National Health Strategy 2000-2003
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Date of publication: March 2001
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Part Four: Strategies Overall approach

Like the National Drug Policy, the National Alcohol Strategy recognises that there is a continuum of harm associated with the misuse of alcohol, and that no single approach or set of strategies can adequately address this entire range of alcohol-related harm.

The strategies outlined in this section are of three kinds:

• supply control – strategies that control the availability of alcohol (for example, regulation and enforcement)

• demand reduction – strategies that encourage reduced and responsible use of alcohol (for example, education campaigns and the provision of information)

• problem limitation – strategies that are aimed at reducing the problems stemming from the use of alcohol (for example, provision of treatment services, and initiatives designed to reduce alcohol-related road crashes and fatalities).

Within these broad categorisations, some of the strategies focus on drinkers, and others on the environment in which drinking occurs or where the impact of drinking manifests itself, while still others focus more on alcohol itself. Taken as a whole, the strategies aim to ensure that all types of alcohol-related harm are comprehensively addressed.

Although some of the strategies are specific, in that they address particular harms or particular groups at risk of experiencing harm, others are more general. This mix of strategies reflects the fact that the causes of alcohol-related harm are complex and multiple, and that both broad and specific strategies are needed to ensure that those causes are effectively addressed. For this reason, certain strategies have been included that do not focus specifically on the harm, population group or concern identified in the desired outcomes specified in the National Drug Policy. These strategies are, nevertheless, expected to make a significant contribution to the achievement of those outcomes.

By adopting a comprehensive approach, the National Alcohol Strategy seeks to address all significant forms of alcohol-related harm, not just those highlighted by the National Drug Policy.

It is also important to note that many of the strategies listed are not new. Some are already in place and known to be effective. While innovation is to be encouraged, it should not be at the expense of worthwhile initiatives being undertaken now, including those being implemented at a community level by committed groups and individuals.

Indeed, resourcing local communities to work on reducing alcohol-related harm can be a potent way to change potentially harmful attitudes and behaviours around alcohol. The community development approach, as outlined in the Ottawa Charter for Health Promotion (1986), and built upon by the Jakarta Declaration on Health Promotion into the 21 st Century (1996), can be used to empower local communities to tackle alcohol issues in ways that suit their particular physical, social and cultural environment. Moreover, community development projects that seek to empower local communities, build skills and capacity, and strengthen social networks, can also lead to unintended or ‘knock on’ benefits, such as a decrease in some types of alcohol-related problems.

As such, the strategies detailed in this section recognise that communities need to be able to address alcohol issues at a local level, and they seek to support communities in doing so.

Finally, the strategies outlined in this part are not described in detail. This reflects the intention behind the strategies, which is to guide action, not to prescribe it.



The Treaty of Waitangi

Beyond this general approach to minimising alcohol-related harm, the National Alcohol Strategy also recognises the Crown’s obligations arising from the Treaty of Waitangi.

In broad terms, Article One of the Treaty (Kawanatanga) places responsibility on government to protect the health of Maori; Article Two (Tino Rangatiratanga) provides for Maori to exercise authority in the development and delivery of initiatives designed to improve their health and Article Three (Oritetanga) requires that Maori be given the opportunity to enjoy a health status at least as good as that enjoyed by non-Maori.

Specific strategies for addressing alcohol-related harm experienced by Maori are threaded through the different groups of strategies outlined in this part.

Principles

The following principles underpin the strategies, and reflect the Crown’s obligations under the Treaty. While each principle is important in its own right, one principle may sometimes be in conflict with another. A demand reduction approach proven to be ‘effective’, for example, may not be ‘efficient’. Taken as a whole, however, the strategies aim to reflect a balanced application of the different principles.

Appropriateness

Appropriateness involves the development of strategies that are consistent with people’s culture, values and behaviour. Appropriateness also means the development of strategies that are consistent with Maori norms, values and beliefs, and that recognise diverse Maori realities.

Effectiveness

Effectiveness is achieved by employing strategies most likely to reduce harm caused by the misuse of alcohol. Effective strategies include those that are targeted, employ evidence-based practice, and have been soundly evaluated. Effectiveness also means using strategies likely to result in a tangible reduction in alcohol-related harm to Maori.

Efficiency

Efficiency recognises that resources are limited and that choices have to be made. Making choices involves a careful examination of the relative costs and benefits of interventions, and attention to where research or evidence indicates that harm can be most effectively reduced with available resources. Efficiency for Maori may involve culturally-specific interpretations of costs and benefits.

Empowerment

Empowerment involves resourcing people to assume greater control over their health. Empowerment for Maori is achieved by Maori being resourced to reduce alcohol-related harm through their own efforts.

Equity

Equity means fairness. It means directing more resources to the areas of greatest need in order that no one group suffers a disproportionate amount of alcohol-related harm. Equity means giving priority to reducing the disproportionate levels of alcohol-related harm experienced by Maori.

Innovation

Innovation recognises that problems are constantly changing. Harm minimisation strategies need to be innovative and responsive to that change. Innovation recognises also that conventional approaches are sometimes no longer sufficient, and that new approaches are needed to tackle old problems. Innovation also means recognising the value of strategies to reduce harm that have been developed by Maori for Maori.

Working together

Responding well to alcohol issues requires a co-ordinated approach involving a range of participants. Collaboration by health workers in government and non-government agencies, the alcohol and hospitality industries, community groups and individuals is essential to the development, implementation and monitoring of effective strategies. Working together also means ensuring that Maori are involved at all levels in deciding, developing, implementing and evaluating strategies to minimise alcohol-related harm.



