Submission on the Mental Health and Addiction Inquiry June 5, 2018

Submission on the Mental Health and Addiction Inquiry June 5, 2018

Submission on the Mental Health and Addiction Inquiry June 5, 2018 Alcohol Healthwatch is an independent charitable trust working to reduce alcohol-related harm. We are contracted by the New Zealand Ministry of Health to provide a range of regional and national health promotion services. These include: providing evidence-based information and advice on policy and planning matters; coordinating networks and projects to address alcohol-related harms, such as alcohol-related injury and fetal alcohol spectrum disorder; and co-ordinating or otherwise supporting community action projects.

Thank you for the opportunity to provide feedback to the Mental Health and Addiction Inquiry.

Our submission focuses on the role of alcohol consumption in mental health and addiction in Aotearoa New Zealand. Prevention, equity and a solutions focus are at the core of our recommendations. If you have any questions on the comments we have included in our submission, please contact: Dr Nicki Jackson Executive Director Alcohol Healthwatch P.O. Box 99407, Newmarket, Auckland 1149, New Zealand P: +64 9 520 7035 E: director@ahw.org.nz

Table of contents Recommendations ___ 1
Alcohol use in New Zealand ___ 2
Harms from alcohol use ___ 3
Relationship between alcohol use and mental health ___ 4
Relationship between alcohol use and addiction ___ 5
Mental health harms from others’ drinking ___ 6
Impact of Fetal Alcohol Spectrum Disorder (FASD) on mental health ___ 7
What needs to be done to improve mental health and reduce addiction ___ 8
1. Alcohol outlet availability ___ 8
2. Trading hours of licensed premises ___ 9
3. Price and affordability ___ 9
4. Purchase/drinking age ___ 10
5.

Advertising and marketing ___ 11
6. Other alcohol policies: screening and brief intervention ___ 11
7. Addressing the wider or social determinants of alcohol use ___ 12
Conclusions . 12

1 Recommendations 1. Alcohol Healthwatch recommends that any efforts or strategies to improve mental health in the New Zealand population must include measures to address hazardous alcohol use. Alcohol use is described as a potent risk factor for suicidal behaviour and is found in New Zealand research to be associated with later depression. 2. Alcohol Healthwatch recommends that the increasing affordability of alcohol must be addressed. To achieve this, alcohol excise taxes should be increased by at least 50% and a Minimum Unit Pricing of at least $1.30 per standard drink be implemented. 3.

Alcohol Healthwatch recommends that the inequitable distribution of alcohol outlets in New Zealand is remedied, in line with the Crown’s obligations under the Treaty of Waitangi to protect Māori health. In particular, the Sale and Supply of Alcohol Act 2012 should be amended to provide for Territorial Authorities to apply sinking lid policies in areas where over-provision of outlets has been demonstrated.

4. Alcohol Healthwatch recommends that the late-night availability of alcohol is reduced by amending the default national maximum trading hours that are prescribed in legislation. 5. Alcohol Healthwatch recommends that the legal purchase age for alcohol is increased to 20 years. 6. Alcohol Healthwatch recommends protecting young people and children from the harms associated with alcohol advertising, sponsorship and promotion by implementing the recommendations made by the Ministerial Forum on Alcohol Advertising and Sponsorship. These measures may also protect New Zealanders with alcohol dependence.

7. Alcohol Healthwatch recommends that a nation-wide alcohol screening, brief intervention and referral to treatment programme is implemented throughout New Zealand. Such screening must also ensure it includes the risk of alcohol to the unborn child. 8. Alcohol Healthwatch recommends that the social determinants of alcohol are addressed to reduce inequities in harm. Policies to address socio-economic deprivation and racial discrimination are imperative. Socio-economic deprivation at the individual, whānau and neighbourhood level need to be remedied. This will require changes to spatial planning processes so that geographic separation between socio-economically advantaged and disadvantaged areas is reduced.

2 Alcohol use in New Zealand 9. From 2006/07 to 2011/12 in New Zealand, the prevalence of drinking in the past year significantly reduced from 83.6% to 79.5%.1 These reductions were demonstrated across most demographic groups, with young people aged 15-17 years showing the largest shifts in drinking prevalence. 10. This period also witnessed significant declines in the prevalence of hazardous drinking. Again, these changes were demonstrated across almost all population groups (Table 1). Table 1. Hazardous Drinkers (AUDIT Score ≥8, among the total population) Hazardous drinkers (%) among the following population groups Year 2006/07 2011/12 2012/13 2013/14 2014/15 2015/16 Total 18.0 14.9 15.4 16.4 17.7 19.3 Men 26.0 21.6 22.0 22.1 24.7 26.6 Women 10.6 8.6 9.1 11.0 11.1 12.3 Aged 15-17 years 19.5 11.7 8.0 15.3 10.8 11.5 Aged 18-24 years 43.2 29.9 32.4 33.4 33.9 32.5 Aged 25-34 years 23.9 24.8 24.4 23.9 21.9 27.6 Aged 35-44 years 16.6 16.0 16.6 15.9 19.5 22.3 Aged 45-54 years 12.2 11.7 12.9 16.3 18.3 18.5 Aged 55-54 years 12.1 8.4 9.1 10.1 13.2 14.4 Aged 66-74 years 7.3 5.5 5.3 5.7 8.8 10.0 Aged 75+ years 3.6 1.6 2.0 1.8 2.8 2.9 Total Māori 33.5 28.6 30.6 30.9 32.4 32.9 Māori men 43.5 37.1 38.8 37.2 38.4 36.9 Māori women 24.2 20.9 23.1 25.2 27.0 29.4 Total Pacific 23.4 19.3 17.2 20.1 23.4 21.1 Pacific men 33.7 29.6 27.4 27.0 34.8 29.4 Pacific women 14.0 10.7 8.6 13.7 13.7 13.3 Total Asian 5.7 4.2 5.1 3.7 4.7 4.7 Asian men 10.1 6.9 7.8 4.7 7.6 7.2 Asian women 1.8 1.8 2.2 2.6 1.7 2.0 Total European/Other 17.9 14.8 15.2 16.7 17.9 20.4 European/Other men 26.2 21.8 22.3 22.9 25.7 29.0 European/Other women 20.2 8.1 8.6 10.8 10.4 12.3 Results for 2016/17 are not shown as the survey question changed and comparisons are not possible.

