenses and consumers spend around $26 billion on alcohol, all together making up nearly three per cent of GDP, for a total economic value of $52 billion in 2018-19.

Alcohol is big business

Yes there are benefits, but on balance, it looks as though the costs outweigh the benefits. What is beyond doubt is that the costs are substantial and that there is a big gap between current consumption levels and the levels recommended by the NHMRC.

The alcohol industry is in business to make money within the rules set for it set by government. Current policy settings, allow alcohol supply to proliferate, increasingly through highly efficient, large-scale, supermarket-style outlets that optimise sales through discounting, and convenient bulk purchasing facilities. Add to this the recent rapid expansion of convenience through online alcohol distribution. From 2001 to 2016 the number of large supermarket style alcohol stores in Victoria grew from 3 to 68. 

Unsurprisingly, the alcohol industry targets product development, pricing and marketing at the under 30s, with an inevitable impact on under-age drinkers. Similarly, there is a heavy empahsis on price promotion, advertising, sponshorsips, community events and product development targeted at low income people, with unfortunate effect that this group, including indigenous communities continue to be disproportionately harmed by alcohol.

Governments have not been willing to tackle consumption

For governments, finding the balance between a good time and nasty outcomes remains fraught. Governments want to reduce harm without telling people to drink less and putting policies in place to make that happen. This is a fudge – a magic pudding. Population harm cannot be reduced without reducing population consumption when average consumption is already well above the recommended limits.

Instead, governments have negotiated an uneasy and piecemeal truce between the alcohol and hospitality industry, public health advocates and others concerned about alcohol consumption. Alcohol advertising is regulated, age limits are in force, alcohol labelling has to include information on standard drinks, responsible serving is required, drink-driving incurs stiff penalties and sales and distribution can only be done under licence. But at the same time alcohol is cheap, widely available and consumption is accepted and promoted in a broad range of public and private settings.

… And it’s not working

The result is that alcohol related harm remains high. After tobacco it is the second most serious drug related cause of disease, far outweighing the impact of highly regulated illict drugs, and it also has massive social and personal costs. Consumption has dropped only marginally and remains stubbornly above the levels implied by the NMRC guidelines. A meaningful decline in consumption is unlikely any time soon. Alcohol related work and vehicle related injuries and deaths have declined, but they remain substantial. Alcohol related Hospitalisations and police call outs are getting worse not better. Alcohol related domestic violence, family breakdown and homelessness remain problematic. Under-age drinking remains a significant problem and the impact of alcohol on indigenous communities remains deeply troubling.

Unlike the highly successful tobacco control policy, Australian governments have failed to add effective demand and supply control strategies to their alcohol policy framework to reduce consumption. Without reducing consumption, harm will not be reduced. Tobacco policies have restricted areas where smoking is allowed, introduced price controls through taxation measures and effectively eliminated tobacco advertising marketing and promotion. Neither of the major parties now accept tobacco industry donations. Alcohol continues to be widely consumed in public venues with few restrictions, there are no price control mechanisms, marketing and promotion continue to be relatively unregulated and venues continue to proliferate. Both parties continue to accept donations from the alcohol industry, which donated $1.3 million to major political parties last year.

Where to from here?

Alcohol-related harm will only be effectively minimised if per capita consumption is reduced, particularly for vulnerable groups. This can only be achieved through a comprehensive policy framework to manage and regulate supply and demand. this includes the venues where alcohol may be consumed, the volume and scale of retail outlets, the types of products that are allowed, and controls on marketing, promotion and pricing levels to reduce demand. Of course consumption is not the only indicator of success for an alcohol policy. But there is little doubt that societal harms won’t be reduced unless consumption is closer to the NHMRC guidelines.