Supply control strategies

Supply control strategies attempt to reduce alcohol-related harm by placing restrictions on the availability of alcohol. Whereas in the past, controlling supply was often seen as the best way of minimising harm, more recently supply control strategies have been considered most effective when adopted in conjunction with demand reduction strategies and problem limitation initiatives.

Legislation

Access to alcohol has long been controlled by legislation in New Zealand (Dormer et al 1990; Hill and Stewart 1998). The Sale of Liquor Act 1989 is the primary legislation dealing with issues surrounding the sale, purchase and consumption of alcohol. The primary objective of the Act is:

To establish a reasonable system of control over the sale and supply of liquor to the public with the aim of contributing to the reduction of liquor abuse,so far as that can be achieved by legislative means.
While the purpose of the Act is straightforward and centres on establishing a system of control over the sale and supply of alcohol, the provisions of the Act have not always been well understood, nor enforced to an extent sufficient to ensure their optimal effect.

It is thus important that the good intentions of licensees and host responsibility training are given appropriate backing. Moreover, it has been found that areas in which the licensing inspector, licensing sergeant and public health officer work closely together as a team, are associated with ‘rationalisation of effort and resources, more routine inspections, a greater focus on host responsibility practices, a proactive approach with licensees and a united response to incidents or poorly managed premises’ (Hill and Stewart 1996).

The Resource Management Act 1991 also has a potential role to play in controlling the availability of alcohol in New Zealand. One aim of the Act is to minimise the adverse effects of land use. A Certificate of Compliance issued under the Act is required before an application under the Sale of Liquor Act can proceed. The Certificate ensures that the proposed use of the land meets the requirements of the Resource Management Act, and that any conditions or restrictions on that use are made explicit.

The Resource Management Act is administered by local authorities. District Licensing Agencies (DLAs) set up under the Sale of Liquor Act are also part of local authorities, but they are not empowered to determine Resource Management Act issues, and their statutory role and licensing criteria are closely governed by the Sale of Liquor Act. Hence, in granting licences, currently DLAs or the central Liquor Licensing Authority may only consider neighbouring land use in relation to setting hours of trade.

Objectives: legislation		Supply control strategies
1	Ensure that the provisions of the Sale of Liquor Act 1989 are well understood.	1.1	Provide clear, comprehensible information on the provisions of the Act to members of the public, alcohol retailers, the hospitality industry, and agencies/officials responsible for administering it.
2	Improve monitoring of compliance with the Sale of Liquor Act by licensees and their employees.	2.1	Support the establishment and/or maintenance of intersectoral groups at a local level to monitor compliance with the Sale of Liquor Act.
3	Ensure the provisions of the Sale of Liquor Act are effectively and consistently enforced.	3.1 3.2 3.3 3.4 3.5 3.6 3.7	Actively enforce the minimum legal age for the purchase, sale and consumption of alcohol on and from licensed premises, and for the consumption of alcohol in public places. Ensure adherence to a ‘no card – no service’ policy for young drinkers. Actively enforce measures aimed at discouraging promotions on licensed premises that encourage excessive or otherwise irresponsible drinking. Actively enforce provisions in the Act relating to the sale and supply of alcohol to intoxicated persons. Encourage, where applicable, the issuing of infringement notices for offences under the Act. Actively publicise the provisions of the Act relating to purchase on behalf of, or supply to, underage drinkers (other than by a parent or legal guardian). Ensure effective and consistent sanctioning of those violating the provisions of the Act.
4	Gather information on the impact of the changes introduced by the 1999 amendments to the Sale of Liquor Act on alcohol-related harm.	4.1 4.2 4.3	Support research on the impact of a reduced legal drinking age on alcohol-related harm. Support research on the impact of the increased availability of alcohol on alcohol-related harm. Support research on the administration of the licensing system, following further devolution of decision-making power to District Licensing Agencies.
5	Encourage local bodies to better address alcohol issues by effective use of legislation, by-laws, policies and plans.	5.1 5.2 5.3 5.4 5.5	Encourage local authorities to address alcohol issues via the development of comprehensive local alcohol policies. Encourage better co-ordination between planners and District Licensing Agencies on alcohol issues. Encourage local authorities to consider the appropriate location of licensed venues and retail alcohol outlets in their District Plans. Encourage local authorities to make the sale of liquor a notifiable land use, so that the likely impacts of licensed premises on particular sites may be considered. Encourage local authorities to support strategies for minimising alcohol-related harm, which have been developed by Maori community service providers and marae-based committees.

Demand reduction strategies

Demand reduction strategies are designed to prevent alcohol-related harm from occurring by ensuring that those who choose to drink do so in a responsible manner.

Such strategies include providing accurate information on the effects of alcohol, and developing education programmes to encourage moderation in the use of alcohol.

Demand reduction strategies also include taking initiatives to encourage the responsible promotion of alcohol in both on- and off-licence premises, monitoring new marketing strategies (particularly those targeting youth), and using different tax levers to vary or maintain the price of alcohol products relative to the price of other consumer products.

Information

People need reliable information to develop the knowledge and skills they require to make responsible decisions about their use or non-use of alcohol. They need to know, for example, what effects it will have on their health and behaviour, and how much they can responsibly drink under what circumstances. Furthermore, those who decide not to drink should feel comfortable in the knowledge that this is an acceptable option.