11. From 2011/12 to 2016/17, the lower prevalence of drinking has been maintained (79.3% in 2016/17) across all population groups.1 12. In contrast, the prevalence of hazardous drinking has been increasing in every age group between 35 and 74 years (Table 1). Increases by more than 50% have been found among those aged 45-54 years (11.7% to 18.5% in 2015/16) and 55-64 years (8.4% to 14.4% in 29015/16).

13. The prevalence of hazardous drinking in the 66-74-year age group has doubled from 2011/12 (5.5%) to 2015/16 (10%).

3 14. As a result of these increases in hazardous drinking (as well as population growth), there were 179,000 more hazardous drinkers in 2015/16 than in 2011/12. 15. Increases in women’s drinking appear to be contributing significantly to the rising prevalence of hazardous drinking. These trends have significant implications for women’s health and wellbeing, equity in society, and the prevalence of, and outcomes associated with, Fetal Alcohol Spectrum Disorder (discussed later).

16. Due to recent changes in the New Zealand Health Survey methodology, changes in hazardous drinking between 2016/17 and earlier surveys is limited. Comparisons between 2015/16 and 2016/17 show no significant changes in hazardous drinking across any age, sex or ethnic group.2 17. The 2016/17 New Zealand Health Survey highlights the continuing, and striking, inequalities in the prevalence of hazardous drinking by sex and ethnicity. In 2016/17, 39% of Māori men and 32.3% of Pacific men were classified as hazardous drinkers. This compares to 28.4% of European/other men.2 Maori women continue to show increases in the prevalence of hazardous drinking, now showing higher levels than at the peak of drinking in 2006/07.

18. Young adults (18-24 years) continue have the highest prevalence of hazardous drinking in New Zealand. In 2016/17, more than one in three young adult men (39.5%) and one in four young adult women (25.7%) were classified as hazardous drinkers.2 Harms from alcohol use 19. Alcohol is the largest risk factor for health loss and disability among 15-49 year old New Zealanders.3 (Figure1). This age group comprises many individuals driving our economy and raising future generations to contribute to a productive and healthy society. Figure 1. Mortality rates by risk factor, New Zealand, both sexes, 15-49 years, 2016.

Global Burden of Disease Compare Data Visualisation (5) 20. Of all drugs available in society, alcohol causes the most harm (Figure 2).4 This arises because of the significant harm to both users (e.g., drug specific death and illnesses,

4 dependence and loss of relationships, etc.) and to others (e.g. crime, injury and social costs). Figure 2. Drugs ordered by their overall harm scores, showing the separate contributions to the overall scores from harms to users and harm to others (4) 21. In 2005/06, the total annual cost of alcohol-related harm was estimated to be $5 billion. One-third of these costs were considered direct costs to Government. Alcohol contributed to just over 70% of all costs from harmful drugs (excluding tobacco).5 22. It is important to note that the $5 billion annual estimate did not include the ongoing costs associated with Fetal Alcohol Spectrum Disorder (FASD), only the direct costs of inpatient care in 2005/06 were calculated.

In 2013, Easton et al.6 calculated that the aggregate losses in productivity from FASD ranged from $49 million to $200 million per year. 23. Of the 802 deaths attributable to alcohol in 2007, injuries accounted for 43%, cancer for 30% and other chronic disease accounted for 27% of all deaths. Too often the policy focus is placed on the acute harms associated with drinking (e.g. injury and crime), neglecting the many deaths in New Zealand resulting from chronic use over time, even at low levels.7 Relationship between alcohol use and mental health 24. It has been proposed that there are three or more potential causal pathways that link alcohol use with poor mental health8 .

They are: (a) Heavy drinking/alcohol use disorders causing depressive disorders (b) Depressive disorders increasing alcohol use and subsequent alcohol use disorders (i.e. ‘self-medication’) (c) A reciprocal causal relationship by another mechanism such as genetic vulnerability.

25. High quality New Zealand and international evidence9–12 shows that the strongest associations between alcohol use and poor mental health (e.g. depression, anxiety, suicidal ideation, etc.) are in relation to alcohol abuse or heavy drinking. 26. Depression: New Zealand studies that have followed individuals over time demonstrate support for the causal pathway whereby alcohol abuse/dependence leads to depression,

5 rather than depression leading to alcohol abuse (e.g. self-medication for depressive symptoms).9–11 27. Suicide: Acute alcohol use is considered a potent risk factor for suicide.

Controlling for the presence of alcohol use disorders, it is estimated that acute alcohol use increases the risk of suicidal behaviour 5-10 fold.13 In addition, regular heavy drinking, as well as acute alcohol use at low levels,14,15 has been shown to be significantly associated with suicide. 28. Data released by the New Zealand Coronial Services to Alcohol Healthwatch showed that traces or more of alcohol were found in 64% of suicides in 2015 (Table 2). Variability by age group was present, with alcohol (including a trace) present in 79% of suicides in the 30 to 34-year age group. Over 40% of all suicides in the 40-44, 45-49, and 50-54-year age group were found to have more than a trace of alcohol.

Table 1. Provisional Alcohol-related Suicides 2014, 2015. Provisional Alcohol-related suicides: Data taken from Toxicology reports of Provisional Suicide cases in 2014 and 2015 Calendar Years 2014 (n=510) 2015 (n=549) No Alcohol found 34% 28% Alcohol above Trace level 34% 34% **Trace of Alcohol in either blood or urine 23% 30% No toxicology report 10% 11% **ESR Reference Trace Level (less than 5 milligrams per 100 millilitres); Trace levels of alcohol may be due to means other than deliberate ingestion. Please note that these details include some active cases which are suspected suicides and as such are provisional pending the Coroner’s official finding.

