Alcohol and the Availability Hypothesis

As it has been suggested that there is a direct relationship between “availability” and addiction, a consideration of other addictions is useful, most notably alcohol. Whilst alcohol is legally available in many jurisdictions, and generates revenue through taxation for

governments, alcohol is known to cause harm, with alcohol-use disorders a major mental and public health issue in Australia (Teesson et al., 2000). A number of studies have considered the relationship between alcohol availability and resultant changes in consumption patterns and alcohol-related harm across distinct communities (Babor et al., 1978; D’Abbs & Tongi, 2000; Smith, 1986; 1988). Alcohol control measures available to governments include: laws to regulate a minimum age of purchase; taxes; licences for retail outlets; penalties for the individual drinker (e.g. drink driving); or penalties for businesses (e.g. for selling to minors).

In addition to these measures, other public heath measures can be adopted to reduce alcohol-related harms such as improving highway safety (minimise negative consequences) or limiting alcohol advertising (reducing attractiveness) (Cook & Moore, 2002). Cook and Moore (2002) argued that governments or regulators must weigh up the loss of individual liberty that these measures bring versus the potential community well-being. There is some evidence that these measures either alone or in combination influence alcohol-related harms.

2.2.1 Effects of changing opening hours or trading days

A study by McLaughlin and Harrison-Stewart (1992) considered the effect of

extended trading hours upon alcohol consumption. Trading hours were extended in Western Australia (WA) to coincide with the America’s cup being held in Fremantle. Trading hours within a 100 kilometer radius of Fremantle were extended. Hotels were permitted to close at 2am instead of midnight from Monday to Saturday. In addition, instead of a half day on Sunday, hotels could trade all day.

McLaughlin and Harrison-Stewart (1992) compared young males in Fremantle (designated as the experimental area) and Mt Lawley (designated as the control area) before and after extended trading hours. Male residents (18-28 years old) in this study were

interviewed in their homes as to their drinking patterns over the course of a week, one month before and six months after the implementation of extended trading hours in Fremantle and were compared to the control area (Mt Lawley). No statistically significant increases in the mean alcohol consumption were found after the 6 month extended trading hours. One month prior to extended trading hours the mean weekly total alcohol consumption was 170.7g (SD=

196.0) for Fremantle and 162.4g (SD = 163.2) for Mt Lawley residents, and following extended trading hours the mean weekly total alcohol consumption was 165.8g (SD= 175.8) for Fremantle and 160.3g (SD = 164.3) for Mt Lawley residents. However there was

considerable variability in the reported amounts of alcohol drunk.

Inspections of McLaughlin and Harrison-Stewart's (1992) means suggested that alcohol consumption in Fremantle increased during extended trading hours on Sunday (mean increase 5.1 gms) and Monday (mean increase 9.8 gms), but decreased on Wednesday (5.4 gms) Thursday (mean decrease 5.1 gms).and Friday (mean decrease 5.0 gms). Participants in

Fremantle reported spending more on alcohol during the extended trading hours, and there were correlations between reported amounts consumed and time spent in hotels (for both groups). The authors felt this was evidence that heavy drinkers made use of the extended trading hours and consumed higher levels of alcohol. The authors also commented that only a minority of people reported frequenting the licensed venues during the extended trading hours, but those who did had higher levels of alcohol consumption for the week. The authors suggested that the extended trading hours may lead to increases in alcohol problems for this particular group.

However, McLaughlin and Harrison-Stewart's (1992) study has been criticised because people with no fixed address were excluded even though they have potentially higher rates of alcohol use. Furthermore, the design of the study had been questioned by Chikritzhs et al. (1997) because the large influx of visitors for the sporting event made it difficult to make any meaningful comparisons about the alcohol consumption habits of people living in these two areas. Furthermore, Chikritzhs et al. (1997) noted that limiting alcohol availability may be difficult for a number of reasons that may be conflicting. For example, the majority of Australians enjoy access to alcohol; the manufacturing industry wishes to have as few

restrictions on it as possible, and retailers want to choose hours that suit them, and

governments want to collect taxes, but there are concerns from welfare groups, as residents have a right to enjoy a safe neighbourhood, and there are concerns for public safety. Despite this, when it comes to alcohol availability, regulators are inclined to alter opening hours and or days in preference to the use of any other control measure, yet there has been little

scientific study done of the effects of increased or decreased hours (Smith, 1986). Such issues are also of interest in the gambling field, especially when viewed in light of potential

increases in the accessibility of gambling technology, through mobile phones, the internet and interactive TV.