Objectives: information		Demand reduction strategies
6	Increase knowledge about risk factors associated with alcohol.	6.1 6.2 6.3 6.4 6.5	Provide clear and accurate information about alcohol and its effects. Widely disseminate the nationally agreed upper limits for responsible drinking. Make information available in a wide variety of settings and through a range of media (eg, Internet). Convey information in ways that reflect the needs and realities of the audiences being targeted. Promote public discussion and debate about the place of alcohol in New Zealand society, and the best ways of minimising alcohol-related harm.
7	Provide consumers with accurate and clear information on alcoholic drink containers.	7.1 7.2 7.3	Introduce standard drinks labelling. Increase public awareness and understanding of the standard drinks concept. Support further examination of the benefits and costs of including additional product information on alcoholic drink containers (eg, health warnings).
8	Make moderate use (including low alcohol use and non-use) viable and attractive options.	8.1 8.2	Promote more strenuously the non-use option, the use of lower-alcohol products, and the importance of eating food with alcohol. Continue moderation advertising.

Targeted health promotion

Two principles that underpin this National Alcohol Strategy are ‘appropriateness’ and ‘empowerment’. To be appropriate, strategies must be consistent with people’s cultures, realities and behaviours. One strategy will not be equally effective for all. For strategies to be empowering, those people who are targeted must have some input into the design of those strategies. Different groups will address alcohol-related harm in different ways, and will identify different priorities for action.

Health promotion is animated by these ideas of appropriateness and empowerment. In helping people to change their lifestyles and move towards a state of optimal health, health promotion initiatives will often be targeted at particular groups within the general population, seeking to facilitate lifestyle change through a combination of efforts to enhance awareness, change behaviours, and create environments that support health.



Youth

Alcohol is readily accessible to people who are under the minimum age for legally purchasing alcohol and who are particularly vulnerable to its effects. Although young people today are probably better educated about alcohol and the problems associated with its misuse than previous generations were, they still feature disproportionately in the statistics that measure alcohol-related harm. Moreover, while it has been found that more youth are abstaining from alcohol, those who do drink appear to be consuming more in binges.10

A common response to such trends is to opt for classroom-based drug education. However, concerns have been raised about the effectiveness of information strategies focused solely on school settings. Various researchers have noted that most individually focused alcohol education programmes have a limited, unsustainable impact on students, and disproportionately use up scarce resources (Wysong et al 1994; Mosher 1996; Wood 1997). A large number of studies and reviews recommend instead that schools adopt a more holistic approach, promoting a more integrated range of strategies addressing school policies, a broad health curriculum with alcohol education sessions, peer support services such as Students against Driving Drunk (SADD), work with parents, and community action (Alcohol and Public Health Research Unit 1999).

Broadly speaking, the international health promotion literature indicates that education on its own is not cost-effective, especially those programmes aimed at young people (Wagenaar and Perry 1992; Perry et al 1996). However, there are still examples of promising curriculum-based programmes that take an explicit harm minimisation approach (McBride et al 2000). Instead, there seems to be more support for community-based approaches that simultaneously focus on schools, parents and the wider community; and that allow young people themselves to play a key role in the design and delivery of interventions.

Embedding health promotion initiatives in this wider framework also takes account of the fact that a significant number of young people are not actually in school, for a variety of reasons. In order to reach these out-of-school youth, programmes targeting young people must be offered not only in their general community, but also through youth-specific media, as well as through new information technologies such as the Internet.

Objective: youth		Demand reduction strategies
9	Reduce the level and likelihood of alcohol-related harm amongst young people.	9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 9.9 9.10 9.11 9.12	Provide clear, accurate and relevant information to young people, their parents and other caregivers, about the effects of alcohol and the harm caused by its inappropriate use. Provide information to young people, their parents and others about assistance for young people who are experiencing drinking problems. Ensure information for young people is appropriately presented, available in a wide variety of settings and through a range of media. Ensure young people are routinely consulted on the development of information-based strategies around alcohol. Promote and support effective programmes and policies in schools that make best use of current knowledge about how to address the decision of whether to drink, and about responsible use of alcohol. Support groups that are shown to deliver effective peer-education on the responsible use of alcohol. Promote and support programmes that assist young people to develop skills to manage drinking situations, and actively involve young people in the planning and delivery of such programmes. Work towards changing the prevailing climate of acceptance of binge drinking by young people. Promote and support the development of community-based initiatives designed to reduce alcohol-related problems amongst young people. Ensure that young people are engaged in the design and implementation of community-based programmes to reduce alcohol-related harm. Support research on the ways that young people access alcohol. Investigate the establishment of a national advisory committee to provide leadership in the development and delivery of programmes targeting young people’s use of alcohol.

Young men

Research continues to show that young men are the most likely to drink in a manner that puts them at high risk of alcohol-related harm. Although this is not a new problem, it is important that resources, energy and innovative thinking are invested in the development and implementation of strategies to minimise the level and likelihood of alcohol-related harm amongst this group of drinkers who are most at risk.

Objective: young men		Demand reduction strategies
10	Reduce the level and likelihood of alcohol-related harm amongst young men.	10.1 10.2 10.3 10.4	Encourage the delayed onset of drinking by young men. Work towards changing the prevailing climate of acceptance of heavy drinking by young men. Include youth-specific media in strategies to disseminate information on alcohol to young men. Promote and support effective male-specific programmes to reduce alcohol-related harm.

Young women

Women’s changing drinking patterns are the result of a complex interplay of social and economic forces. An increased proportion of women in employment, changing ideas of gender and family responsibilities, and targeted marketing strategies have led to the trend whereby young women today drink substantially more than young women one or two generations ago.