29. Dementia: Alcohol use disorders have been found to be a major risk factor for the onset of all types of dementia, especially early-onset dementia.16 Alcohol consumption over time is associated with detrimental effects on brain structure. 30. Mental health and alcohol use disorders: Poorer mental health has been shown8 to be associated with increased alcohol consumption among low-level drinkers and may be involved in sustaining high alcohol consumption among heavy drinkers. In the Dunedin Longitudinal study,17 depression (in combination with a range of child and adolescent risk factors) was found to be associated with adult substance use disorders.

31. Sleep: The contribution of alcohol to sleeping problems18 has been extensively studied.

Poor sleep is a known contributor to poor mental health. 32. Mental health benefits: Alcohol is well-known as a social lubricant and is perceived to reduce social anxiety, freeing individuals from a fear of social rejection. However, it is suggested that rather than alcohol itself reducing social phobic anxiety, it may be the expectancies about the effects of alcohol which may contribute to the positive effect.19 Relationship between alcohol use and addiction 33. Alcohol use disorders: Findings from the Christchurch Health Development Study found that an earlier onset of drinking was associated with frequency of drinking, consuming high amounts of alcohol and experiencing alcohol-related problems at age 15 years.20

6 34. However, age of first drinking (between 11 and 13 years) was not found to be associated with alcohol use disorders during the period 15-35 years in the Christchurch study.21 Rather, factors relating to family functioning and individual characteristics appeared to play major roles. This finding is supported by a systematic review of five longitudinal studies showing small, but inconsistent, effects relating to age of first drink and adult drinking and related problems.22 35. Although there is debate regarding the impact of age of onset of drinking on later dependence, patterns of alcohol consumption in adolescence have been shown to be associated with alcohol dependence in early adulthood.

A review of longitudinal studies has found consistent evidence that higher alcohol consumption in late adolescence continues into adulthood and is associated with alcohol problems including dependence. 23 36. As such, a prevention approach to reducing alcohol addiction will necessarily seek to address the early trajectory of dependence that begins in adolescence. Early intervention is particularly important given the challenges and costs associated with intervening in dependence at later years.24 37. Tobacco use disorders: There is evidence that frequent heavy drinking is associated with lower rates of quitting and making a quit attempt.25 In New Zealand, one-third (33.1%) of smokers in a national survey were found to be hazardous drinkers.26 Mental health harms from others’ drinking 38.

Mental health harms from drinking also need to consider the harms associated with, or resulting from, the drinking of others. A growing body of evidence has documented these harms in the New Zealand context.27–29 39. Findings from this New Zealand research reveal significant associations between poor mental health and close exposure to the drinking of others (especially friends and partners). Significant harms include increased odds of depression and anxiety and lower reported well-being.

40. These findings concur with international studies on the harms resulting from the drinking of others.30 41. It is estimated that for every 100 alcohol or drug-impaired drivers or riders killed in road crashes, 50 of their passengers and 19 non-alcohol impaired road users die with them.31 This outcome will no doubt have ripple effects in terms of the mental health of others. 42. Suicide certainly has far reaching effects in terms of the mental health of others. For many years it was estimated that for each suicide, six others were affected. However, recent research has now quantified the legacy of suicide death to be much greater, ranging from 10 to 135 persons exposed to the suicide of someone they knew.32 33 34 43.

The impact of suicide among friends, families and communities is devastating. Those left behind are shown to have much higher suicide rates than the general population.35

7 Impact of Fetal Alcohol Spectrum Disorder (FASD) on mental health 44. Of all drugs available in society, alcohol is the most harmful to the developing fetus.36 45. New Zealand’s low-risk drinking guidelines37 recommend that women avoid alcohol consumption during pregnancy.38 46. It has been estimated that more than 50% of New Zealand pregnancies, on average, are alcohol exposed (~30,000 babies in 2017 (of 59,610 births)). 47. While most New Zealand women stop or reduce their drinking when they find out they are pregnant, it has been found that 28% continue to drink alcohol throughout their pregnancy and 9% report binge drinking during pregnancy.39 The Growing Up in New Zealand longitudinal study40 found that almost one-quarter (23%) of NZ women reported some alcohol use in the first trimester and 13% of mothers consumed any alcohol after the first three months.

Among women with unplanned pregnancies, 13% consumed four or more drinks of alcohol per week in the first trimester.

48. Consumption of alcohol during pregnancy is clearly related to the frequency and pattern of drinking prior to pregnancy. 49. Mental health status has been found to relate to alcohol consumption during pregnancy. In one study41 , women with a lower self-perceived mental health status were 1.40 (95%CI 1.18–1.67) times more likely to have consumed alcohol during pregnancy (compared to self-perceived excellent mental health). Alcohol consumption whilst breastfeeding was unrelated to mental health status.

50. There is a myriad of outcomes associated with drinking during pregnancy, including miscarriage, stillbirth, and lifelong physical, behavioural, and intellectual disabilities.

These disabilities are known as fetal alcohol spectrum disorders (FASDs). 51. Among children diagnosed with FASD, an increased prevalence of mental and development disorders has been found.41,42 52. The reasons for this may also be varied. Poorer mental health may be, in part, due to secondary disabilities arising from prenatal exposure to alcohol (e.g. intellectual disability, alcohol’s effect on neurobiological systems that increase vulnerability to later disorders such as depression and anxiety, attention deficits, heightened emotional reactivity, sleep disorders, irritability, etc.).43–45 53.

High rates of attempted suicide have been observed in persons with FASD.46,47

8 What needs to be done to improve mental health and reduce addiction 54. Alcohol consumption affects mental health, and vice versa. Reducing hazardous alcohol consumption in New Zealand should be integrated into any overarching strategy to improve the mental health and well-being of the population. 1. Alcohol outlet availability (density) a) The evidence 55. Suicide: Significant findings have been found in relation to the impact of outlet density on suicide completion and attempts. Four studies in the US were reviewed48 , finding that suicide completion was significantly associated with greater availability of:  total alcohol outlet density49  total alcohol outlet density (among young males, but not among young females50 )  bar and off-licence density (but protective effects for licensed restaurant density51 )  off-licence density (for suicides with a blood alcohol content >0 g/dl and ≥0.08 g/dl for men, but not for women52 )  on-licence alcohol outlet density (for suicides involving alcohol with a blood alcohol content >0 g/dl for both men and women, and with a blood alcohol content ≥0.08 g/dl for men only)52 .

