The dose-response relationship between alcohol and cancer risk (i.e. risk increases in line with consumption) means any reduction in the dose, or the amount and frequency of alcohol consumed, reduces the risk of developing an alcohol-related cancer.
There is a large body of evidence on the effectiveness of alcohol policy interventions in reducing alcohol consumption and improving long-term health outcomes. A key example is the the World Health Organization's ‘STEPwise approach’ to alcohol policy options for the prevention and control of non-communicable diseases. This approach, which is consistent with alcohol policy priorities to reduce short-term harms, ranks mechanisms that impact on alcohol affordability, availability and promotion as top interventions to reduce alcohol-related harm.
In Australia, the National Preventative Health Taskforce has developed Australia's most comprehensive strategy for minimising adverse population health outcomes linked to alcohol consumption as part of its Roadmap for action report.
The strategy’s targets include reducing the proportion of Australians who drink at long-term risky or high-risk levels from 10.3% to 7.5% by 2020. Based on the best available evidence for reducing alcohol-related harms, the recommendations include:
- improve the safety of drinkers and those around them through liquor control regulations, controls on outlet density and better policing;
- promote a safer drinking culture through social marketing and school, community and workplace programs;
- phase out alcohol promotion to young people;
- reform alcohol taxation/pricing;
- provide targeted programs for Indigenous Australians;
- strengthen/support primary healthcare to provide interventions; and
- strengthen data collection and the evidence base for interventions.
This section focuses on the recommendations with the most potential to reduce the risk of alcohol-related cancer on a population basis.
Regulating alcohol price
Current taxation and pricing arrangements
Under the current alcohol taxation system in Australia, different alcohol products are taxed differently:
- The excise duty is a volumetric tax based on alcohol content per volume of product and applies to beer and spirits. The excise tax is levied twice a year in relation to changes to the Consumer Price Index as a means of maintaining the real cost of alcohol to the consumer.
- The Wine Equalisation Tax (WET) is an ad valorem, or value-based, fixed-rate tax that applies to wine based on the value of the goods at the last wholesale sale.
- Customs duties are a combination of both volumetric and ad valorem levies (see Table 1).
A 10% goods and services tax (GST) applies to all retail alcohol sales.
Australia's alcohol taxation system is not based on public health or alcohol harm minimisation principles. As explained below, the system's ad hoc development has led to inconsistencies that do not encourage low-risk alcohol consumption.
Evidence shows that increasing alcohol prices through taxation decreases both alcohol consumption and alcohol-related harms. It has been estimated that a price increase of 10% reduces alcohol consumption by an average of 5%.
Evidence also suggests that this reduction in consumption applies to all groups of drinkers, not just heavy or problem drinkers. Price increases have also been shown to reduce the amount of alcohol consumed at a population level over time. Therefore, increasing the price of alcohol has potential to reduce alcohol-related cancer risk on a population basis, particularly in view of the dose/response relationship between alcohol consumption and cancer risk.
Alcohol consumption among younger people also decreases when price is increased. This is significant in a cancer prevention context, because young people who drink at high-risk levels are more likely to continue consuming alcohol at harmful levels over the long term, thus their risk of alcohol-related cancer increases significantly.
WHO also recommends alcohol taxes as a means to fund prevention and treatment programs, thereby further reducing alcohol-related harms. This is consistent with local analyses, including one Australian study that concluded taxation measures could reduce the social costs of alcohol in Australia by between 14 and 39% (or between $2.19b and $5.94 billion in 2004-05 dollars).
Studies have shown that a "volumetric" alcohol taxation system - where tax is levied on the alcohol content of a product by volume – has the potential to reduce alcohol consumption and related harm, provided it translates to an overall increase in alcohol tax as well as consistency in how alcohol tax is levied.
It is also highly cost-effective; one study estimated that a volumetric tax on all alcohol products set at the existing rate for spirits could reduce overall alcohol consumption by 24%, resulting in a net health gain of 170,000 DALYs and an increase in revenue of over $3 billion. Another recent study, the ACE-Prevention report, showed a volumetric tax at 10% above the current excise on spirits would not only provide significant public health benefits, it would be cost-saving. ("Cost-effective" public health measures are those that provide a significant return on investment when measured in DALYs; cost-saving interventions result in direct economic returns to government that are higher than the investment.)
