Gretchen: Alcohol is often described as an integral part of Australian culture. We make mates as we drink beer, cement friendships over wine and cocktails. There is a strong expectation that we drink when we socialise and many of us drink at home after work to wind down. Alcohol as the song by the Specials goes, “gives some people a real good time but it also causes untold misery”. While guidelines from the NHMRC suggests fewer than 10 standard drinks a week to reduce the risk of alcohol-related injury and disease and minimise population-wide impacts, nearly a fifth of Australian adults are drinking more than that but it’s complicated, not all communities in Australia drink in uniform ways there are cultural differences and stage-of-life differences too. In this regard, what was accepted as normal 10 years ago has shifted considerably but the fact remains alcohol is a modifiable risk factor in preventable disease, ranked fifth behind tobacco, being overweight, dietary risks and high blood pressure. There are short-term risks, such as road accidents and domestic violence and long-term risks, including various kinds of cancer but The Australian Prevention Partnership Centre has recently worked with New South Wales Health and Cancer Institute NSW to produce an Evidence Review and an accompanying brief on the value of prevention to reduce alcohol use at a population level.
Today, Prevention Works invited two authors of the review to explore some of these challenges. Nikki Woolley, Skin and Lifestyle Portfolio Manager at the Cancer Institute NSW and Dr Elly Howse, who is the Prevention Centre’s Research Manager and Senior Research Fellow. Welcome to you both. Nikki, let’s get straight into it and set the scene with the types of cancer alcohol can cause?
Nikki: Well, if you can imagine the alcohol moving into the body, that’s a good way of remembering that it comes in through the mouth, the lips, past the larynx, the pharynx, the oesophagus, and then down into the bowel, so bowel cancers and also liver cancers, mouth and neck cancers, breast cancer as well. So, it moves through the body and does impact at that cellular level and can cause harm that leads to cancer.
Gretchen: It’s interesting though, I mean of course it’s never quite straightforward as that is it because as I understand it, kidney cancer decreases a little but liver cancer increases significantly?
Nikki: Yes, it impacts a little bit by how much you drink. So, if you have two or more alcoholic drinks a day, then that increases your risk of bowel cancer and three or more a day increases your risk of stomach and liver cancers. Up to two alcoholic drinks a day may or seems to decrease your risk of kidney cancer, but more than two drinks per day it’s actually not clear yet what the impact is as far as cancer goes so it’s about weighting that evidence about the harm. That harm from cancer is of a bigger weight, weighs more, than that possible beneficial effect.
Gretchen: And how many cancer cases are caused a year, approximately with alcohol?
Nikki: In Australia we think over the next 10 years or so there will be about 15,000 cancers and in 2018 in Australia 4% of all deaths were attributable to cancer, to alcohol, so that was 6,500 deaths and total in 2018. So that’s really significant numbers.
Gretchen: And what’s the cost per year, Elly, you might be able to answer this for us?
Elly: I think there’s quite a variation in terms of how you actually measure the cost of alcohol use to the Australian population. You can measure it in terms of taking a healthcare perspective so actually looking at direct costs in terms of the health system and what all of those diseases and conditions and premature deaths and disability and illness actually mean for the health system and then you can also take a broader costing approach, which is looking at it in terms of a societal approach, so looking beyond the health system and actually costing things like lost productivity, absenteeism from work but also costs to other sectors.
Gretchen: Crime, for example?
Elly: Exactly, or any other kind of contributions to the criminal justice system. So yes, it depends how you want to measure it but the costs are pretty significant and range in the millions and billions of dollars.
Gretchen: You’ve been working together on this Evidence Review could you describe what each of you brought to the review?
Nikki: Yes, so the Cancer Institute NSW and the Centre for Alcohol and Other Drugs at the Ministry of Health New South Wales met and talked about this fantastic report, The Value of Prevention report which the Prevention Centre worked on, which looked at a whole range of risk factors, but excluded alcohol because of various reasons and we thought this is great, wouldn’t it be great to have something like this for alcohol. So, the Prevention Centre have really excellent kind of analysis and academic connections and the ability to analyse the research and also do modelling and economic costings, et cetera. So, we commissioned that research, it was kind of an extension from something that we’d already seen and we could already see the value of and it really is for us to help guide our policy I suppose, and where we put our efforts and what can we learn about working together better to try and change this in a systemic way.