56. Anxiety or depression: Limited evidence is available in relation to the impact of alcohol outlet density on mental health conditions such as anxiety or depression. Two Australian studies found mixed results (one showing a protective effect for density53 and one showing no relationship54 ). One New Zealand study55 found an overall linear trend of dual diagnosis for alcohol/drug abuse and anxiety/mood disorder being less likely with increasing distance or decreasing density of alcohol outlets. 57. Heavy alcohol use and alcohol use disorders: A wealth of New Zealand studies have shown alcohol outlet density to be associated with adolescent and adult hazardous drinking and a range of alcohol-related harms.56–59 In relation to the impact of density on more chronic or severe use, the evidence is sparse.

A recent study has shown60 that living in a neighbourhood with one or more alcohol outlets was associated with a 16% increase in the probability of developing an alcohol use disorder. Relapse or recurrence of alcohol use disorders was not affected by outlet density, although the authors acknowledged the cases included in the study may have represented the more severe end of the spectrum of alcohol use disorders.

b) What to do 58. The density of licensed premises in New Zealand has increased markedly since 1989. The number of on-licences and off-licences have trebled and doubled, respectively. Over the same period, the population grew by 42%. There is significant inequity in the distribution of outlets, exemplified by areas of high socio-economic deprivation having disproportionately greater densities of off-licences than more advantaged areas.61 59. In agreement with the World Health Organisation and Centre for Disease Control62 , Alcohol Healthwatch recommends that action is taken to:  Reduce alcohol outlet density, particularly in areas that experience high levels of alcohol-related harm.

Amending the Sale and Supply of Alcohol Act 2012 to provide

9 for Territorial Authorities to apply sinking lid policies in areas of over-provision of alcohol outlets would assist in this regard. 2. Trading hours of licensed premises a) The evidence 60. Mental health: There is limited evidence in relation to the impact of trading hours of licensed premises on mental health. One study found that extensions to bar trading hours in Wales and England in 2005 was associated with a marked increase in heavy drinking and poorer mental health.63 61. There is certainly strong evidence of the negative impact of late on-licence closing hours on hazardous drinking and alcohol-related harm.64 Two studies examining the impact of restricted off-licence hours show positive reductions in harm for young people.65,66 In New Zealand, heavy drinkers have been found to be more likely to purchase at later hours from both off-licences and on-licences.67 62.

The impact of trading hours on chronic alcohol use disorders is unknown. b) What to do 63. The Sale and Supply of Alcohol Act 2012 specifies the default national maximum trading hours for premises in areas without a Local Alcohol Policy. These are:  8am to 4am for on-licences and club licences  7am to 11pm for off-licences 64. To reduce the availability of alcohol, particularly opportunistic purchases late at night, the national maximum hours need to be reduced. For example, off-licence hours in Sweden and Norway are no later than 8pm (mostly 7pm) during the week, 3pm on Saturdays and off-licences are closed on Sundays.

65. Alcohol Healthwatch recommends that the default national maximum trading hours are reduced. We recommend off-licences should not be granted hours past 9pm. 3. Price and affordability a) The evidence 66. Suicide: In total, five studies50,68–71 have examined the relationship between alcohol prices and suicide. 67. In a 2016 review49 of four studies published, two studies further examined differences in effect by age, and one further examined differences by sex. 68. In total, the four studies examined 12 different estimates relating to the relationship between alcohol prices and suicide.

69.

Overall, five of the 12 estimates were significant. Three showed lower rates of suicide among young males (10-14 years, 15-19 years, 20-24 years) when prices were increased. One showed significant reductions in suicide in the total population, and one showed significant increases in suicide when prices (taxes) increased. This counter-intuitive finding in the latter study could be due to the study failing to adjust for likely confounders in the relationship between price and suicide over the 30-year time period examined.

10 70. When all of 12 estimates were combined in a meta-analysis72 , no relationship was evident between alcohol prices and suicide. When the outlier study was removed from the analysis, a significant association was found. 71. Since the publication of the meta-analysis, one US study has shown suicide mortality rates were significantly reduced following changes in the excise tax on wine, but not following changes in the excise taxes on spirits or beer.70 72. In relation to affordability, an analysis of data from 1998 to 2010 in the United Kingdom found a significant positive correlation between psychiatric admissions for alcohol-related disorders and alcohol affordability.73 b) What to do 73.

The evidence suggests that increases in the price of alcohol may be effective in reducing suicide among young males. Positive effects on young females may also result. 74. Alcohol Healthwatch recommends:  Increasing the alcohol excise tax rates by at least 50%  Requiring excise rates to be adjusted annually for changes in affordability  Implementing a Minimum Unit Pricing Policy of at least $1.30 per standard drink  Implementing legislation to require all alcohol manufacturers, importers and wholesalers to file annual returns to the Government (similar to Section 35 of the Smokefree Environments Act whereby all tobacco manufacturers and importers must file an annual return to the Director-General of all the tobacco products (by types, by brands and by weight) released for sale in the New Zealand market.).

This information should be mandated to inform effective alcohol pricing policies. 4. Purchase/drinking age a) The evidence 75. Suicide: US studies have found that mental health harms (including alcohol-related suicide/self-inflicted injuries) increase at point of which alcohol consumption is legal (e.g. 18 or 21 years).74,75 In one study, the statistical significance of this finding was not specified.

76. Similar to the effect of other alcohol policies, results pertaining to the impact of the legal drinking age vary by sex (one study showed stronger effects among females)76 and age (greater impact among young adults). One study found no significant effect of a reduced legal drinking age on suicide mortality rates among young adults in their first year after attaining legal right to drink alcohol, and found a small but significant decrease in suicide mortality rates after the first year.77 77. Other mental health outcomes: Limited evidence is available in relation to the impact of legal drinking or purchase age policies on other mental health harms.

One study found no impact on psychological well-being of young adults when they reached the legal age to drink (at 21 years). The generalisability of these findings to the New Zealand context that has a legal purchase age of 18 years is unknown.