There is evidence that it is more difficult for women to admit problems with their drinking than it is for men (Gray and Norton 1998). Furthermore, based on previous New Zealand studies it seems that because of their beliefs about ‘problem drinking’, many women do not realise that the amount of drinking that they regard as ‘ordinary’ is above generally accepted responsible limits (Park 1991).

Given the growing evidence of the dangers of drinking while pregnant, it is important that women, particularly young women, are well informed about responsible drinking and the possible harmful effects of excessive alcohol consumption.

Objective: young women		Demand reduction strategies
11	Reduce the level and likelihood of alcohol-related harm amongst young women.	11.1 11.2 11.3 11.4 11.5 11.6	Encourage a delay in the onset of drinking by young women. Widely promote responsible drinking guidelines for women. Ensure that clear and accurate information on the effects of alcohol on women is made available to health professionals. Develop and actively disseminate information about alcohol and pregnancy to young women, including culturally appropriate information for young Maori and Pacific women. Ensure that young women’s drinking is not overlooked in media campaigns designed to reduce alcohol-related harm. Include the use of youth-specific media in strategies to disseminate information on alcohol to young women.

Older people

Like younger people, older people are vulnerable to alcohol problems. They are more prone to the adverse effects of alcohol because they are more strongly affected by it than those in middle age. Older people are also more prone to adverse interactions between alcohol and the medication they may be taking. Moreover, life situations commonly experienced by older persons, such as loneliness and bereavement and other losses, may increase the likelihood that they will seek consolation from alcohol.

Objective: older people		Demand reduction strategies
12	Reduce the level and likelihood of alcohol-related harm amongst older people.	12.1 12.2 12.3 12.4	Make information readily available to older people about the effects of alcohol, and about responsible drinking practices. Ensure all health and social service professionals and volunteers providing services to older people are well informed about the effects of alcohol on older people, and about lower-risk drinking practices. Ensure information on the effects of alcohol, and on lower-risk drinking practices, is readily available to the families, relatives and friends of older people. Ensure information about assistance for older people experiencing drinking problems is readily available to older people, their families and health and social service professionals.

Maori

There is evidence that Maori drinking patterns are different in some respects from those of other New Zealanders. Differences in drinking patterns, cultural values and social practices mean that specifically developed and targeted strategies are needed to reduce alcohol-related harm amongst Maori.

Objective: Maori		Demand reduction strategies
13	Reduce the level and likelihood of alcohol-related harm amongst Maori.	13.1 13.2 13.3 13.4 13.5 13.6 13.7 13.8	Resource Maori community development initiatives as a way of reducing alcohol-related harm. Foster the development of kaupapa Maori alcohol and drug services, especially in those Maori communities that do not have such services. Support the further development and delivery of Maanaki Tangata and other health promotion programmes designed by Maori for Maori. Support the development of appropriate advertising and other marketing strategies for Maori to promote both moderation in the use of alcohol and the non-use option. Ensure all initiatives for age-related alcohol health promotion, especially those targeting youth and older people, also address the needs of Maori. Support the work of Maori wardens in the reduction of risky drinking practices by Maori. Ensure Maori communities are involved fully in developing policies on alcohol, including control/regulation, education, treatment and research. Improve linkages between Maori communities and statutory agencies to ensure co-ordinated and integrated planning, and to avoid the separation of alcohol-related initiatives from other social and health-related initiatives.

Pacific peoples

Pacific cultures emphasise the importance of the group over the individual. They encourage generosity and the provision of abundant food and drink. Health promotion strategies such as host responsibility, based as they are on a concept of moderation, may meet with limited success amongst people for whom generosity is paramount. Effective strategies for a reduction in alcohol-related harm amongst Pacific peoples will be different from other approaches, and may need to draw on values and influences such as the role of the church in Pacific communities, and the importance placed on genealogy (Alcohol Advisory Council of NZ 1997b; Ministry of Pacific Island Affairs 1999).

Objective: Pacific peoples		Demand reduction strategies
14	Reduce the level and likelihood of alcohol-related harm amongst Pacific peoples.	14.1 14.2 14.3 14.4 14.5 14.6 14.7	Support policy-relevant research on the place of alcohol in the lives of Pacific peoples in order to establish accurate baseline data. Resource the development and implementation of alcohol-related programmes by Pacific peoples for Pacific peoples. Develop alcohol-related information resources in different Pacific languages. Ensure all initiatives for age-related alcohol health promotion, especially those targeting youth (eg, schoolbased drug education programmes), also address the needs of Pacific peoples. Explore and utilise existing cultural structures, mechanisms and channels of communication to promote responsible use of alcohol amongst Pacific peoples. Ensure Pacific peoples are involved in developing policies on alcohol, including control and regulation, education, treatment and research. Improve linkages between Pacific communities and statutory and non-statutory agencies (eg, churches), to ensure co-ordinated and integrated planning for minimising alcohol-related harm.

Minority groups

There are indications that members of some minority groups are at greater risk of alcohol-related harm than the population as a whole.

Although the evidence is mixed, some sources suggest that gay, lesbian, bisexual and transgender people, especially younger members of these communities, are at greater risk of alcohol-related harm than other people (Smith et al 1999; Fergusson et al 1999; MacEwan and Kinder 1991; MacEwan 1994; Heffernan 1998).11

Also, new arrivals from other countries, especially those from countries where alcohol is not widely used, may be at greater risk. This vulnerability exists for short-term tourists to New Zealand, as well as for people who are emigrating to New Zealand to live.

Strategies aimed at reducing alcohol-related harm amongst members of minority groups need to recognise and be in tune with the different life experiences and realities of the members of these groups.