Gretchen: And Elly, how did you mobilise the Prevention Centre’s skillset and and offerings?
Elly: The Prevention Centre has as one of its kind of core principles that we are about helping to translate evidence and knowledge into policy and practice. So, we want to help our policy partners and practitioners that we work with use evidence and knowledge about prevention in a way that’s going to help inform their services and programs and the policies that they want to implement.
So, we do that by bringing together the top researchers in this area and in this case, we worked with a fantastic health economist Paul Crosland and a team of health economists to bring together all of the epidemiological evidence and the economic evidence about alcohol harms and then we also combined that with a rapid review of interventions that address alcohol use and harms at that primary prevention level so population-wide. That’s essentially what we contributed to the project and I guess I should say that this is not like a normal systematic review that is usually published in the medical and health literature. This was a rapid review bringing in evidence from lots of different types of grey literature, as well as the peer-reviewed literature, and really looking at that kind of high-level evidence, bringing it and synthesizing it together to help it make sense for our policy partners in the case of Cancer Institute NSW and the Centre for Alcohol and Other Drugs.
Nikki: The other player was the Sax Institute, which was a really fantastic intermediary organisation to help us refine what we actually wanted to know and why.
Gretchen: Given that alcohol is something that’s so embedded in our culture and it’s seen as Aussie and it’s seen as larrikin and so on. How realistic is it to hope that we might reduce our drinking down to zero as a population and what kind of allowances can be made for the cultural elements of drinking alcohol?
Nikki: I think Australian culture changes and evolves all the time of course and there is that stereotype there which is based on the prevalence of alcohol and so many social occasions et cetera and even though there is no safe level of alcohol consumption for cancer there are guidelines that the Cancer Institute NSW supports, which reduces the overall lifetime risk and short-term risk of harm and they are this 10 standard drinks in a week, and so when you said, “what chance do we have to remove alcohol consumption or eliminate social drinking?” I don’t think that’s realistic for the population and there’s always some weighing up between the impact or the cost for the individual, the costs for society, the cost for a particular community, the cost for a family, the cost for what you can achieve in your life and what you might be able to achieve in your life and how much do you understand alcohol impacts on that. How much do you perceive? So, there’s lots of elements to do with alcohol and what we want to do is to raise the awareness that there is no safe level and why is it that it is so prevalent, and can we have a good time without it? Can we make it easier for people not to drink and not feel that they are the exception and have more fluidity there so that people can actually make choices about their own consumption without being faced with alcohol everywhere they turn.
Gretchen: It’s super interesting isn’t it, just watching the development of that, I mean I know people certainly around my age in their fifties who are now talking about the best kind of low-alcohol beer and there are now options for that but it’s systemic as I think you’d like to point out Elly, there are a whole range of factors that need to play into reducing the amount of alcohol drunk as a population?
Elly: A pretty famous epidemiologist about 30 years ago, Geoffrey Rose, coined this idea that actually a lot of work that we do in prevention is kind of targeting a small high-risk group who have particular health behaviours that you want to shift quite dramatically and the point that he made was that we need to look at the whole population and we need to shift the overall risk of the population down and to do that even just quite small affects. If everyone were to have one less standard drink at a time, or per week, you could actually see quite measurable and impressive health improvements for the whole population and that’s what public health and prevention is really all about, how do we change the overall prevalence and risk across the whole population?
Yes, we need to target and support people who have a very high risk of ill-health due to particular health behaviours but we also need to make sure we are targeting the population as a whole and to do that we really need to have supportive environments and systems that enable that behaviour change – so it’s not enough to give people educational information you’ve also got to make it easy for them to put that information and education into practice.
Gretchen: When I think about culture, one of the things that the review pointed out was that those from culturally and linguistically diverse backgrounds are apparently less likely to drink at risky levels. Can you talk about what that means to a review of this kind when you start to really consider that Australia is not a homogenous place, what does it mean?
Elly: I think one thing I should note is while that can be noted in terms of culturally and linguistically diverse groups, on the other hand, for the second part of the review where we looked at the effectiveness or the benefits of different interventions targeting different groups we actually found very little evidence about successful or effective interventions targeting culturally and linguistically diverse groups. So, I think that’s a really clear gap in the literature and evidence that other partners and other researchers might want to think about going forward.