78. One study78 evaluated the effect of a 1967-68 experiment that increased availability of high strength beer to those aged over 16 years in a small number of counties, while the age of access remained at 21 years in other counties. Analysis of national insurance registry data over the following 43 years found that those who had been exposed to the temporary increase in availability of alcohol were significantly more likely to later receive

11 a disability pension due to an alcohol use disorder (hazard ratio 1.39 [95%CI: 1.25 to 1.54]) or mental disorder (1.26 [1.22 to 1.30]).

79. Alcohol use disorders: Lower minimum legal drinking ages have been found to be associated with an increased odds of alcohol use disorders.79 In New Zealand, the reduction in the legal purchase age from 20 years to 18 in 1999 was found to be associated with an increase in a number of alcohol-related harms for young people, including alcohol-related hospitalisations80 , prosecutions for driving with excess alcohol and disorder81 , and traffic crashes82,83 80. The evidence relating to the effect of minimum legal drinking/purchasing age on drug use disorders is very mixed.

b) What to do 81. As described above, heavy alcohol use during adolescence is associated with later dependence or addiction. To reduce the acute and short-term harms from adolescent drinking, Alcohol Healthwatch recommends that the legal purchase age is returned to 20 years. 5. Advertising and marketing a) The evidence 82. Longitudinal studies have demonstrated significant associations between exposure to alcohol advertising and adolescent alcohol consumption (particularly heavy use).84–86 83. Persons with alcohol dependence (particularly those receiving inpatient treatment) may have heightened vulnerability to the effects of advertising.87 Many will actively seek to avoid alcohol advertising in their environment.

However, there remains mixed evidence with regards to the impact of alcohol advertising on relapse.88–90 b) What to do 84. In 2014, a Ministerial Forum on Alcohol Advertising and Sponsorship91 was tasked to review the recent evidence on the links between advertising/sponsorship and harm. The Forum reported its recommendations in October 2014, signalling the need for significant changes in relation to the regulation of alcohol advertising and sponsorship. 85. To reduce the harm from alcohol, particularly to young people, Alcohol Healthwatch recommends that the Forum’s recommendations are implemented in full.

86. In addition, to reduce the prevalence of alcohol consumption during pregnancy, Alcohol Healthwatch recommends that alcohol and pregnancy warning labels are mandated on all alcohol products. Currently, alcohol producers are voluntarily adding warnings to their products, but this approach has resulted in labels that are miniscule (less than the size of a pea)92 and subject to misinterpretation.93 6. Other alcohol policies: screening and brief intervention 87. It is important that drinkers who consume alcohol at levels which place them at risk of acute and/or long-term harm are identified within healthcare and community settings.

88. Screening for at-risk drinkers and providing them with brief intervention is a cost-effective measure to reduce hazardous and harmful drinking.94

12 89. Alcohol Healthwatch recommends that a nation-wide alcohol screening, brief intervention and referral to treatment programme is implemented throughout New Zealand. This approach has been a focus of preventing suicide in Scotland.95 Since 2008 in Scotland, alcohol brief interventions have been delivered in settings including primary care, A&E and antenatal care settings. 90. Such screening must also ensure it includes the risk of alcohol to the unborn child. 7. Addressing the wider or social determinants of alcohol use 91. By far, socio-economic position is one of the biggest drivers of hazardous alcohol use. Policies that raise incomes and welfare have been shown to have some of the greatest impacts on reducing alcohol-related mortality. This is particularly important in the early childhood years, especially in relation to periods of repeated poverty.96 92. Other determinants of alcohol use include:
  • neighbourhood-level socio-economic disadvantage97,98
  • family relationship breakdown or disruptive family relationships;99
  • disadvantaged status of Māori in the context of New Zealand society (reflecting marked effects of colonisation);100
  • cultural alienation, racial discrimination101 , confusion over identity, prominence of valuing individualism in society; and
  • job stress102 and long working hours.103 93. Alcohol Healthwatch recommends that addressing the wider determinants of alcohol use can significantly reduce inequities in harm.

Conclusions 94. Efforts to improve mental health in the New Zealand population level should encompass measures to reduce hazardous alcohol use. 95. Reducing consumption not only has the ability to improve the health and well-being of our current population, but can being about significant potential to reduce harm to future generations (particularly in relation to Fetal Alcohol Spectrum Disorder). 96. We thank the Inquiry Panel for this important work and wish them well in future deliberations.

13 References 1. Ministry of Health. Annual Update of Key Results 2015/16: New Zealand Health Survey.

(2016). 2. Ministry of Health. Annual Data Explorer 2016/17: New Zealand Health Survey [Data File]. URL: https://minhealthnz.shinyapps.io/nz-health-survey-2016-17-annual-update. 3. Institute for Health Metrics and Evaluation. Institute for Health Metrics and Evaluation. Global Health Data Exchange: GBD Results Tool 2017. 4. Nutt, D. J., King, L. A. & Phillips, L. D. Drug harms in the UK: a multicriteria decision analysis. The Lancet 376, 1558–1565 (2010).

5. Slack, A. & Nana, G. W. M., Stokes, F., Wu, J.,.(2009). Costs Harmful Alcohol Drug Use 6. Easton, B., Burd, L., Rehm, J., & Popova, S. Productivity losses associated with Fetal Alcohol Spectrum Disorder in New Zealand. N. Z. Med. J. Online 129, 72–83 (2016). 7. Connor, J., Kydd, R., Shield, K. & Rehm, J. The burden of disease and injury attributable to alcohol in New Zealanders under 80 years of age: marked disparities by ethnicity and sex. N. Z. Med. J. 128, 15–28 (2015). 8. Bell, S. & Britton, A. An exploration of the dynamic longitudinal relationship between mental health and alcohol consumption: a prospective cohort study.

BMC Med. 12, 91 (2014).

