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Technical Paper 3:
Preventing Alcohol-related harm in Australia: a window of opportunity

4.1 - Current activity

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Considerable activity aiming to prevent alcohol-related harm is currently under way in Australia. The extent to which the considerable preventative desire and activity (planned or under way) is likely to be effective, and how well this activity reflects an evidence-based approach, is considered in the next section of this paper. In general, the measures that are most often called for by community members tend to be the least effective, while the most effective measures are the least popular and are thus probably the most difficult for governments to introduce, usually requiring strong leadership and well-planned implementation.

What is prevention in this area?

The stated aim of Australia’s current National Drug Strategy is to ‘prevent the uptake and minimise the harmful effects of drug use in Australian society’. Known as ‘harm minimisation’, this approach has been defined as encompassing:

• Supply reduction strategies designed to restrict the harmful supply of drugs
• Demand reduction strategies designed to prevent the uptake of harmful drug use
• Harm reduction strategies to reduce drug-related harm for individuals and communities.

The approach of harm minimisation, while complex and requiring continuing support from public advocates, is based on scientific evidence and underpins the definition of prevention adopted for the review of alcohol-related interventions in this paper. It can encompass universal as well as targeted interventions (both selective: particular high-risk sub-populations; and indicated: those with emerging problems).

Though not explored in detail in this paper, the concept of the prevention paradox assists in understanding prevention approaches in the areas of public health and public safety. This approach suggests that more (net) harm may be prevented through universal interventions – focusing on the majority who are less seriously involved in harmful alcohol/drug use, rather than through interventions that only target the smaller proportion of high-risk users.
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What works in alcohol-related prevention?

The following discussion is informed by recent reviews of the available research evidence. This includes:

• the World Health Organization’s (WHO) international review of alcohol-related research and
  public policy[13]
• a recent Australian research monograph on the prevention of substance use, risk and harm[7]
• a recent update of the latter, with a focus on prevention interventions targeting adolescents.[41]

Other recent reviews have also been drawn upon, to a lesser extent, including Stockwell 2004,[42] Loxley et al. 2005[7, 43] and NDRI 2007.[36]

The conclusions reached in the WHO report[13] with regard to the respective strengths and weaknesses of different types of interventions, according to the available international research evidence, are summarised in Table 6. Included in this table are Australian-authored evaluations of the equivalent interventions provided by Loxley et al.[7] and Toumbourou et al.[41] The scales used to rate the interventions by the respective authors are summarised in Table 5 below.

Table 5: Key to the rating scales shown in Table 6

Rating	Evidence of effectiveness	Breadth of research support	Test across cultures	Australian evaluation
	Lack of effectiveness	No studies undertaken	Not tested	Limited investigation
	Limited effectiveness	1 well-designed study completed	Tested in 1 country	Evidence for implementation
	Moderate effectiveness	2–4 studies completed	Tested in 2–4 countries	Evidence for outcome effectiveness
	High degree of effectiveness	5+ studies completed	Tested in 5+ countries	Evidence for effective dissemination
	No evidence available			N/A
				Warrants further research
				Evidence is contra-indicative

This rating scale applies to the WHO’s international review [13] and Australian reviews.[14].
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Of the 39 interventions listed in Table 6, at least half of these are universal (targeted at the whole population) and approximately half are targeted at high-risk groups. The international review by Babor et al. concludes that interventions targeting the whole population generally have higher effectiveness ratings and are less costly to implement and maintain, on average, than those targeting high-risk groups.[13] In general, the types of interventions that are considered most effective according to the ratings are, in order:

1. Regulating physical availability
2. Taxation and pricing
3. Drink-driving countermeasures
4. Treatment and early intervention

The types of interventions for which there is somewhat less evidence of effectiveness are, in order:

5. Altering the drinking context
6. Regulating promotion
7. Education and persuasion

There are differences in the ratings of some interventions between the international review[13] and the Australian review.[7] (for example, the treatment of alcohol problems and mass media campaigns). Also, importantly, it should be recognised that although the effectiveness of some interventions do not rate highly, in some cases this may be due to the limited research evidence that is available to inform the rating (for example, advertising content controls).

Table 6: Ratings of policy-relevant strategies and interventions

Strategy or intervention		Effectiveness	Breadth of research	Cross-cultural testing	Cost to implement	Australian evaluation
Regulating physical availability	Total ban on sales				High
	Minimum legal purchase age				Low
	Hours and days of sale restrictions				Low
	Restrictions on density of outlets				Low
	Staggered closing times for bars and clubs					X
	Server liability				Low
	Different availability by alcohol strength				Low
Taxation and pricing	Alcohol taxes				Low
	Hypothecated tax to pay for treatment / prevention
	Setting floor prices / banning discounting
Drink-driving counter-measures	Sobriety checkpoints				Moderate
	Random breath testing				Moderate
	Low BAC limits				Low
	Administrative licence suspension				Moderate
	Low BAC for young drivers				Low
	Graduated licensing for novice drivers				Low
	Designated drivers and ride services				Moderate
	Ignition interlocks
Treatment and early intervention	Brief intervention in primary health settings				Moderate
	Alcohol problems treatment				High
	Thiamine supplementation
	Workplace interventions
	Mutual help/self-help attendance				Low
	Mandatory treatment of repeat drink drivers				Moderate
Altering the drinking context	Bans on serving intoxicated persons				Moderate
	Training staff to prevent intoxication / aggression				Moderate	(X if not enforced)
	Voluntary codes of bar practice				Low	(X if not enforced)
	Enforcement of on-premises regulations and laws				High
	Promoting alcohol-free events				High
	Community mobilisation				High
	Plastic or tempered-glass serving containers
	Food service
Regulating promotion	Advertising bans				Low
	Advertising content controls				Low
Education and persuasion	Alcohol education in schools				High
	College student education				High
	Parent education				Moderate
	Public service messages / Mass media campaigns				Moderate
	Warning labels / National drinking guidelines				Low

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