The landmark "Henry Review" of Australia’s taxation arrangements calls for alcohol taxation to be "levied on a common volumetric basis across all forms of alcohol, regardless of place, method or scale of production". Taxing all alcohol products on a volumetric basis would make stronger (more carcinogenic) alcohol products more expensive, therefore driving sustained shifts in consumption toward products with lower average alcohol content by volume. The Henry Review's rationale for recommending a volumetric tax on alcohol products in Australia is on page 55 of the report.
For more background on the public health benefits of a volumetric tax on alcohol, particularly in relation to cancer control, see Cancer Council Australia's Position statement - Alcohol pricing and taxation.
The absence of a minimum price based on alcohol volume can provide relatively easy access to products for people who drink at harmful levels. Alcohol products that are inexpensive to produce and distribute can be sold cheaply, irrespective of alcohol content. Increasingly, retail outlets such as supermarkets heavily discount alcohol products, often to below-cost prices, to attract customers into their stores. Reduced-price promotions at licensed venues also encourage binge drinking.
A minimum floor price for alcohol per standard drink may assist in reducing the supply of cheaper, more harmful drinking options. It may also encourage switching from high alcohol products to lower-strength, less harmful options. Establishing a minimum price for alcohol, which raises the cost of products at the cheapest end of the spectrum, is likely to have a substantial impact both on overall consumption levels and on drinkers at most risk of short and long-term harm.
Additional information on pricing options aimed at reducing the population health harms caused by risky or high-risk alcohol consumption is available from Cancer Council Australia's Position statement - Alcohol pricing and taxation.
Table 1. Alcohol tax measure by product type
|Beer||Spirits and RTDs||Wine||Cider|
|Customs duty (ad valorem)||No||Yes (imported)||Yes (imported)||No|
|Customs duty (per unit of alcohol)||Yes (imported)||Yes (imported)||No||No|
RTDs - Ready-to-drink
The ad hoc development of Australia's alcohol taxation system has resulted in inconsistencies that do not encourage low-risk alcohol consumption.
Currently, the tax payable by consumers per standard drink (10 grams of pure alcohol) for different types of alcoholic beverages varies considerably. These variations in tax payable do not reflect the relative contribution of different beverage types to alcohol-related harms.
Some of these inconsistencies are highly problematic in a public health context. For example, the tax payable per standard drink for low-price cask wine with an alcohol content of 12.5% is only $0.05, whereas the tax payable per standard drink of mid-strength beer in a can/stubbie with an alcohol content of just 3% is $0.26.
Figure 1: Tax payable per standard drink* of alcohol, various products, Australia, June 2008
*A standard drink is equal to 0.001267 litres or 10 grams of pure alcohol.
Note: WET (Wine Equalisation Tax) payable per standard drink of wine is based on a 4 litre cask of wine selling for $13.00 (incl. GST), a 750ml bottle of wine selling for $15.00 (incl GST),Bottled Wine 1], a 750ml bottle of wine selling for $30 (incl GST)[Bottled Wine 2] and a 750ml bottle of port selling for $13.00 (incl GST)
Source: Vandenberg 2008
Restrictions to marketing and promotion of alcohol
The WHO defines alcohol marketing and promotion as “any form of commercial communication or message that is designed to increase, or has the effect of increasing, the recognition, appeal and/or consumption of particular products and services".
Alcohol beverages are marketed and promoted through a mix of television, radio and print advertisements, point-of-sale marketing and sponsorship of sporting and cultural events. Embedded and incidental advertising through product placement in films and television programs is also significant.
Marketing strategies are becoming increasingly based on internet and mobile phone technology to target young people. While this is a priority for alcohol companies keen to recruit new customers, it is particularly problematic in a public health context because the harms of excessive alcohol consumption impact disproportionately on younger age groups. (Younger people who consume alcohol at risky or high-risk levels are likely to also do so over the longer term, thus significantly increasing their risk of alcohol-related cancer.)
Although alcohol companies contend that advertising only affects market share between brands without increasing overall consumption, evidence has shown a small but consistent association between alcohol advertising, consumption levels and related harms. This association may be understated, as most studies published to date have focused on the effects of direct advertising by alcohol companies. A review of the literature published in the Journal of Public Health Policy in 2005 recommended that the impact of other marketing activities, such as price promotions, distribution, point-of-sale activity and new product development, also be evaluated in relation to consumption.
Current regulatory environment
There are very few legislative restrictions upon the content or placement of alcohol advertising and promotion in commercial and subscription media; advertising is largely self-regulated, predominantly through voluntary industry codes of practice. These include:
- the Alcohol Beverages Advertising Code, an alcohol-specific advertising code of practice and complaints mechanism, which covers the content of alcohol advertising in most media. The code does not apply to alcohol sponsorships and advertising related to sponsorships.