9. Fergusson, D. M., Boden, J. M. & Horwood, L. J. Tests of causal links between alcohol abuse or dependence and major depression. Arch Gen Psychiatry 66, 260–6 (2009). 10. Fergusson, D. M., Boden, J. M. & Horwood, L. J. Alcohol misuse and psychosocial outcomes in young adulthood: results from a longitudinal birth cohort studied to age 30. Drug Alcohol Depend. 133, 513–519 (2013). 11. Fergusson, D. M., Boden, J. M. & Horwood, L. J. Structural models of the comorbidity of internalizing disorders and substance use disorders in a longitudinal birth cohort. Soc. Psychiatry Psychiatr. Epidemiol.

46, 933–942 (2011).

12. Flensborg-Madsen, T. Alcohol use disorders and depression–the chicken or the egg? Addiction 106, 916–918 (2011). 13. Conner, K. R., Bagge, C. L., Goldston, D. B. & Ilgen, M. A. Alcohol and suicidal behavior: what is known and what can be done. Am. J. Prev. Med. 47, S204–S208 (2014). 14. Borges, G. et al. A meta-analysis of acute use of alcohol and the risk of suicide attempt. Psychol. Med. 47, 949–957 (2017). 15. Conner, K. R., Bridge, J. A., Davidson, D. J., Pilcher, C. & Brent, D. A. Metaanalysis of mood and substance use disorders in proximal risk for suicide deaths. Suicide Life. Threat.

Behav. (2017).

16. Schwarzinger, M. et al. Contribution of alcohol use disorders to the burden of dementia in France 2008–13: a nationwide retrospective cohort study. Lancet Public Health 3, e124– e132 (2018). 17. Meier, M. H. et al. Which adolescents develop persistent substance dependence in adulthood? Using population-representative longitudinal data to inform universal risk assessment. Psychol. Med. 46, 877–889 (2016). 18. Garcia, A. N. & Salloum, I. M. Polysomnographic sleep disturbances in nicotine, caffeine, alcohol, cocaine, opioid, and cannabis use: a focused review. Am. J. Addict. 24, 590–598 (2015).

19. Himle, J. A. et al. Effect of alcohol on social phobic anxiety. Am. J. Psychiatry 156, 1237– 1243 (1999). 20. Fergusson, D. M., Lynskey, M. T. & Horwood, L. J. Childhood exposure to alcohol and adolescent drinking patterns. Addiction 89, 1007–16 (1994). 21. Newton-Howes, G. & Boden, J. M. Relation between age of first drinking and mental health and alcohol and drug disorders in adulthood: evidence from a 35-year cohort study. Addiction 111, 637–644 (2016).

14 22. Maimaris, W. & McCambridge, J. Age of first drinking and adult alcohol problems: systematic review of prospective cohort studies.

J Epidemiol Community Health jech– 2013 (2013). 23. McCambridge, J., McAlaney, J. & Rowe, R. Adult consequences of late adolescent alcohol consumption: a systematic review of cohort studies. PLoS Med 8, e1000413 (2011). 24. Sellman, D. The 10 most important things known about addiction. Addiction 105, 6–13 (2010). 25. Kahler, C. W. et al. Alcohol consumption and quitting smoking in the International Tobacco Control (ITC) Four Country Survey. Drug Alcohol Depend. 100, 214–220 (2009). 26. Wilson, N., Weerasekera, D., Kahler, C. W., Borland, R. & Edwards, R. Hazardous patterns of alcohol use are relatively common in smokers: ITC Project (New Zealand).

N. Z. Med. J. Online 125, (2012).

27. Connor, J. & Casswell, S. The burden of road trauma due to other people’s drinking. Accid. Anal. Prev. 41, 1099–103 (2009). 28. Connor, J. & Casswell, S. Alcohol-related harm to others in New Zealand: evidence of the burden and gaps in knowledge. N. Z. Med. J. 125, 11–27 (2012). 29. Connor, J., You, R. & Casswell, S. Alcohol-related harm to others: a survey of physical and sexual assault in New Zealand. N. Z. Med. J. Online 122, (2009). 30. Karriker-Jaffe, K. J., Room, R., Giesbrecht, N. & Greenfield, T. K. Alcohol’s harm to others: Opportunities and challenges in a public health framework.

J. Stud. Alcohol Drugs 79, 239–243 (2018).

31. Ministry of Transport. Alcohol and drugs. (2017). 32. Berman, A. L. Estimating the population of survivors of suicide: Seeking an evidence base. Suicide Life. Threat. Behav. 41, 110–116 (2011). 33. Dyregrov, K. What do we know about needs for help after suicide in different parts of the world? Crisis (2011). 34. Cerel, J. et al. How many people are exposed to suicide? Not six. Suicide Life. Threat. Behav. (2018). 35. Pompili, M. et al. Bereavement after the suicide of a significant other. Indian J. Psychiatry 55, 256 (2013).

36. Stratton, K., Howe, C. & Battaglia, F. C. Fetal alcohol syndrome: Diagnosis, epidemiology, prevention, and treatment.

(National Academies Press, 1996). 37. Health Promotion Agency. Low-risk alcohol drinking advice. Available at: http://alcohol.org.nz/help-advice/advice-on-alcohol/low-risk-alcohol-drinki ng-advice. 38. Parackal, S. M., Parackal, M. K. & Harraway, J. A. Prevalence and correlates of drinking in early pregnancy among women who stopped drinking on pregnancy recognition. Matern. Child Health J. 17, 520–529 (2013).

39. Ho, R. & Jacquemard, R. Maternal alcohol use before and during pregnancy among women in Taranaki, New Zealand. N. Z. Med. J. Online 122, (2009). 40. Morton, S.M.B. & Atatoa Carr, P.E., I., V. C. Growing Up in New Zealand: A longitudinal study of New Zealand children and their families. Report 1: Before we are born. (2010). 41. Lange, S., Quere, M., Shield, K., Rehm, J. & Popova, S. Alcohol use and self-perceived mental health status among pregnant and breastfeeding women in Canada: a secondary data analysis. BJOG Int. J. Obstet. Gynaecol. 123, 900–909 (2016). 42. Weyrauch, D., Schwartz, M., Hart, B., Klug, M.

G. & Burd, L. Comorbid mental disorders in fetal alcohol spectrum disorders: a systematic review. J. Dev. Behav. Pediatr. 38, 283– 291 (2017).