One study by Smith (1986) compared men drinking in hotels with early opening hours (6am – 7am) to men drinking in hotels with standard opening hours (10am) in Western Australia. The participants for the study were not significantly different on any demographic variable (marital status, education, occupation, place of residence, on the dole, income, engaging in shift-work). It was found that men in the early-opening group (n=72) drank significantly greater amounts of alcohol, spent longer drinking per week and had a higher number of drinking sessions per week compared to the control group (n=87). They were also more likely when compared to controls to have a second drinking session on a given day, and to consume more alcohol during this time. In addition, Smith found that the early drinkers had significantly higher scores on an alcohol screening instrument (SMAST) and

approximately 50% using this instrument were classed as problem drinkers, versus 37% in the control group. In addition to being classed as problem drinkers, Smith (1986) also considered the relative amount of alcohol being consumed by individuals. It was found that 53% of the early opening group compared with 41% of controls drank more than 80gms alcohol per day, a level that is regarded as unsafe.

Norstrom and Skog (2005) looked at changes in consumption associated with extended trading days. They studied the implementation of Saturday alcohol trading in Sweden during 2 phases. Phase I was a control period where only certain areas were allowed to trade, and Phase II represented trading through the whole country. The authors measured alcohol sales and some alcohol harm related measures including number of reported assaults and drunk-driving levels. They found significant increases in alcohol sales during phase I (3.7%) and in phase II (3.6%) and an increase in drink driving (12% during phase I only).

There were no significant differences relating to assaults. The authors suggested that

increased availability leads to increased consumption only and that increases in drunk driving were due to increased police scrutiny around the areas allowed to trade on a Saturday during the control period.

2.2.2 Effects on alcohol-related problems

Smart and Mann (1987) examined the relationships across time (1963-1975) between alcohol consumption and several problems related to alcohol use such as hospitalisation for alcohol dependence, death rates for alcohol dependence, chronic liver disease or cirrhosis due to alcohol, alcohol poisoning and drink driving data. They found that while the problem data paralleled the consumption data, when consumption rose, morbidity and mortality did by higher levels compared to consumption. When consumption measures stabilised the mortality and morbidity indictors declined. This may be due to a number of factors. For instance, only historical aggregate data were used and any inaccuracies or non-reported events would not have been included in the analysis. In addition, because of the large time period included, it may also be that patterns of consumption changed due to the influence of a third variable such as an aging population or an increased effort on governments and heath services to promote healthy drinking and living.

Northridge, McMurray and Lawson (1986) compared data for the periods 1971 and 1976, versus 1977 and 1982 for cases of alcohol self-poisoning admissions to a hospital in Scotland after changes in licensing laws that allowed extended evening trading, Sunday trading, and all day licenses. They found a significant increase in hospital admissions following the change in liquor laws. However, this finding is speculative and does not address causation of the increased admissions.

Smith (1988) found that after implementation of Sunday alcohol sales in Brisbane there was an increase in the number of traffic casualties and property damage compared with a control area. However, this has been criticised by Chikritzhs et al. (1997) because while Smith showed an increase in accidents in comparison with a control state on the day of availability, there was an overall increase in total numbers of accidents at all times, making it difficult to rule out that out that people’s drinking and driving have been redistributed across the week.

2.2.3 Effects of price

In the gambling literature, electronic gaming machines (EGMs) have been cited as a major contributor to problem gambling (Breen & Zimmerman, 2002; Dowling et al., 2005).

EGMs are ‘per game’ one of the cheaper forms of gambling, with minimum bets of 1c per spin not uncommon. Hence price is another factor that determines access and availability to a particular substance or activity. For example, the effect of restricting sales of alcohol by setting maximal amounts of purchases in one transaction and by taxing some forms of alcohol higher than others has been used in order to control accessibility. A study in rural Australia examined the impact of limiting alcohol availability in five regional and remote towns in NT and WA (D’Abbs & Tongi, 2000). To limit availability, there were restrictions on the sale of cask wine (limited to casks under 4L) and also the maximal take-away per-capita sales.

