Chapter 3: Literature Review
3.4 Potential Policy Solutions: The Environmental Context of Alcohol Use
3.4.2 Population Availability and Economic Availability
A body of knowledge is already to hand to form strong public alcohol policy. Evidence supports the general supply and availability of alcohol as important to public policy direction. Availability of alcohol has been acknowledged as a significant indicator of alcohol consumption and related harms over many decades (Bruun et al. 1975; Single 1988; Stockwell & Gruenewald 2001). Availability as a concept represents how easy it is to obtain alcohol in a physical, economic and legal sense (Babor et al. 2003; Babor et al. 2010; Loxley et al. 2004). Availability is related to all the control policies made by governments, the physical and legal arrangements enabling the purchase and consumption of alcohol (Smart 1977). Availability is further explained in social terms (Moskowitz 1989), representing access to alcohol in social circumstances and community setting.
In support of availability as crucial to alcohol policy, a level of consistency is evident between alcohol availability measures outlined in an Australian monograph (Loxley et al. 2004) and strategies espoused by Bruun and colleagues (Bruun et al. 1975) and Babor and
associates (Babor et al. 2003; Babor et al. 2010). Regulation of physical availability is achieved through: legislation;taxation and excise measures; minimum legal purchase age; enforcement of liquor laws;server liability; restrictions on hours and days of sale;
restrictions on the density of outlets; and consideration of differences with regards to alcohol strength (National Preventative Health Taskforce 2009). The most effective strategies to reduce the economic availability of alcohol are taxation and other measures which increase the cost of purchase, and render alcohol less affordable and therefore less financially available (Babor et al. 2003; Babor et al. 2010; Room, Babor & Rehm 2005). Those legislative policy levers with the greatest impact on availability for high risk drinkers include server liability and a minimum legal purchase age (Babor et al. 2003; Babor et al. 2010).
In an American context, availability is conceptualised as all the legislative arrangements determining access: “off premise sales; hours and days of sale; population restrictions; restrictions on servers; forms of ‘on premise’ sales; criminal penalties; administrative penalties; authority to enforce alcohol control laws; dram shop liability; and local control” (Janes & Gruenewald 1991, pp. 203, 204). Janes and Gruenewald (1991) further define availability as: price restrictions; excise taxes; price advertising; and other pricing control measures. Yet, amendments to legislation and taxation reform can take years to
accomplish. As an alternate policy measure, immediate and beneficial change can be achieved through more effective enforcement of the laws already in existence (Stockwell & Gruenewald 2001). Hence, there is some certainty in strategies to reduce availability, representing an important contribution to public health policy solutions associated with alcohol.
Taking these findings into account, a reduction in availability is a powerful policy lever to challenge the risk and harms from alcohol. Broad structural frameworks and local access arrangements affect the extent of availability as well as harms at both population and community levels. But, as research shows, there is much variability in the effects of decreased physical and economic availability at the point of purchase; the consequence of a reduction in physical availability in the near vicinity could be the integration of alcohol purchases with other essentials like groceries (Gruenewald & Treno 2000). This outcome reduces the real cost and effort required to access alcohol (Abbey, Scott & Smith 1993; Room, Osterberg, et al. 2009). Yet, price increases at local outlets can result in a switch to cheaper alcohol products.
Other perspectives on the effect of price show price elasticities vary between countries, but pricing changes do not always produce a corresponding change in net consumption (Room, Osterberg, et al. 2009). These authors provide examples of Sweden and Denmark, where saturation point for alcohol is thought to have occurred and population consumption stasis is now reached. They suggest the influence of price varies between poor and affluent drinkers; change in price has a greater effect on the young. However, price elasticities can result from wider social, cultural and economic circumstances and are not an attribute of alcohol as a beverage (Osterberg 2001). Pricing changes have differential effects from those of general physical availability, at least on subpopulations of drinkers (Makela 2002). Purchasing power in relation to income also has an effect, with the economics of purchase remaining influential up to a certain level (Room, Osterberg, et al. 2009).