43. Lussier, A. A., Weinberg, J. & Kobor, M. S. Epigenetics studies of fetal alcohol spectrum disorder: where are we now? Epigenomics 9, 291–311 (2017).

15 44. Walthall, J. C., O’Connor, M. J. & Paley, B. A comparison of psychopathology in children with and without prenatal alcohol exposure. Ment. Health Asp. Dev. Disabil. 11, 69–78 (2008). 45. O’connor, M. J. & Paley, B. Psychiatric conditions associated with prenatal alcohol exposure. Dev. Disabil. Res. Rev. 15, 225–234 (2009). 46. O’Malley, K. & Huggins, J. Suicidality in adolescents and adults with fetal alcohol spectrum disorders.

Can. J. Psychiatry 50, 125–125 (2005).

47. Streissguth, A. P., Barr, H. M., Kogan, J. & Bookstein, F. L. Understanding the occurrence of secondary disabilities in clients with fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE). Final Rep. Cent. Dis. Control Prev. CDC 96–06 (1996). 48. Xuan, Z. et al. Alcohol policies and suicide: a review of the literature. Alcohol. Clin. Exp. Res. 40, 2043–2055 (2016). 49. Escobedo, L. G. & Ortiz, M. The relationship between liquor outlet density and injury and violence in New Mexico. Accid. Anal. Prev. 34, 689–694 (2002). 50. Markowitz, S., Chatterji, P. & Kaestner, R. Estimating the impact of alcohol policies on youth suicides.

J. Ment. Health Policy Econ. 6, 37–46 (2003).

51. Johnson, F. W., Gruenewald, P. J. & Remer, L. G. Suicide and alcohol: do outlets play a role? Alcohol. Clin. Exp. Res. 33, 2124–2133 (2009). 52. Giesbrecht, N. et al. Acute alcohol use among suicide decedents in 14 US states: impacts of off-premise and on-premise alcohol outlet density. Addiction 110, 300–307 (2015). 53. Pereira, G., Wood, L., Foster, S. & Haggar, F. Access to alcohol outlets, alcohol consumption and mental health. PLoS ONE Electron. Resour. 8, e53461 (2013). 54. Lamb, K. E. et al. Associations between access to alcohol outlets and alcohol intake and depressive symptoms in women from socioeconomically disadvantaged neighbourhoods in Australia.

BMC Public Health 17, 83 (2017).

55. Pearson, A. L., Bowie, C. & Thornton, L. E. Is access to alcohol associated with alcohol/substance abuse among people diagnosed with anxiety/mood disorder? Public Health 128, 968–976 (2014). 56. Connor, J. L., Kypri, K., Bell, M. L. & Cousins, K. Alcohol outlet density, levels of drinking and alcohol-related harm in New Zealand: a national study. J. Epidemiol. Community Health 65, 841–6 (2011). 57. Huckle, T., Huakau, J., Sweetsur, P., Huisman, O. & Casswell, S. Density of alcohol outlets and teenage drinking: living in an alcogenic environment is associated with higher consumption in a metropolitan setting.

Addiction 103, 1614–21 (2008). 58. Cameron, M. P. et al. Alcohol outlet density is related to police events and motor vehicle accidents in Manukau City, New Zealand. Aust. N. Z. J. Public Health 36, 537–42 (2012). 59. Cameron, M. P. et al. The Impacts of Liquor Outlets in Manukau City Report No. 3: The spatial and other characteristics of liquor outlets in Manukau City. (Alcohol Advisory Council of New Zealand, 2012).

60. Karriker-Jaffe, K. J., Ohlsson, H., Kendler, K. S., Cook, W. K. & Sundquist, K. Alcohol availability and onset and recurrence of alcohol use disorder: Examination in a longitudinal cohort with co-sibling analysis. Alcohol. Clin. Exp. Res. (2018). 61. Hay, G. C., Whigham, P. A., Kypri, K. & Langley, J. D. Neighbourhood deprivation and access to alcohol outlets: a national study. Health Place 15, 1086–93 (2009). 62. Services, T. F. on C. P. Recommendations for reducing excessive alcohol consumption and alcohol-related harms by limiting alcohol outlet density. Am. J. Prev. Med. 37, 570– 571 (2009).

63. Green, C.P, Hollingsworth, B. & Navarro. M. Longer Opening Hours, Alcohol Consumption and Health. (2015).

16 64. Wilkinson, C., Livingston, M. & Room, R. Impacts of changes to trading hours of liquor licences on alcohol-related harm: a systematic review 2005–2015. Public Health Res Pr. 26, (2016). 65. Marcus, J. & Siedler, T. Reducing binge drinking? The effect of a ban on late-night offpremise alcohol sales on alcohol-related hospital stays in Germany. J. Public Econ. 123, 55–77 (2015). 66. Wicki, M. & Gmel, G. Hospital admission rates for alcoholic intoxication after policy changes in the canton of Geneva, Switzerland.

Drug Alcohol Depend 118, 209–15 (2011). 67. Casswell, S., Huckle, T., Wall, M. & Yeh, L. C. International alcohol control study: pricing data and hours of purchase predict heavier drinking. Alcohol. Clin. Exp. Res. 38, 1425–31 (2014).

68. Birckmayer, J. & Hemenway, D. Minimum-age drinking laws and youth suicide, 1970- 1990. Am. J. Public Health 89, 1365–1368 (1999). 69. Sloan, F. A., Reilly, B. A. & Schenzler, C. Effects of prices, civil and criminal sanctions, and law enforcement on alcohol-related mortality. J. Stud. Alcohol 55, 454–465 (1994). 70. Son, C. H. & Topyan, K. The effect of alcoholic beverage excise tax on alcohol-attributable injury mortalities. Eur. J. Health Econ. 12, 103–113 (2011). 71. Yamasaki, A. et al. Tobacco and alcohol tax relationships with suicide in Switzerland. Psychol. Rep. 97, 213–216 (2005).

72.