Gretchen: What was also interesting to me talking about diverse groups of people and Australians not being homogenous, there’s been an increased drinking level in people over 70 and anecdotally, as I understand it, younger generations are less interested in going out and getting absolutely hammered and obviously that’s going to be different in different communities but I think those two facts are quite interesting. I would not have expected people over 70 to be drinking, perhaps more?
Elly: I think when you look at the health burden we outlined in the first part of the review you can certainly see that there is an increased health burden from alcohol use in middle-age to older age groups and I think there has been quite a bit written about in recent years about the increase for women of that age group as well, but it is still predominantly middle-aged and older men who experienced the most severe health outcomes from alcohol use and drink at the riskiest levels consistently and that’s what the health burden evidence that we looked at showed quite clearly but it is true that overall younger people are abstaining from alcohol in greater numbers than they were say 20 or 30 years ago. So, I think that’s quite interesting and I think a lot of people would be quite surprised to hear that in fact the people we are really concerned about is middle-aged and older Australians particularly men but also women.
Gretchen: When you consider the cost and the culture together and you consider the individual and the population and how the two interplay, what happens at a population level if an individual cuts back by a drink or two a week? Do we have models that show that? I mean, given that we have to consider there’s complexities there of genetics, otherwise healthy or unhealthy lifestyles, existing diseases, how do you weigh all that up and then come to an analysis that dropping a couple of drinks will actually make a considerable difference?
Elly: We do have national standardised surveys that track alcohol usage at that population level. That is one of the main ways in which we can tell if there’s been a change in reported consumption across the population, that’s one of the main ways we would work that out or determine that and states and territories also do run their own health surveys and there’s lots of other ways in which data is collected as well.
Nikki: And then the case of the Australian Guidelines, alcohol guidelines, that is essentially a very long, comprehensive document that has a shortened version of what the guidelines are, that’s where that comes from. It’s from tracking what would be the harm if the population drank at a certain level or under and so that’s where the no more than 10 standard drinks in a week and no more than four standard drinks on a single occasion comes from and for women who are considering pregnancy or are pregnant, no alcohol at all and under 18 year olds no alcohol at all, that’s where that comes from it shows that if people drank at those levels or no greater than over a population the harm will be less in the short term from harms, like for example, road deaths, and in the longer term, for example, cancer. They’ve done the work for us and now the guidelines are super clear.
Gretchen: So Nikki, what are the mechanisms for change then? We’re all familiar with the campaigns of the past, the public campaigns Slip, Slop, Slap and tobacco and smoking campaigns, but that’s about the individual and success there is varied, what else? What might structural and regulatory intervention do?
Nikki: So the visibility of public health, often people see campaigns and that’s what they think of first or they think of health education in schools and those are important parts of the public health but they’re only part of the whole and the value of prevention to reduce alcohol consumption report really says that we need to have a systematic approach across the whole of society, across legislation, labelling, availability, licensing and that health promotion programs need to work with communities and communities that have a role in deciding their own alcohol-related prevention programs tend to be more successful than those that are imposed on communities. In a sporting context, it’s a good setting, you know where people spend their time, to look at that are related to alcohol because quite often sporting clubs are licensed, not always, and also they may use alcohol for fundraising purposes and so a program that’s running in Australia, Good Sports is its name, it’s a program where it looks at alcohol at a policy level in terms of signage and the club and all the licensing and the responsible service of alcohol training for staff. It has a whole range of different factors and clubs work their way through and then keep renewing their activity and what that program has shown is that through those simple measures with the involvement of the committee at the club and the membership, over time there has been less harm shown in and around sporting clubs from alcohol as a result of that program. And as a program that has been shown to be scalable it can as it’s happening at thousands of clubs. So, that’s a good example of how it works on a whole range of different areas, not a single one and I think that’s where this report reminded us that the Cancer Institute NSW is a sizeable organisation within New South Wales but there’s only so much we can do alone. The whole of government can only do so much alone. There is a whole lot of non-governmental organisations that can have a role in this too and then together we can all contribute to some programs and then what we need to do is to evaluate those programs, then show what worked, what didn’t, and then share those findings. So that’s where we, I think this is what that report’s really shown us, that we need to fill some of the gaps in the evidence, we need to contribute to that evidence, and we need to do more together.
