Evidence informing policy
The dose-response relationship between alcohol and cancer risk (i.e. risk increases in line with consumption) means significant reduction in the dose, or the amount and frequency of alcohol used, 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 World Health Organization's ‘STEPwise approach’ to alcohol policy options for the prevention and control of non-communicable diseases. This approach ranks mechanisms that impact on alcohol affordability, availability and promotion as the best interventions to reduce alcohol-related harm.
The evidence supports the following interventions for reducing alcohol-related harms:
- reforming alcohol pricing;
- phasing out alcohol promotion to young people;
- improving the safety of drinkers and those around them through liquor control regulations, controls on outlet density and better policing;
- promoting a safer drinking culture through social marketing and school, community and workplace programs;
- providing targeted programs for Aboriginal and Torres Strait Islander people;
- strengthening/supporting primary healthcare to provide interventions; and
- strengthening 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.
Alcohol pricing reform
Current taxation and pricing arrangements
Under the current alcohol taxation system in Australia, different alcohol products are taxed differently (See Table 1), however not according to risk and harm in relation to alcohol content. Alcohol is taxed on either a volume or value basis, with a range of tax rates depending on the type of beverage and packaging, alcohol strength, place of manufacture and the method or scale of production.
There are currently four categories of taxes applied to alcohol:
- Goods and Services Tax (GST) - a 10% ad valorem (i.e. according to the value of the goods) tax on all retail sales of alcohol;
- Excise duties - a volumetric tax based on alcohol content per volume of product; calculated by reference to the Consumer Price Index and levied twice a year. It is levied on a per litre of alcohol (Lal) basis, at rates that vary according to the type of beverage, size of container and alcoholic strength; and
- Wine Equalisation Tax (WET) - an ad valorem tax that applies to wine based on the value of the goods at the last wholesale sale;
- Customs duties – a combination of both volumetric and ad valorem tax imposed on imported products only.
Table 1. Alcohol tax measure by product type
|Beer||Spirits and RTDs||Wine||Cider|
|WET||No||No||Yes||Yes (excluding flavoured ciders)|
|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
Australia's alcohol taxation system is not based on public health or alcohol harm minimisation principles. The ad hoc development of Australia's alcohol taxation system has resulted in inconsistencies that do not encourage lower risk of alcohol use.
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
Evidence shows that increasing alcohol prices through taxation decreases both alcohol use and alcohol-related harms. It has been estimated that a price increase of 10% reduces alcohol use by an average of 5%.
Evidence also suggests that this reduction in use applies to all groups of drinkers, including high-risk drinkers. Price increases have also been shown to reduce the amount of alcohol drunk 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 use and cancer risk.
Alcohol use 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 using alcohol at harmful levels over the long term, thus their risk of alcohol-related cancer increases significantly.
One Australian study 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). The returns from taxation measures can be used to fund prevention and treatment programs, as recommended by WHO, thereby further reducing alcohol-related harms.
Studies have shown that a single "volumetric" alcohol taxation system - where tax is levied on the alcohol content of a product by volume – has the potential to reduce alcohol use and related harm, provided it translates to an overall increase in the price of alcohol as well as consistency in how alcohol tax is levied. Taxing all alcohol products on a volumetric basis would make stronger (more carcinogenic) alcohol products more expensive, therefore driving sustained shifts in use toward products with lower average alcohol content by volume.
It is also the most cost-effective intervention; it has been estimated that a volumetric tax on all alcohol products set at the existing rate for spirits could reduce overall alcohol use by 24%, resulting in a net health gain of 170,000 Disability Adjusted Life Years (DALYs) and an increase in revenue of over $3 billion. Abolishing the WET and replacing it with a volumetric tax on wine would increase taxation revenue by $1.3 billion per year, reduce alcohol use by 1.3%, save $820 million in health care costs and avert 59,000 DALYs. 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".
A minimum floor price ensures alcohol cannot be sold below a certain amount. The absence of a minimum price based on alcohol volume can provide relatively easy access to products for people who drink at harmful levels, encouraging high-risk consumption. 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, including 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. The Northern Territory Government has introduced a minimum floor price for alcohol to minimise the harms associated with high-alcohol, low-cost alcoholic beverages. It may encourage heavy and high-risk drinkers to switch 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 drinking levels and on drinkers at most risk of short and long-term harm.
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, online (including social media), radio and print advertisements, point-of-sale marketing and sponsorship of sporting and cultural events. Embedded and incidental advertising through product placement in social media, 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 high-risk alcohol use impact disproportionately on younger age groups. Evidence from systematic reviews has shown direct associations between exposure to advertising and age of drinking onset, prevalence of drinking and the amount of alcohol use by young people. Younger people who consume alcohol at risky or high-risk levels may continue to do so over the longer term, thus significantly increasing their risk of alcohol-related cancer.
Current regulatory environment
There are very few legislative restrictions upon the content or placement of alcohol advertising and promotion in commercial and subscription media and social media; advertising is largely self-regulated, predominantly through voluntary industry codes of practice. These include:
- the Alcohol Beverages Advertising Code (ABAC), an alcohol-specific advertising code of practice and complaints mechanism, which covers the content and placement 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 free-to-air television and the Subscription Broadcast Code of Practice;
- the Outdoor Media Association Code of Ethics; and
- the Commercial Radio Code of Practice.