Wagenaar, A. C., Tobler, A. L. & Komro, K. A. Effects of Alcohol Tax and Price Policies on Morbidity and Mortality: A Systematic Review. Am. J. Public Health 100, 2270–2278 (2010). 73. Green, B. H. & Griffiths, E. C. Hospital admission and community treatment of mental disorders in England from 1998 to 2012. Gen. Hosp. Psychiatry 36, 442–448 (2014). 74. Callaghan, R. C., Sanches, M. & Gatley, J. M. Impacts of the minimum legal drinking age legislation on in-patient morbidity in Canada, 1997–2007: a regression-discontinuity approach. Addiction 108, 1590–1600 (2013).

75. Callaghan, R. C., Sanches, M., Gatley, J. M. & Cunningham, J. K. Effects of the minimum legal drinking age on alcohol-related health service use in hospital settings in Ontario: a regression–discontinuity approach. Am. J. Public Health 103, 2284–2291 (2013). 76. Grucza, R. A. et al. The legacy of minimum legal drinking age law changes: long-term effects on suicide and homicide deaths among women. Alcohol. Clin. Exp. Res. 36, 377– 384 (2012). 77. Jones, N. E., Pieper, C. F. & Robertson, L. S. The effect of legal drinking age on fatal injuries of adolescents and young adults. Am. J. Public Health 82, 112–115 (1992).

78. Thern, E. et al. Effects of increased alcohol availability during adolescence on the risk of all-cause and cause-specific disability pension: a natural experiment. Addiction 112, 1004–1012 (2017).

79. Norberg, K. E., Bierut, L. J. & Grucza, R. A. Long-term effects of minimum drinking age laws on past-year alcohol and drug use disorders. Alcohol. Clin. Exp. Res. 33, 2180–2190 (2009). 80. Everitt, R. & Jones, P. Changing the minimum legal drinking age--its effect on a central city emergency department. N. Z. Med. J. 115, 9–11 (2002). 81. Huckle, T., Pledger, M. & Casswell, S. Trends in alcohol-related harms and offences in a liberalized alcohol environment. Addiction 101, 232–40 (2006). 82. Kypri, K. et al. Minimum purchasing age for alcohol and traffic crash injuries among 15- to 19-year-olds in New Zealand.

Am J Public Health 96, 126–31 (2006). 83. Kypri, K., Davie, G., McElduff, P., Langley, J. & Connor, J. Long-term effects of lowering the alcohol minimum purchasing age on traffic crash injury rates in New Zealand. Drug Alcohol Rev. doi: 10.1111/dar.1237 (2016). doi:10.1111/dar.12378

17 84. Anderson, P., de Bruijn, A., Angus, K., Gordon, R. & Hastings, G. Impact of alcohol advertising and media exposure on adolescent alcohol use: a systematic review of longitudinal studies. Alcohol Alcohol 44, 229–43 (2009). 85. Smith, L. A. & Foxcroft, D. R. The effect of alcohol advertising, marketing and portrayal on drinking behaviour in young people: systematic review of prospective cohort studies. BMC Public Health 9, 51 (2009). 86. Stautz, K., Brown, K. G., King, S. E., Shemilt, I. & Marteau, T. M. Immediate effects of alcohol marketing communications and media portrayals on consumption and cognition: a systematic review and meta-analysis of experimental studies.

BMC Public Health 16, 465 (2016).

87. Treise, D. M., Taylor, R. E. & Wells, L. G. How recovering alcoholics interpret alcoholicbeverage advertising. Health Mark. Q. 12, 125–139 (1995). 88. Witteman, J. et al. Cue reactivity and its relation to craving and relapse in alcohol dependence: a combined laboratory and field study. Psychopharmacology (Berl.) 232, 3685–3696 (2015). 89. Cooney, N. L., Litt, M. D., Morse, P. A., Bauer, L. O. & Gaupp, L. Alcohol cue reactivity, negative-mood reactivity, and relapse in treated alcoholic men. J. Abnorm. Psychol. 106, 243 (1997).

90. Seo, D. et al. Disrupted ventromedial prefrontal function, alcohol craving, and subsequent relapse risk.

JAMA Psychiatry 70, 727–739 (2013). 91. Ministerial Forum on Alcohol Advertising and Sponsorship. Ministerial Forum on Alcohol Advertising and Sponsorship: Recommendations on alcohol advertising and sponsorship. (2014). 92. Tinawi, G. et al. Highly deficient alcohol health warning labels in a high-income country with a voluntary system. Drug Alcohol Rev. (2018). 93. Rout, J. & Hannan, T. Consumer awareness and understanding of alcohol pregnancy warning labels. (2016).

94. World Health Organization. Global Strategy to Reduce the Harmful Use of Alcohol. (2010). 95. Scottish Government. Suicide Prevention Strategy 2013 - 2016: Progress since 2002: (2013). 96. Najman, J. M. et al. Timing and chronicity of family poverty and development of unhealthy behaviors in children: A longitudinal study. J. Adolesc. Health 46, 538–544 (2010). 97. Jackson, N., Denny, S. & Ameratunga, S. Social and socio-demographic neighborhood effects on adolescent alcohol use: a systematic review of multi-level studies. Soc. Sci. Med. 115, 10–20 (2014).

98. Jackson, N., Denny, S., Sheridan, J., Zhao, J.

Ameratunga, S. The role of neighborhood disadvantage, physical disorder, and collective efficacy in adolescent alcohol use: a multilevel path analysis. Health Place 41, 24–33 (9). 99. Bernburg, J. G., Thorlindsson, T. & Sigfusdottir, I. D. The neighborhood effects of disrupted family processes on adolescent substance use. Soc. Sci. Med. 69, 129–137 (2009). 100. Hutt, M. & Andrews, P. Māori & Alcohol: A History. (Health Services Research Centre/ALAC, 1999).

101. Crengle, S., Robinson, E., Ameratunga, S., Clark, T. & Raphael, D. Ethnic discrimination prevalence and associations with health outcomes: data from a nationally representative cross-sectional survey of secondary school students in New Zealand. BMC Public Health 12, 45 (2012). 102. Head, J., Stansfeld, S. A. & Siegrist, J. The psychosocial work environment and alcohol dependence: a prospective study. Occup. Environ. Med. 61, 219–224 (2004).

You can also read
Next part ... Cancel