Objectives: Minority groups		Demand reduction strategies
15	Reduce the likelihood of alcohol-related harm among gay, lesbian, bisexual and transgender people.	15.1 15.2 15.3 15.4	Incorporate information on the effects of alcohol and on responsible drinking practices in queer health initiatives, and via gay and lesbian media. Promote community activities for gay, lesbian, bisexual and transgender people that are not oriented around drinking alcohol. Ensure that alcohol-related health promotion strategies for men and women address the needs of people who are same-sex-attracted. Ensure initiatives for all alcohol health promotion for young people address the needs of same-sex-attracted youth.
16	Reduce the likelihood of alcohol-related harm among tourists to New Zealand, and people recently settled in New Zealand.	16.1 16.2 16.3 16.4	Ensure people visiting or settling in New Zealand are informed about the effects of alcohol, responsible drinking practices, and legislation governing alcohol in this country (eg, drink driving limits, minimum legal drinking age). Ensure new arrivals receive information about assistance for those experiencing drinking problems. Ensure members of minority groups are involved in the design and delivery of initiatives to prevent and reduce alcohol-related harm amongst members of their communities. Support research on the drinking patterns and practices of tourists and those recently settled in New Zealand.

Responsible marketing

Unlike most food and other drinks that are sold freely over the counter, alcohol has the capacity to alter mood, thought and behaviour. For these reasons, it is important that alcohol is marketed responsibly, and with a clear appreciation of its potential for harm.

Alcohol marketing encompasses a wide variety of strategies designed to: maintain or increase the frequency with which alcohol is purchased; attract new customers; and improve market share. Examples of such strategies include (but are not limited to): advertising; sponsorship of sports, cultural and social events; on-licence point-of-sale promotions, such as ‘happy hours’; the use of loss-leaders in off-licence outlets; merchandising, such as the sale of branded clothing; new products, like ‘alcopops’; and the use of new distribution modes, such as the Internet and vending machines.

Of the various marketing strategies, advertising has received the most attention. Although previously absent from television and radio, alcohol brand advertising was introduced in 1992, and now has an established presence in these broadcast media.

Alcohol advertising in New Zealand is covered by the Advertising Standards Authority (ASA) and the Broadcasting Standards Authority (BSA), which operate formal codes of practice, backed by systems for addressing any complaints made under the codes. In addition, the Liquor Advertising Pre-vetting System (LAPS) exercises some control over the way alcohol is promoted in the media, offering a ‘front-end’ checking system.

Whether alcohol advertising increases consumption (either in aggregate or in specific cohorts), or whether it simply influences brand allegiance, is unclear. In the absence of convincing evidence that alcohol advertising does not increase consumption, however, particularly in certain market segments, a cautious approach to advertising is required.

Objectives: responsible marketing		Demand reduction strategies
17	Ensure that alcohol advertising/sponsorship conforms to the relevant codes of practice.	17.1 17.2 17.3	Require regular independent reviews of the ASA and BSA codes of practice and procedures governing alcohol advertising and sponsorship. Ensure reviews of alcohol advertising include the consideration of evidence about the possible need for tighter controls on such advertising. Support the continuation of the LAPS Committee.
18	Minimise the exposure of young people to alcohol marketing messages.	18.1 18.2 18.3	Resist any relaxation of the broadcast time constraints on alcohol advertising. Advocate against new sales and distribution strategies that are difficult to police and have the potential to increase underage drinking. Monitor compliance with the National Guidelines on the Naming, Packaging and Merchandising of Alcoholic Beverages (ALAC 2000), especially regarding the responsible marketing of ‘alcopops’ and related products.
19	Minimise the use of marketing strategies that may cause or contribute to alcohol-related harm.	19.1 19.2 19.3 19.4	Advocate against the use of aggressive pricing strategies, including loss-leader strategies, aimed at attracting new customers. Monitor compliance with the National Protocol on Alcohol Promotions, (Hospitality Association of New Zealand et al 2000) regarding the responsible use of point-of-sale marketing techniques (eg, ‘happy hours’, half-priced drinks). Commission research to determine the impact of point-of-sale alcohol promotions on alcohol consumption. Consider alternative sponsorship sources for current alcohol-sponsored sporting events.
20	Ensure that any new detrimental alcohol marketing strategies are identified early, and do not become established in New Zealand.	20.1	Establish a body to monitor new alcohol marketing and sales strategies and provide advice on their likely effects on alcohol consumption, including consumption by underage drinkers.

Taxation

Within the range of factors that determine how people use alcohol, price is an important influence, both on total alcohol consumption and individual drinking patterns.

The effect of price changes on alcohol consumption has been extensively investigated (Wette et al 1993; Edwards et al 1994; Lehto 1995; Godfrey 1997; Ponicki et al 1997). Research has consistently shown that, all other factors being equal, a rise in price leads to a drop in consumption, and a decrease in price leads to a rise in consumption. There are, however, differences in the degree to which these typical patterns hold true: there is greater price sensitivity to some beverages than to others (Grossman et al 1994) and some groups in the population, such as young people, appear to be more sensitive to price changes than the population as a whole (Zhang and Casswell 1999).

Some critics have suggested that the heaviest drinkers are not very sensitive to price, and that this undermines the ability to use taxes to influence their drinking behaviour. However, it has been demonstrated that significantly raising the price of alcohol does in fact lead to a decrease in consumption by excessive drinkers (Hawks 1993). Indeed, one classic study found that during a period of economic recession, it was the heavier drinkers who reduced their alcohol consumption more than any other group within the population (Kendell et al 1983).