Gretchen: Can you describe, practically speaking, what some of those interactions might’ve looked like in different communities?
Nikki: Sure. I think policy and licensing is a really good one. How many liquor licenses are in a specific location and how many more are approved is a really key factor so that’s a really significant one. And then at a labelling level, about making it clear what standard drinks it is on, the pricing of alcohol, the sort of big picture policy, legislative issues and then locally it can come down to programs that we just described in sport. It might be community action on alcohol knowledge in a community but also availability and involvement of communities and those things, not just policy makers, but community themselves.
Gretchen: Like that might mean deciding how many liquor outlets there are in a particular area?
Nikki: Deciding that a community is going to actually have a say and say something about a proposed new license would be a good example of that where community can have a really significant voice and say, we don’t want another big liquor outlet in our area.
Gretchen: And that has happened, hasn’t it? I think that’s happened in Darwin, right?
Nikki: Yes, it’s a complicated issue because of the size of the outlet and at what level of government that decision can be made. So, it’s quite complex, especially when it’s disputed, but yeah, there’s definitely a key role for community there and not all communities understand that they have that ability to have a voice and I think that is significant.
Gretchen: This is where one of the things that you’ve found is that there needs to be more evidence around economic costing. Why is that so critical and what factors should actually go into that costing, it’s big business right?
Elly: So, one of the things we did identify as part of the review was that we do need more economic evidence about the value of prevention in regards to alcohol use and harms and I think after doing the previous review where we looked at tobacco and obesity, unhealthy diet and physical inactivity. There’s lots of economic evidence and evaluations of interventions targeting tobacco use and obesity but there’s much less in regard to alcohol use and so what we proposed is that actually working with health economists who are used to and have expertise in costing not just the actual intervention and the delivery of the interventional strategy to a particular community or group or state or population. You have to cost those bits of the intervention, but you’ve also got to put a value on the benefits that might accrue from those interventions, as well as any other unintended consequences as well. So, it’s really about putting a dollar figure on all of those things and in doing so you can actually demonstrate if government were to implement this type of intervention, these are the types of benefits that would accrue and this is the dollar figure that we’re able to put on those benefits for this community or this population and sometimes we can say, not only is this intervention cost effective but it might also be cost saving, so it’s going to save money in the long run while it’s implemented and I think that’s often quite powerful and persuasive and it’s quite normal in other areas of government for that to occur so when you’re proposing big new transport projects, for example, you really have to often show a kind of return on investment or a cost benefit analysis of that transport intervention or that road, the new brand new road that you’re putting in place. We’re slowly kind of building up the evidence in that area I think in Australia and we have some really world leading health economists who are doing that work and coming up with different ways of being able to say yes, public health and prevention and stopping things from happening is really valuable and it’s saving us money and it’s accruing all these other benefits such as reduced rates of crime or other types of sort of social benefits as well, or improvements in educational attendance in schools.
So that’s what we’re interested in, finding out a bit more about is how do we cost all of those great benefits that come from public health and preventative interventions.
Nikki: And the other part of that is that alcohol is a big part of our economy and so there’s profit there but there’s also harm and then there’s the benefit of reducing overall consumption of a population separate to an individual increase or decrease. So, a bigger picture and so this kind of analysis and evidence helps us weigh that up in the bigger picture so that we can actually have a more informed conversation about harms and benefits.
Gretchen: And as you say it’s not only a huge industry with employees, a lot of people and so forth, but it also contributes greatly in terms of taxes to government coffers so I guess that’s something that has to be weighed up is how much comes in terms of taxes and how much goes out in terms of health issues?
Elly: Alcohol companies are actually very good at doing their own internal economic analyses and sharing those with governments in order to lobby and to sometimes push back against regulatory measures. They are quite skilled at doing that. The quality of their economic evaluations and costings I think is sometimes a bit challenging to find out and I think that’s one of the really important things about public health and prevention research is being really open and transparent about the methods that we use to cost things and to do economic evaluations and that’s the importance of publishing in peer-reviewed journals and having others look at your work and to challenge you if need be, if there’s any sort of lack of clarity about the way in which you’ve evaluated this particular intervention and the costs that you’ve put on that. So, I think alcohol companies are very successful at sometimes using pretty woolly economic measures to make their case and so I think that there’s probably a lot of research out there that could be done which might actually push back or challenge some of those claims.