D’Abbs and Togni (2000) found a small decrease in consumption 0 -7% in cask wine after these measures were introduced, however this was partially offset by increases in other types of alcohol sold. The authors also found significant decreases in alcohol-related harm

including property damage, decreases in presentations to hospitals and decreases in criminal charges over varying time periods after the intervention.

Harm is not necessarily directly linked to factors such as alcohol content. Differences between problem behaviours and their association with particular types of alcohol were considered by Stockwell and Crosbie (2001). External factors such as price and product image help to determine patterns of consumption and harm. They note that there is a large difference between the price per standard drink (10g ethanol) and the tax, e.g. between cask wine – 0.34c, 0.07c tax; standard alcohol beer $1.04, 0.29c tax, pre-mixed cans $2.71, 0.71c tax, wine $2.25, 0.47c tax.

Her et al. (1999) conducted a review on deregulation/privatisation of alcohol sales on consumption and problem levels. Their review focused on changes in physical availability (number of outlets to purchase) and economic availability (price). It was found that deregulation resulted in increased hours of sale, more outlets, increased days/week, longer hours and changes in price. Furthermore, in most cases increased availability led to increased consumption e.g. they note that in Iowa and Quebec increased alcohol consumption led to increased price in the short term for popular products and that these price increases

counteracted the increased physical availability. Her et al. (1999) also suggest that more work needs to be done in the area to explore the underlying causes of changing consumption patterns.

Manning, Blumberg and Moulton (1995) also considered relationships between alcohol consumption and price, but as the consumption of alcohol varies across the

community, they considered how light, moderate or heavy drinkers responded as a function of differences in price. The distribution of alcohol consumption within the community is skewed, with the majority drinking small amounts, while a minority drinking much larger amounts. For instance, Manning, Blumberg, and Moulton (1995) observed that the upper 5%

of drinkers consume 36% of alcohol. Hence the distribution of alcohol consumption within the community appears log normal in nature and is sometimes referred to as a Ledermann curve (Ledermann, 1956). Manning, Blumberg and Moulton (1995) were interested in the possible influence of increasing excise upon alcohol consumption. Hence they looked at prices for some standard alcohol purchases (six pack of beer; 750 ml bottle of wine; and 750 ml bottle of whisky) across 232 cities, and considered how relationships between

consumption and price varied for different percentiles of alcohol consumption in the

community. Their regression analysis considered quantities reported consumed as a function of price, for light, moderate and heavy drinkers. They found that the amounts of alcohol consumed by moderate drinkers appeared to respond to price (namely greater price, less consumed). Nevertheless price had less impact upon light and heavy drinkers. Hence they concluded that increasing taxes would not deter heavy drinking, and would impose a burden upon individuals that were not heavy drinkers, and that were causing fewer problems to the community. Note however that the study used self report, and it is believed that people underreport their alcohol consumption (particularly heavy drinkers).

2.2.4 Effects of advertising controls and business controls

Within the liquor industry, advertising has been constrained in an effort to limit the consumption of alcohol (Agostinelli & Grube, 2002), or to target particular groups (e.g.

adolescents, underage drinkers) (Jernigan et al., 2004). Jernigan et al. (2004) considered the amount of exposure that different age groups received through magazines that were read

primarily by 12-20 year olds and 21-34 year olds. They found that advertising to the younger age group, and particularly to underage girls (12-20) of alcohol products increased from 2001-2002, and the authors suggested that while in the past self-regulation by the alcohol industry had been responsible for limiting the amount of advertising seen by underage drinkers, that this mechanism of self-regulation was not sufficient to limit advertising to this age group.

In addition to looking at exposure to alcohol advertising, some research has

considered the effects of limiting alcohol advertising on alcohol-related harms. For example, Saffer (1991) looked at the relationship between fatality rates and alcohol advertising and found that after controlling for price and regional socio-economic differences, advertising rather than price was significantly positively related to both total and night time fatalities.

This suggests than alcohol advertising plays a role in subsequent alcohol-related harms, however the mechanism of such change is less clear. Whether limiting alcohol advertising itself results in such changes or whether increased knowledge of the effects of alcohol and the potential harms also influences people’s behaviour requires more study.