Building from these research findings, taxation has been widely used as an instrument to vary the price of alcoholic drinks.

Broadly speaking, excise tax is imposed on alcohol to:

• offset the external costs of alcohol misuse. Alcohol imposes costs (such as those associated with death and injuries on the roads, increased health care, violence, and lost productivity) on the community, which drinkers do not pay. An excise tax on alcohol helps to compensate for these negative externalites

• reduce harm. A review of evidence indicates that proportionately higher alcohol prices (and taxes) are associated with fewer alcohol-related problems. Separate studies have shown small, but statistically significant, reductions in drink-driving, suicide deaths, cancer, homicides, rapes and assaults when alcohol prices have been raised through taxation (Kenkel and Manning 1996; Chikritzhs et al 1999).

In terms of excise loading, currently the alcohol in beer and wine is taxed at a considerably lower rate than is the alcohol in spirits. As it is the alcohol component of the beverage that is responsible for alcohol-related harms, some have suggested that a more equitable form of excise might be one based on alcohol content rather than on beverage type. To this end, officials at The Treasury have observed that:

An increase in excise on beer and wine and a reduction in that on spirits,so that the excise rate on all beverages were equalised and overall revenue were unchanged,would increase overall welfare (Hall 1997; Crosbie et al 2000).
It should be noted, however, that from a public health perspective, it is the final cost to the consumer of different beverages that will be the critical factor, rather than their excise loadings. This final cost, in turn, will be influenced by the price relativities of alcohol when judged against a consumer’s disposable income and overall purchasing power. Recognition of this fact has led public health advocates to argue that excise tax should be indexed to the rate of inflation, thereby maintaining the relative price of alcohol.

Objectives: taxation		Demand reduction strategies
21	Develop a comprehensive taxation policy on alcohol to discourage excessive use, and recoup some of the external costs caused by the misuse of alcohol.	21.1 21.2 21.3	Retain an inflation-indexed excise tax on alcohol. Investigate the adoption of an excise tax based on alcohol content, rather than beverage type. Retain a specific levy on alcohol to fund work by the Alcohol Advisory Council of New Zealand.

Problem limitation strategies

The notion of problem limitation accepts that alcohol is a part of many people’s lives, and that strategies are needed to minimise problems that can result from its misuse.

Problem limitation involves encouraging those who serve alcohol to do so responsibly. It also means taking steps to ensure that drinking environments, especially those linked with alcohol-related harm, are made as problem-free as they can be.

Importantly, problem limitation strategies also include the provision of treatment. Even with effective strategies for supply control and demand reduction in place, some people will always require help to manage problems that are associated with their drinking.12

Environments

Licensed venues and other social settings

The development of low-risk drinking environments requires, in particular, responsible serving of alcohol, whether on licensed or private premises, to avoid alcohol problems amongst customers or guests. Responsible serving aims to prevent over-consumption and to reduce the incidence of intoxication and its associated problems.

The five requirements of being a responsible host are:

• providing and promoting substantial food

• providing and promoting non-alcoholic and low alcohol beverages

• serving alcohol with care and responsibility

• identifying, and responsibly dealing with, intoxicated and underage drinkers

• arranging safe transport options.

Given that many licensed premises provide both alcohol and gaming opportunities, there is also an increasing awareness of the need to incorporate host responsibility principles and practices around gambling, as well as alcohol, in these environments.

Objectives: licensed and social settings		Problem limitation strategies
22	Encourage the development of licensed premises as places where alcohol can be consumed responsibly.	22.1 22.2 22.3	Continue to promote initiatives, such as host responsibility, which are designed to reduce alcohol-related problems on licensed premises. Display information for patrons in all licensed premises that explains host responsibility and outlines responsible drinking practices. Promote the availability of low alcohol and non-alcoholic drinks, and encourage licensees to price such drinks in a way that reflects their lower cost to the licensees.
23	Ensure that licensees and managers understand and implement the principles of host responsibility.	23.1 23.2 23.3 23.4	Refine targeted training packages to assist and encourage the implementation of host responsibility practices. Continue to require that those applying for new or renewed licences have a written host responsibility policy, which includes provisions for ongoing training of staff. Ensure staff of licensed premises are trained to manage alcohol-related problems that may occur, especially those likely to result from intoxication. Encourage the inclusion of more comprehensive host responsibility principles and practices in licensed premises that provide alcohol and gaming opportunities.
24	Encourage host responsibility in homes and other social settings.	24.1	Increase awareness of host responsibility among members of the public, and promote its importance for those who are hosting a private function.

Workplaces

People whose drinking affects their work can jeopardise both their own safety and productivity, and the safety and productivity of others.

Legislation such as the Health and Safety in Employment Act 1992 makes employers responsible for providing a safe working environment. That means doing as much as possible to reduce the risk of accident and injury.

Effective workplace programmes aimed at reducing alcohol-related harm are likely to include the development of workplace alcohol policies, employee education and employee assistance programmes (EAP). In some workplaces, such as those where workers use heavy machinery or where public safety is at stake, testing for alcohol may also need to be considered.

Objective: workplaces		Problem limitation strategies
25	Reduce alcohol-related harm in the workplace.	25.1 25.2 25.3 25.4 25.5 25.6 25.7	Develop and promote workplace alcohol policies that incorporate host responsibility principles and practices. Educate employers and employees about the effects of alcohol, including ‘day after’ effects of heavy drinking on work performance and safety. Develop and promote policies for the effective management of alcohol-related problems in the workplace (eg, intoxication and alcohol-related accidents, absenteeism). Promote the use of EAP programmes as a way to help employees with alcohol-related problems. Investigate the desirability of using alcohol testing in workplaces where the safety of workers and the public is at stake. Investigate the introduction of reduced ACC or insurance levies for industries and organisations with approved alcohol policies in place. Support research into the extent of alcohol-related problems in New Zealand workplaces.