- television broadcast codes of practice such as the Commercial Television Industry Code of Practice, which regulates the placement of alcohol advertising on commercial television and the Subscription Broadcast Code of Practice;
- the Outdoor Media Association Code of Ethics;
- the Publishers' Advertising Advisory Bureau’s Guiding Principle for Alcohol Beverage Advertising, which covers point-of-sale marketing; and
- the Commercial Radio Code of Practice.
Why current regulatory arrangements are inadequate
Australia's well-documented consumption of alcohol at harmful levels suggests improvements in the regulation of alcohol marketing and promotion are urgently required. Key limitations in the current framework include:
- The codes are voluntary; they cannot be enforced and there are no penalties for breaches. Voluntary codes have been shown internationally and in Australia to be ineffective;
- Scope is limited. The Alcohol Beverages Advertising Code, with which a number of the codes comply, does not apply to key marketing techniques such as point-of-sale and in-store promotions, viral and emerging media;
- Inadequate protection for children and adolescents from exposure to alcohol advertising. Although the Commercial Television Industry code restricts alcohol advertising to mature and adult viewing classification periods (i.e. after 8.30pm), alcohol advertising is permitted during live broadcasts of weekend and public holiday sporting events and events broadcast simultaneously across a number of time zones. This exposes children to intensive alcohol advertising; significant numbers of children also watch TV after 8.30pm. As a result of these regulatory inadequacies, alcohol advertising is just as likely to be seen by children as adults.
- Ineffective complaints procedures. A review of ABAC in 2003 found that many complaints were not investigated; when they were, the process was excessively lengthy and inconclusive.
The National Preventative Health Taskforce recommends a staged phase out of alcohol promotions from times and placements which have high exposure to young people aged up to 25 years, including:
- Advertising during live sport broadcasts
- Advertising during high adolescent/child viewing
- Sponsorship of sport and cultural events.
The Taskforce also recommends the introduction of independent regulation through legislation if voluntary approaches are not successful in phasing out alcohol promotions from times and placements which have high exposure to young people up to 25 years.
For detailed information on reforms to alcohol marketing and promotion for reducing the health harms of alcohol consumption, see Position statement - Marketing and promotion of alcohol.
Consumer information and labelling of alcohol
Health information (e.g. ingredients, alcohol volume) and warning labels on alcohol products have the potential to increase public awareness of alcohol harms, notably because they can directly target the user at purchase and during consumption.
Health information labelling
In Australia, Standard 2.71 of the Food Standards Australia New Zealand (FSANZ) Act 1991 (“Labelling of Alcoholic Beverages and Food containing alcohol”) stipulates that an alcohol label is to include alcohol by volume (expressed in mL/100g or % alcohol by volume) and the estimated number of standard drinks contained. The size and legibility of the information, however, varies markedly between products. In addition, a list of ingredients or nutritional information, such as the amount of sugar, kilojoules or preservatives, is not required on alcohol products as it is on non-alcoholic beverages.
In 2009, the National Preventative Health Taskforce recommended health advisory information labelling on all containers and packaging of alcoholic beverages, including:
- nutritional data and ingredients;
- information on the amount of alcohol by volume and number of standard drinks per container;
- NHMRC alcohol guidelines; and
- text and graphic warnings on the health and safety risks of alcohol consumption.
Evidence shows that warning labels have the potential to help reduce risky and high-risk alcohol consumption.
A comprehensive review of key international studies, done in British Columbia in 2006, concluded that warning labels raised awareness of alcohol-related harms. Individual studies have also shown that warning labels could help to encourage culture-change towards less hazardous consumption levels, while others indicate that the effectiveness of labels may depend on their design, content and targeting. A study funded by the Victorian Government in 2008 concluded that warning labels on a product make an important "symbolic" statement that can translate to long-term culture change.
'Blewett' labelling review
In 2011, the report of the "Blewett review" of food and beverage labelling policy in Australia, Labelling Logic recommended:
...that generic alcohol warning messages be placed on alcohol labels but only as an element of a comprehensive multifaceted national campaign targeting the public health problems of alcohol in society.
The Foundation for Alcohol Research and Education (FARE) has published recommendations on alcohol labelling, available on its website. FARE's core position is that alcohol warning labels should be mandatory on all alcohol products and product packaging in Australia, and consist of a comprehensive suite of labels regularly rotated.