Legalised business complies with laws, regulations and guidelines in order to maintain licenses to serve alcohol and to avoid penalties. Regarding fines for businesses, Cook and Moore (2002) reported that the behaviour of servers of alcohol is partly influenced by management’s perception of whether they will be sued. Hence some of the concerns with business relate not only to public health concerns, but also to economic sanctions that may be levelled against any business breaking the rules. For example in the state of Victoria, more than 100,000 license holders, and people who serve alcohol have completed the responsible service of alcohol course since 1992 (Consumer Affairs Victoria, 2008). This course contains information not only about facts about alcohol, but on the laws and responsibilities that are applicable to businesses including their duty of care to patrons and the requirement to not serve alcohol to individuals who are already intoxicated (Consumer Affairs Victoria, 2008).

In another study conducted in Wollongong in Australia (Babor et al., 1978), a number of venues (17) were monitored over an 8-week period for the advertising which they

promoted. It was found that only a few included advertising that could be considered positive to public health (e.g. free food, transport), while the majority of the promotions encouraged excessive drinking – breaking both the spirit and letter of the voluntary code – e.g. extended happy hours, drink cards with multiple free drinks, drinks in non-standard measures which encouraged binging, “all you can drink” offers, free drinks all night for women etc. This is important because previous research has identified that both heavy and non-heavy drinkers consume more than twice as much alcohol during simulated happy hours as they did during non-happy hours (Babor et al., 1978).

Another study based in the US around college campuses’ found that a ‘wet’

environment exists around US college campuses where lower sale prices, more promotions and higher rates of alcohol advertising are present and these are correlated with increased rates of binge drinking and the number of drinks consumed by students in the previous month (Kuo et al., 2003). The authors argue that while education on drinking behaviour is important in highlighting the harms of binge drinking, that the marketing strategies used by businesses should also be regulated.

A case study using the UK as an example by Cooke et al. (2004) found that marketing is a powerful took for the alcohol industry to attract young (and underage drinkers. They

noted that the UK has a number of voluntary controls on alcohol advertising, but argued that this is ineffective. For example, the regulations stipulate that alcohol must not be marketed in a publication if more than 25% of its readership is under 18 years. However, they found that popular magazines specifically for youth were filled with alcohol marketing of products aimed at those groups e.g. pre-mixed spirit drinks.

2.2.5 Effects of community measures and physical availability

Community action can also be used in order to limit availability. For example, Reynolds, Holder and Gruenewald (1997) suggested that in addition to limiting availability through price, or the number of physical outlets selling alcohol, it is useful for police or authorities to be involved to ensure compliance with sales and service regulations (e.g. age limits; not serving those already drunk in a bar). However, not all research has demonstrated this as Forster et al. (1995) found that enforcement of laws limiting the sale of alcohol to minors is often minimal, and not a sufficient deterrent for this population to reduce their buying.

A model for alcohol access and resulting problems has been put forward by Reynolds et al. (1997) (see Figure 2.2). This model describes how availability to alcohol influences consumption patterns, and how routine activities when paired with alcohol use can lead to negative outcomes. Note that simply looking at “outlet density” to measure alcohol

availability is too simplistic because it depends on where people are buying their alcohol. For example, if you live next to a pub, but never visit it and instead drive to a liquor store to purchase your alcohol then the store is more important for availability purposes, rather than the pub even though it is located closer geographically (Reynolds et al., 1997).

Figure 2.2. Conceptual model for alcohol access (Reynolds et al., 1997).

Gruenewald, Madden and Janes (1992) found that the density of outlets selling alcohol was greater in US states where alcohol consumption was high. The authors suggested that when considering locations of alcohol sellers that geographic availability rather than population estimates are more useful because the number of people in an area may be few or many but their access to alcohol can remain the same.

2.2.6 Alcohol purchasability

Forster et al. (1995) highlighted a difference between alcohol availability and that of a related issue, that of alcohol purchasability. For example, in places where the physical availability of alcohol may be low, one business that supplies minors may be enough to supply for the whole local youth population. This means that the purchasability of alcohol for this group is high, even though it may be against the law for them to buy it. Previous

research has supported this notion finding that college students know where alcohol is

research has supported this notion finding that college students know where alcohol is