Public places

Throughout the year, but particularly in late December to early January, media around the country typically carry reports of outdoor events marred by drunken violence and vandalism. Many people choose to celebrate traditional festivals outside when the weather is good. However, the harm associated with large quantities of alcohol being quickly consumed, often by young people in unsupervised settings, can be significant.

Indeed, it was a recognition of these types of seasonal problems that lay behind the Local Government Amendment Act (No 4) 1999. This Act strengthened the power of local authorities to prohibit the consumption or possession of alcohol in public places on specified days.

As well as traditional festive occasions, more organised events such as sports fixtures and open-air concerts are frequently the sites of problems resulting from excessive consumption of alcohol. Sporting events, in particular cricket matches, have often been the scene of disruptive and dangerous behaviour by people who have had too much to drink.

Quite apart from large scale public events, problems can arise when individuals or small groups drink in public places. The 1995 National Alcohol Survey found that outdoor public places were the third most popular drinking venue for those aged 14–17 years (Wyllie et al 1996).

There are also concerns about individuals or small groups who drink outside as part of other recreational activities, and for whom the effects of alcohol may be compounded by their exposure to the sun all day. As mentioned in Part Two, more and more evidence is beginning to emerge about the role of alcohol in drownings, and questions are increasingly being asked about the involvement of alcohol in boating accidents (Smith et al 1993; Warner et al 2000).

Objectives: public places		Problem limitation strategies
26	Reduce alcohol-related harm at organised public events such as sporting fixtures and concerts.	26.1 26.2 26.3 26.4 26.5	Educate event organisers on how to manage the availability and use of alcohol, and the problems that may arise from its misuse, at organised public events. Support the implementation of guidelines on Managing a Successful Public Event, to help reduce alcohol-related problems at public events. Encourage interagency planning for major public events that involve the use or sale of alcohol. Support and promote alcohol-free events. Develop host responsibility guidelines for events with special licences.
27	Reduce alcohol-related harm at informal and/or unplanned public events.	27.1 27.2	Raise awareness of local authorities’ power to set conditions around the possession and use of alcohol in public places. Provide guidelines for managing alcohol-related problems that may occur at unplanned events.
28	Raise public awareness of the dangers of combining alcohol with water-based recreational activities.	28.1 28.2	Educate the public about the dangers of drinking alcohol before and while swimming or boating. Investigate ways to enhance the powers of regional and local bodies to better manage the use of alcohol during water-based public events.

Roads

Although alcohol-related fatalities and crashes on the roads have been significantly reduced in recent years, there is still more to be done. A national strategy to reduce alcohol-related harm cannot overlook the personal, social and economic costs of drinking and driving.

Objective: roads		Problem limitation strategies
29	Further reduce the incidence of alcohol-impaired driving.	29.1 29.2 29.3 29.4 29.5 29.6	Increase the frequency of compulsory breath testing. Actively promote initiatives designed to reduce alcohol-impaired driving (eg, designated drivers, the availability of public transport options). Increase the emphasis on addressing drinking and driving in known areas of high risk, such as rural roads. Develop targeted strategies to reduce alcohol-related road crashes amongst Maori. Improve strategies for dealing with repeat drinking drivers, and those with very high breath and/or blood alcohol concentrations. Continue to monitor international evidence on different legal limits for breath/blood alcohol levels when driving vehicles, and assess the relevance of such evidence for New Zealand.

Treatment

Regardless of what general strategies are in place to minimise alcohol-related harm, some individuals will require help for problems associated with their drinking.

The treatment of alcohol problems has evolved over time. The recent development of more accurate assessment techniques and specialised treatment programmes has enabled those involved in this area to improve the effectiveness of their services. Pharmacological interventions for the treatment of alcohol problems, such as the use of Naltrexone and Acamprosate, are also showing real promise (Hoes 1999; Garbutt et al 1999 and Anton et al 1999).

The benefits of treatment, both to individuals having difficulties with their drinking and to the wider community, are well established (Some of the most recent studies are Hoes 1999; Garbutt et al 1999; and Anton et al 1999). One of the most widely quoted statistics is that every dollar spent on treatment generates seven dollars’ worth of ‘downstream’ savings, primarily through the health care and criminal justice systems (Holder et al 1996; Gossop et al 1998).

An important advance in recent times has been the recognition that there are different degrees of drinking problems (see Figure 9 below). No one kind of treatment is able, nor should it be used, to respond to them all. A range of responses needs to be offered.






While to some extent a range of treatments already exists, further development is required, especially in the delivery of brief interventions to those experiencing problems that are at an early stage (Powell et al 1996; Adams et al 1997 and McCormick et al 1999). In this regard, the National Health Committee’s Guidelines for Recognising, Assessing and Treating Alcohol and Cannabis Abuse in Primary Care offer a valuable tool for frontline workers, and efforts must now be directed at implementing the Guidelines (National Health Committee 1999).

A key challenge will be to deliver the required range of interventions coherently, and in a manner that ensures both adequacy of coverage and a high quality of service.

Another important development has been the move to take the stigma out of getting treatment for alcohol problems. It has been commented that, in much the same way as dental checks are seen as a normal part of life, more needs to be done to ensure that screening for alcohol problems becomes a part of standard health care delivery (MacEwen 1999; National Health Committee 1999).