I think one thing I would just add about alcohol taxation in Australia is it’s incredibly complex and one of the big interventions that has been promoted for a very long time now has been that we should have a volumetric tax on alcohol. Now in this review we didn’t look at taxation on alcohol and the evidence around that because the evidence of effectiveness and cost-effectiveness is actually really, really strong. If you increase the taxes on alcoholic products you will see a decrease in consumption and we’ve already seen that at local levels in terms of minimum unit pricing in places like the Northern Territory where there has already been a really sizable decrease in terms of alcohol-related harms and for example, presentations to hospital emergency departments.
Nikki: And if you look at the costs of health services if you can actually reduce the harm from alcohol then there’ll be less money needed to be spent on health services and cancer treatment, for example. So, you know that is a real benefit and a reason to look at this with clear eyes and weigh up all the evidence because the long-term benefit of prevention has really been proven that it does help reduce those costs related to health services. So it’s really worth doing.
Gretchen: Can you talk about systems approaches and how that might look with respect to alcohol and perhaps tell us about the Hunter New England Local Health District?
Nikki: I think in prevention it’s really great to work more systemically and think about how you contribute to the whole. So, in a systematic approach where health promotion looks at healthy public policy and personal behaviour and healthy settings and accessible and good health services. So, in any area, like the Hunter New England an approach that has a public health lens across the whole wellbeing of society, the built environment, communities is really, really valuable. So, you have a public health approach, you have a group of researchers who are embedded in health services and are researching and delivering programs as they go. And I know there’s work related to obesity and healthy eating and active living that’s happening and it’s a great approach with people who are public health researchers are also managers and leaders of programs, so that there’s a translation of the research into practice and to better practice as you go, and then a tracking of that implementation and how effective that is and that’s happening in a particular way in Hunter New England and in other ways elsewhere. So I think that kind of separation of academia and health services should be a historical one and that we need to work together much more closely so that we can turn around what we finding out into actual better programs more quickly.
Elly: One of the really interesting aspects of the Hunter New England Local Health District collaboration that they have with the University of Newcastle is that embedding of partnership and collaboration between research and academia and also health services and delivery. So it’s that, that combination of high quality research around issues and harms like alcohol combined with that being embedded within provision of health services and management and they’re also doing some really fantastic research that’s funded by the Prevention Centre looking at maternity services and how do we become better at implementing as part of routine antenatal care guidance and support for pregnant women around alcohol use, tobacco and healthy eating and active living. So, I think it’s a really fabulous example of researchers and health services managers and health promoters working really closely in partnership to address these really challenging health issues that we’ve got.
Gretchen: Nicki, at a population level do we have enough evidence about what works to change behaviours?
Nikki: Yeah. I think what this report found by looking through the evidence, the rapid review found that it wasn’t necessarily proven to be cost saving but it was cost-effective so a lot of these systematic interventions are very cost-effective ways of reducing harm from alcohol at a population level.
Elly: I think that there’s quite good evidence about those structural or environmental interventions that we were talking about such as changes to density of outlets and availability of alcohol and so on those types of interventions. I think that also based on the review we looked at that there’s some evidence around what we call e-health and m-health interventions so your kind of mobile phone apps or internet and online-based health promotion apps and websites and sharing the information and things like that.
Gretchen: So, what happens next? I wonder what gaps need filling here? Will you share this review with policy makers and health practitioners? Where are you going to next?
Elly: From a research perspective, I think we’ve been able to identify some clear opportunities for future prevention research particularly in the economic space so one of the projects that has kind of come out of this is we are working with a couple of local health districts and with the Ministry Of Health in New South Wales to better do costing economic costing of liquor license changes and decisions in New South Wales. And we hope through that we’ll be able to build what we’d call some kind of decision support tool to help local health districts be able to show and demonstrate for each additional liquor license that’s granted in this area we could potentially see these costs and harms to the health system and to the community as a whole and to be able to better weigh up those costs and benefits of those decisions. So, I think that’s a really exciting project that we’ll be leading and doing over the next six months or so. And again that’s very much an example of academic researchers working in partnership with local health services and health promotion.