Culmination of the paper by Room and others (2009) is a model suggesting:
“taxes, control on availability and societal responses to alcohol problems push down the real level of alcohol available for
consumption; greater availability and access, purchasing power, and promotion and advertising increase the level; while cultural customs and habits, and structural changes such as urbanisation or change in gender functioning in society, drinking norms and cultural politics affect the level of alcohol in ways that are not predictable” (p. 571).
The importance of pricing policy is not negated by experiences in Sweden and Denmark where stasis is reached; findings highlight the need for sizable price changes to withstand the effects of counter influences (Holder 2009). According to some, saturation is a crude measure lacking explanatory power (McCambridge & Kypros 2009). But, saturation point is likely now reached in alcohol promotion and sponsorship arrangements associated with sporting events (Sherriff & Griffiths 2010), a concept easily understood. Nonetheless, Holder (2009) considers the position of Room and colleagues (2009) supportive of a theoretical perspective on complex alcohol systems, but questions the need for a full understanding of pricing and other matters to reduce associated harms. Moreover, the whole supply and marketing side of alcohol is as much about the way alcohol is used as it is about its regulation (Sulkunen 2009).
Even so, for some individuals, the availability and affordability of alcohol do not always translate to consumption or to the experience of harms. While restricting access and lowering availability are powerful interventions, these interrelationships are highly complex (Stockwell & Gruenewald 2001). Review of the pricing literature shows an inverse relationship between drinking and price: increased price is considered as an
effective policy response to alcohol use and harms (Wagenaar, Salois & Komro 2009). But, the effects of pricing policies vary between product types, point of sale and drinking venues (Meier, Purshouse & Brennan 2010). Meier and colleagues (2010) concur that population groups are differentially affected by price, due to diverse risk profiles related to alcohol; the effects of pricing policies on alcohol related harms are likewise variable.
Taking the evidence into account, control of the availability of alcohol through physical, economic and legal means is an important public health goal (Babor et al. 2003; Babor et al. 2010; Bruun et al. 1975; d'Abbs 2001; Edwards et al. 1995; Groves 2010; Single 1988; Stockwell & Gruenewald 2001). Yet, the heterogeneity required in pricing policy across populations (Meier, Purshouse & Brennan 2010) makes the development of a retail pricing index by government a complex undertaking. Some connections are presumed between the more global perspectives of government control systems and local response
mechanisms (Gruenewald & Treno 2000). But the connections between availability as supply, and consumer demand are not unidirectional; change in national acceptance of alcohol is often responsible for increased demand (Edwards & Holder 2000), or indeed, decline.
Nonetheless, price does bring about some change in acceptability and demand, at the very least, at the household budget level. Disposable income is strongly related to access to alcohol through economic means (Moskowitz 1989); the greater the amount of disposable income, the greater the likelihood of purchase and consumption. Consistent with this position, financial benefits are seen by Australians as one of the gains from reducing consumption or abstaining from use (National Drug Strategy 2002). But, as early as the 1970s, a focus on price in alcohol control policy was seen as weak and inconclusive (Parker & Harman 1978). This position does not however negate the importance of the
economic availability of alcohol as significant to alcohol use (Babor et al. 2003; Loxley et al. 2004; Room, Babor & Rehm 2005). Similarly, the viewpoint of Parker and Harman (1978) does not preclude use of a range of evidenced availability measures to reduce the risk and harms from alcohol (National Preventative Health Taskforce 2008).
Limits to all forms of alcohol availability offer strong protective effects to the general population (World Health Organization 2007b). Some variability in the impact of
availability is due to personal attributes related to drinking, reasons for drinking, previous experiences with alcohol, and a number of other factors (National Health and Medical Research Council 2009). Research covered earlier in the literature review suggests where drinking occurs and who drinkers associate with also influence vulnerability to risk. Thus the immediate effects of physical availability are altered. Moreover, it ispossible that strong measures to reduce availability will assist drinkers to control uptake as well as intake, irrespective of other factors that contribute to harm. Such an approach represents an effective demand reduction strategy. But, as the next section shows, policy effort by governments to control availability and reduce demand are countered by industry
advertising that seeks to influence perception of alcohol as a beverage, and perception of alcohol’s availability.