Why current regulatory arrangements are inadequate
Young people are exposed to the same number of alcohol advertisements as adults and the alcohol advertisements that appeal to young people increases their intention to use and purchase the advertised products. Australia's well-documented use 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;
- Platform scope is limited; some media channels are excluded including cinema advertising;
- 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 sport programs on 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. Recent research has shown that children are being exposed to as much alcohol advertising when viewing televised sport as adults.
- ABAC relies solely on receiving complaints from the public. Community awareness of the complaints process is low.
Cancer Council 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 all sport programs
- Advertising during high adolescent/child viewing
- Advertising on outdoor signage and public transport
- Sponsorship of sport and cultural events.
For detailed information on reforms to alcohol marketing and promotion for reducing the health harms of alcohol use, see Position statement - Marketing and promotion of alcohol.
Restrictions to alcohol availability
There is a wealth of evidence demonstrating that restricting the availability of alcohol can reduce the use of alcohol and alcohol-related harm, and that it is a highly cost-effective measure.
A 2019 umbrella review of systematic reviews found that limiting on- and off-premise outlet density could be beneficial in reducing alcohol use and subsequently reducing alcohol related harm. A separate systematic review with meta-analysis found that limiting the physical availability of take-away alcohol (days and hours of sale and outlet density) would reduce alcohol use. For each additional day of sale there was a 3.4% increase of per capita total alcohol use. These findings support the implementation of policies designed to restrict hours of sale and number of outlets.
Inadequate restrictions potentially result in increased harm from alcohol. In Australia, increased market availability of alcohol has been found to be associated with a significant increase in alcohol use and consequently significant increases in mortality from head and neck, lung, colorectum and overall cancers for males and head and neck and colorectum cancers for females.
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 drinking.
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. Mandatory energy labelling and prohibition of sugar and carbohydrate claims on alcohol products are being considered by FSANZ.
Evidence shows that warning labels have the potential to help reduce risky and high-risk alcohol use. In tobacco control, the use of graphic tobacco warning labels is effective in increasing awareness, changing attitudes as well as changing behaviour, suggesting graphic warning labels can reduce alcohol use as well. A comprehensive review of key international studies, done in British Columbia in 2006, concluded that warning labels raised awareness of alcohol-related harms. Cancer warning labels on alcohol products have the potential to increase awareness of the link between alcohol use and cancer risk. 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.
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 use 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 such as the Red Book, SNAP guide and Green Book.
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 drinking at lower risk levels, it is a complex area, partly because perceptions of drinking vary widely; the evidence on optimal effectiveness remains unclear and warrants further research.
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, an evaluation of Western Australian campaigns showed that public education campaigns increased parental awareness of adolescent alcohol use and can increase awareness of the links between alcohol and cancer. Furthermore, targeted public education campaigns – for example those linked to complementary alcohol control policy measures such as random breath testing of motorists – can be effective.
Given the potential benefits of appropriately targeted, integrated social marketing strategies, 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 use; it is also important to raise community awareness about the link between long-term alcohol use and cancer risk. Moreover, any campaigns that have the effect of reducing overall alcohol use on a population basis have the potential to reduce the disease burden of alcohol-related cancers.
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- ↑ Wilk AI, Jensen NM, Havighurst TC. Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Intern Med 1997 May;12(5):274-83 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9159696.
- ↑ Department of Health and Ageing. Primary health care reform in Australia: report to support Australia's first national primary health care strategy. Canberra: Commonwealth of Australia; 2009 Available from: http://www.health.gov.au/internet/yourhealth/publishing.nsf/Content/nphc-draftreportsupp-toc/$FILE/NPHC-supp.pdf.
- ↑ Royal Australian College of General Practitioners. Smoking, nutrition, alcohol and physical activity (SNAP): a population health guide to behavioural risk factors in general practice. South Melbourne: RACGP; 2004 Available from: http://www.racgp.org.au/download/documents/Guidelines/snapguide2004.pdf.
- ↑ Royal Australian College of General Practitioners. Putting prevention into practice: guidelines for the implementation of prevention in the general practice setting. 2nd ed. South Melbourne: RACGP; 2006 Available from: http://www.racgp.org.au/download/documents/Guidelines/Greenbook/racgpgreenbook2nd.pdf.
- ↑ Johnston RS, Stafford J, Jongenelis MI, Shaw T, Samsa H, Costello E, et al. Evaluation of a public education campaign to support parents to reduce adolescent alcohol use. Drug Alcohol Rev 2018 Jul;37(5):588-598 Available from: http://www.ncbi.nlm.nih.gov/pubmed/29672988.
- ↑ Dixon HG, Pratt IS, Scully ML, Miller JR, Patterson C, Hood R, et al. Using a mass media campaign to raise women's awareness of the link between alcohol and cancer: cross-sectional pre-intervention and post-intervention evaluation surveys. BMJ Open 2015 Mar 11;5(3):e006511 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25762231.