Gretchen: And Nikki, do we have to wait till we know everything before we start working on this? I think the answer is clearly no?
Nikki: No. I mean, I think I think it’s a matter of just keeping moving forward and planning really well together as much as possible as practitioners and policy makers so that we can plan out how together we’re going to really reduce the impact of alcohol on the population in government and non-government organisations as individuals and communities and families really thinking about our relationship with alcohol and what we want that to be rather than just going through the motions of doing what we’ve always done or those increased consumption going out without really noticing it. So no we don’t need to wait we can keep moving but I think, you know, now we need to connect with each other a little bit more and make sure that we do that really good evaluation planning from the start of programs and then try and keep learning from what we’re doing and doing it better for sure.
Gretchen: So, in terms of the National Preventive Health Strategy what role might this report play?
Elly: I think this report about the value of prevention, in regard to alcohol and reducing alcohol harms has, will play hopefully a really important role in terms of shaping what that conversation looks like. The National Preventive Health Strategy was recently released by the federal health minister. And I think there’s some really clear calls to action and goals in there around reducing the harms associated with alcohol use across Australia. So, I think the preventive health strategy has given us sort of way forward and it’s now up to lots of different actors to actually implement the various parts of that strategy, not just in regard to alcohol, but in regard to other risk factors like overweight and obesity, tobacco, so on.
Nikki: So, the Australian-wide National Preventive Health Strategy 2021 to 2030 does recognise the harm from alcohol use as significant and there are two targets to reduce this harm that we’re all going to need to contribute to that are quite ambitious. The first is at least a 10% reduction in harmful alcohol consumption by Australians over 14 years by 2025 and a 15% reduction by 2030 so that means that we need to be able to measure that reduction.
And then the second target is less than 10% of young people are consuming alcohol so that’s 14 to 17-year-olds that less than 10% of that group are consuming alcohol by 2030. So we are trying to increase that reduction in young people and have less young people consuming alcohol at that young age. I think there is lots that can be done there for adults as our particular interest at the Institute but also young people as well. And as well as the national strategy, in New South Wales we do have a new cancer plan that outlines alcohol as a risk factor for cancer and the Cancer Institute NSW is working with a whole range of partners to try and reduce the harm from alcohol to make a direct link and reduce the harms from cancer in New South Wales so alcohol is definitely mentioned as a risk factor there too.
Gretchen: So, will this rapid review go to policy makers and health practitioners, what will you do with it?
Nikki: It will be available from the Prevention Centre website and we will certainly be linking to the report from the Cancer Institute NSW website and the Ministry of Health are also very keen that people can get access to this report. It’s of relevance for the whole country though, it’s not just New South Wales relevant, so what we are hoping is people will look at it and will use it as a leap-off point for the next steps for themselves as well and then we can all come together at different occasions and do some planning together. I think from the Cancer Institute NSW’s perspective it really helps add to the story about the impact of alcohol on cancer and that there is actually a direct link to cancer that I don’t think is really well understood.
Gretchen: That’s Nikki Woolley, Skin and Lifestyle Portfolio Manager at Cancer Institute NSW and Dr Elly Howse, who is the Prevention Centre’s Research Manager and Senior Research Fellow. I’m Gretchen Miller, this is Prevention Works, the podcast of The Australian Prevention Partnership Centre. You’ll find more details on our website, looking forward to your company next time.
The Prevention Centre together with New South Wales Health and Cancer Institute NSW recently produced an Evidence Review on the value of prevention to reduce alcohol use. In this episode, Dr Elly Howse, Research Manager at the Prevention Centre, and Nikki Woolley, Skin and Lifestyle Portfolio Manager at Cancer Institute NSW, explore the value and challenges of prevention for reducing alcohol consumption and misuse in Australia.
Resource category: Evidence ReviewsDate
Resource category: Evidence ReviewsDate
- National Preventive Health Strategy 2021-2030
- National Health and Medical Research Council (NHMRC) National Guidelines on Alcohol
- NSW Health Centre for Alcohol and Other Drugs
- Cancer Institute NSW
- Hunter New England Local Health District
- Geoffrey Rose, original premise published in 1985 and republished in 2001.