FARE has also published an analysis comparing its recommendations to those supported by DrinkWise, an alcohol industry body that promotes "a healthier and safer drinking culture" in Australia. FARE's market research found overwhelmingly that its proposed labels had much greater potential to raise awareness about the harms of alcohol than the voluntary system supported by DrinkWise.
In December 2011, the intergovernmental Legislative and Governance Forum on Food Regulation announced that within two years it would mandate the introduction of labels warning on the risks of drinking in pregnancy. The alcohol industry has the opportunity to introduce appropriate labelling on a voluntary basis in the interim.
Awareness of the relationship between alcohol and cancer risk is low; the potential for warning labels to help raise awareness of cancer as well as other health risks should be explored further.
For more information on Cancer Council's position, see Position statement - Consumer information and labelling of alcohol.
Alcohol availability refers primarily to the time (trading days and hours) that alcohol products are available, either for consumption in licensed premises or as takeaways, and the density and number of alcohol outlets. In Australia, alcohol availability is largely regulated by state/territory governments and, to a lesser extent, local governments (municipal councils).
Evidence shows that the availability of alcohol has a direct relationship with the harms caused by excessive drinking; the easier alcohol is to obtain, the greater the harms. Easy accessibility of alcohol translates to increased high-risk drinking, with evidence showing the associated harms include increased motor vehicle accidents, pedestrian injury, risky sexual behaviour, child maltreatment and neighbourhood amenity problems.
However, an overall reduction in alcohol consumption on a population basis would nonetheless translate to reduced risk of alcohol-related cancer in Australia. Cancer Council Australia therefore supports measures to regulate the availability of alcohol as recommended in the Preventative Health Taskforce report.
Role of general practitioners
Around 86% of Australia's population visit their GP every year, making primary care an important healthcare sector for chronic disease prevention. Studies show that advice in general practice consultations can reduce harmful alcohol consumption in men; the effect is less clear in women. An international review of 29 controlled trials in 2007 showed GP advice could reduce harmful drinking in men by 20-30%; a US-based analysis of 12 randomised controlled trials published in 1997 showed men who drank at harmful levels were at least twice as likely to moderate their drinking if advised by their GP. Despite these findings, the primary care sector in Australia receives limited support for implementing preventive healthcare interventions such as alcohol counselling.
The Royal Australian College of General Practitioners produces guidelines on interventions targeted at smoking, nutrition, alcohol and physical activity (SNAP), such as:
- The RACGP "Red Book" (Guidelines for preventive activities in general practice), which recommends asking patients aged 15 and over about the quantity and frequency of alcohol intake and advising patients who drink at risky levels to change their behaviour;
- SNAP: A population health guide to behavioural risk factors in general practice, which provides more extensive information and recommendations on alcohol (among other common lifestyle risk factors) based on "the five A's" (ask, assess, advise, assist, arrange); and
- The RACGP "Green Book" (Putting prevention into practice: guidelines for the implementation of prevention in the general practice setting), for developing systems in general practice to support prevention activities.
In addition, the Australian Department of Health and Ageing funds the Lifestyle Prescriptions program ("Lifescripts"), which provides evidence-based tools to GPs to help patients address lifestyle risk factors for chronic disease such as alcohol misuse. And the Australian Government's national health reform agenda seeks to enhance the role of primary care. Current initiatives include funding to support practice nurses in providing of a range of primary care services such as preventative health programs.
Social marketing/public education
Social marketing – i.e. a range of targeted communication and public education strategies – has been effective in raising awareness about important health issues and encouraging positive behaviour change, particularly when integrated with supportive public policies. While there is potential for social marketing programs to encourage safer alcohol consumption, it is a complex area, partly because perceptions of drinking vary widely; the evidence on optimal effectiveness remains unclear and warrants further research. For example, some schools-based education programs have proven counter-productive by stimulating interest in alcohol.
It should be noted that social marketing campaigns to raise awareness of the harms of alcohol use have never been run on a sustained, large-scale basis, so there is no direct evidence of their effectiveness. However, targeted public education campaigns – for example those linked to complementary alcohol control policy measures such as random breath testing of motorists – can be effective.
So given the potential benefits of appropriately targeted, integrated social marketing strategies, and the establishment of the Australian National Preventive Health Agency and the inter-jurisdictional Partnership Agreement on Preventive Health, research into the development of effective campaigns should be a priority. Social marketing and public education to date have focused on the short-term harms of alcohol misuse; it is also important to raise community awareness about the link between long-term alcohol consumption and cancer risk. Moreover, any campaigns that have the effect of reducing overall alcohol consumption on a population basis have the potential to reduce the disease burden of alcohol-related cancers.
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