The increased awareness that drinking problems manifest themselves in a variety of ways and contexts indicates that there is a need to train people across a range of disciplines to recognise and respond to these problems. Frontline workers in health, justice and social services need to be alert to early indications of drinking problems amongst their clients, and to be aware of how to intervene appropriately. For an example taken from general medical practice, refer to Paton-Simpson et al 2000. In addition, it is essential that there exists an effectively trained, specialist workforce to provide back-up support for those at the front line, and to treat any drinkers who present with serious problems.

Research has identified a number of groups whose treatment needs are not being adequately met, including women, adolescents, clients of the criminal justice system, Maori and Pacific peoples, and those with one or more co-existing mental health problems. There are also a several areas in the country where public funding of community assessment and treatment services is below benchmark levels.13

To ensure that treatment is accessible to all groups within society, levels of treatment provision need to be raised, and the treatment sector better resourced, to meet the needs of different groups. In addition, there is an urgent need to develop new and innovative ways of reaching and providing assistance to the many problem and dependent drinkers who do not participate in formal or informal interventions (MacEwan 1999). The success of the Alcohol Helpline telephone service, established in 1995, has underlined the unmet needs in this area; the wider field of consumer health informatics14 may offer some of the best ways of providing services for people who are not accessing traditional ‘bricks and mortar’ services, such as people who live in rural and remote communities, and those who feel uncomfortable presenting for help in person.

As demands on health and welfare budgets continue to increase, so further research will be necessary to ensure that funds spent on treatment are used to the best effect. In addition, research is required to better understand and respond to treatment needs of Maori and Pacific peoples, and other population groups who may have special treatment needs (for instance, people who are same-sex-attracted), as well as to explore the effectiveness of new approaches that are producing encouraging results overseas.

Objectives: treatment		Problem limitation strategies
30	Increase understanding of the range, the causes and the treatment of drinking problems.	30.1 30.2 30.3	Provide information on the range of problems that individuals have with alcohol, the diversity of the causes of such problems, and patterns of recovery. Make information more widely available on the range of treatment options for drinking problems. Continue to support and strengthen the National Centre for Treatment Development (Alcohol, Drugs & Addiction) as a centre of excellence for the theory and practice of treating drinking problems.
31	Increase primary care workers’ early identification of and response to alcohol-related problems.	31.1 31.2 31.3	Educate and resource primary care workers to recognise and respond to alcohol-related problems. Incorporate teaching in alcohol studies into a wide range of health and social service training. Explore the use of contractual levers and other incentives for general practitioners to provide screening and brief interventions for alcohol problems.
32	Ensure the provision of a coherent and comprehensive approach to alcohol treatment.	32.1 32.2	Provide well-resourced, publicly funded and nationally co-ordinated treatment services. Provide a comprehensive range of treatment options, including effective pharmacotherapies.
33	Ensure treatments are accessible.	33.1 33.2 33.3 33.4 33.5	Publicise the full range of alcohol treatment and support services. Promote the idea that seeking help for a drinking problem is equivalent to getting help for any other health problem. Address specific barriers to treatment such as location and cultural appropriateness. Ensure community-based assessment and treatment options are accessible to people throughout the country. Explore and support options for delivering treatment (eg, consumer health informatics) for which access is not dependent upon location.
34	Ensure treatments are effective.	34.1 34.2 34.3 34.4	Further encourage the development of independent assessment services to ensure people receive treatment appropriate to their needs. Develop treatment manuals and protocols. Promote and support research into treatment effectiveness, particularly in regard to cultural and other facets specific to the provision of treatment in New Zealand. Support increased training opportunities for treatment workers.
35	Ensure that treatment services are responsive to unmet and emerging needs.	35.1 35.2 35.3 35.4 35.5 35.6 35.7	Improve treatment services for adolescents. Provide services that better meet the needs of Maori. Provide services that better meet the needs of Pacific peoples. Address any special treatment needs of other groups that experience alcohol-related harm (eg, women). Improve the ability of treatment services and staff to respond effectively to the needs of people with both alcohol use problems and mental health problems. Increase and improve treatment services for clients of the criminal justice system. Increase the responsiveness of treatment services to the needs of family members and other supporters of people receiving treatment.

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10 The Alcohol Advisory Council defines ‘binge drinking’ as drinking five or more glasses on one drinking occasion. This is in line with standard international definitions of binge drinking: refer to Substance Abuse and Mental Health Administration 1996; Schulenberg et al 1996.

11 There are also several useful papers on substance use in the conference proceedings of Health in Difference: First national lesbian, gay, transgender and bisexual health conference (University of Sydney, 2–5 October 1996).

12 It is important to note, however, that the majority of people who misuse alcohol or are alcohol dependent do not seek help for their drinking problems: see Hornblow et al 1990. A key challenge in the treatment field is thus exploring opportunities for early intervention with such people, in forms that do not require individuals to come into a traditional treatment setting.

13 A 1999 assessment against benchmarks found that some of the most poorly served areas were in parts of Auckland, Waikato, the Bay of Plenty, Manawatu, Porirua, Wellington and Central and North Otago (Health Funding Authority 1999). The most up-to-date analyses suggest that, although service gaps still remain, these spatial patterns may have changed.

14 This term refers to the use of computer-based and telecommunications technologies to help consumers obtain information, analyse their health care needs, and make healthy decisions.

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Related information

Other Ministry of Health Strategies

Alcohol in New Zealand

National Drug Policy website