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St Vincent’s Health Australia’s Alcohol-Related Harm and Violence Policy St Vincent’s Health Australia has a plan to reduce alcohol-related harm and violence. From what we see in our hospitals and treatment services, we know the damage alcohol can do and what needs to be done to reduce its impact. Alcohol harm can’t be reduced through a single policy initiative or individual campaign. To achieve our goal will take constructive dialogue between A new approach governments, businesses, the community and health sectors, and the broader public, along with an integrated It’s time for Australia to take a new approach to alcohol to reduce its negative approach over many years. effects on our community.

We recognise that alcohol has deep cultural and social significance in Australia and is of major economic importance.

Yet all the evidence points overwhelmingly to the fact Australia has an alcohol problem – one that is not restricted to a small proportion of heavy and/or dependent drinkers, and which is greater than that posed by any Reduce alcohol-related illness and injury illegal – and requires our urgent intervention. in Australia by 20% by 2025, including: Unfortunately, alcohol policy has become the product of competing interests, values and ideologies. Alcohol-related emergency department presentations. Achieving our targets will require Australians and their governments to start thinking differently about alcohol and the way we interact with it. Hospital admissions for alcohol use disorders. It will require Commonwealth and state and territory governments to display the same level of commitment commonly shown towards tackling other major health issues, by embracing the reforms and providing the Alcoholic liver disease deaths. resources necessary to reduce its harm. This is our primary aim. Background St Vincent’s Health Australia is one of the nation’s largest not-for-profit health and aged care organisations. It has a 176 year heritage of providing compassionate healthcare to Australians from all walks of life, but most notably vulnerable members of the community, including homeless people, people with mental illness, prisoners, urban Aboriginal and Torres Strait Islanders, and people struggling with alcohol and drug addiction.

Our two major tertiary public hospitals – St Vincent’s in Our Alcohol-Related Harm and Violence Policy is built on an Melbourne’s Fitzroy and St Vincent’s in Sydney’s Darlinghurst extensive environment scan and interviews with more than 80 – have long catered to the entire spectrum of alcohol-related experts – many of them national and international leaders in harm and violence, and by virtue of their locations, the horrific their field – on the social and health effects of alcohol. alcohol-fuelled injuries that occur in the entertainment Our goal is to prevent and reduce alcohol-related harm, in the precincts of both cities. same way efforts such as seat belts, plain cigarette packaging, Australia’s first medically-based clinical and academic program random breath testing, immunisation, sun protection, and for the treatment and study of alcohol dependence was HIV awareness have prevented and reduced harms in other established at St Vincent’s, Melbourne in 1964. St Vincent’s areas. Public health policy has played a significant role in all of Sydney followed with its own similar program in 1971. these areas and has become a growing asset in recalibrating our culture, attitudes and beliefs. St Vincent’s Sydney’s Alcohol and Drug Service is a recognised leader in the management of alcohol and drug-related health Over time we are confident our voice, research and problems including hospital inpatient, an outpatient Wellness experience will result in our recommendations being accepted Clinic, multidisciplinary care hospital liaison services, and a by governments, business and the broader community. 20-bed non-medical residential withdrawal unit, Gorman House.

St Vincent’s Melbourne’s Department of Addiction Medicine offers a combination of in and outpatient services including the 12 bedroom DePaul House, a medical residential withdrawal We believe it’s our responsibility, unit, consultation liaison services, drink driving education, counselling and research. knowing what we know as one More recently, St Vincent’s Health played a lead role of the nation’s largest healthcare supporting measures to reduce the availability of alcohol in Sydney’s inner city – advocacy that was an important factor groups, to stand up and say... in the NSW Government’s introduction of a suite of reforms, known commonly as the ‘lockout laws’, in February 2014.

The success of this advocacy was a catalyst to bring our resources, expertise and experience together to address alcohol-related harm and violence more broadly across Australia. Alcohol is second only to tobacco as the leading preventable cause of death and hospitalisation in Australia.1

As a health organisation we are faced daily The harms associated with alcohol and the with the outcomes of the harmful consumption increasing scientific evidence regarding the of alcohol across the lifespan. health outcomes influenced by alcohol is persuasive to anyone involved in health care This may be harm caused by alcohol-related and clearly indicates that action must be taken. road trauma or violence treated in our emergency departments, trauma wards, operating theatres The effects of alcohol-related harm, however, or intensive care units. It may also be through the extend beyond the individual and the health care of our patients with mental illness or chronic system and include social and economic disease brought about by harmful alcohol costs of harm to families, communities and consumption over the longer term. Or it may be society at large. through dealing with developmental problems or intoxication is implicated arising from alcohol use in pregnancy, including in violence – both domestic and public, foetal alcohol spectrum disorders. unemployment, financial problems and poverty, drink driving, traffic accidents, industrial and work accidents, fires, falls, homelessness, and suicide.

1 National Health and Medical Research Council (2009). Australian guidelines to reduce health risks from drinking alcohol. Commonwealth of Australia. {cited 2011 February 2} Available from: www.nhmrc.gov.au In Australia, 3.2 per cent of the total burden 3.2% of disease is related to alcohol use.1 total burden of disease Hurts

deaths every day

15 In Australia, alcohol kills 15 Australians every day, 5,554 each year (3,467 male deaths 2 increase in off-licence /5,554 and 2,087 female deaths). 10% liquor outlets deaths each year A 10 per cent increase in off-licence liquor outlets is associated /3.3% with a 3.3 per cent increase in domestic violence.7 hospitalisations every day increase in domestic violence

430 Alcohol hospitalises 430 Australians every day, 157,132 each year (101,425 for males and 55,707 for females).3 For every 10,000 additional litres of pure alcohol sold at a packaged liquor outlet, the risk of violence experienced /157,132 in a residential setting increases by 26 per cent.8 hospitalisations each year 26% increased risk of violence in residential setting Alcohol’s harm to others costs Australians more than $20.6 billion, including $14.3 billion in tangible costs (eg: out-of-pocket costs, forgone wages or productivity, hospital and child protection costs) and Studies have shown that 60 per cent of people presenting with $ $6.4 billion in intangible costs (the costs assigned injuries to emergency wards had consumed alcohol bought cost of alcohol’s 4 to pain and suffering, and diminished quality of life). 9 20.6 harm to other australians 60% from a store in the hours leading up to their injuries. people admitted to hospital BILLION consumed alcohol more Ambulances are more commonly called to neighbourhoods One-in-12 of all presentations to hospital emergency near bottle shops, with areas near larger chain stores reporting of all presentations to hospital emergency 10 departments in Australia and New Zealand departments in Australia and New Zealand are alcohol- ambulances even higher injury rates. iN are alcohol-related related, equating to more than half a million people called to neighbourhoods each year. In peak times (6pm Friday night to 6am near bottle shops 1 Sunday morning) the rate increases to one-in-eight.5 There were almost 30,000 police reported incidents of alcohol-related domestic violence in 2011 1 Begg S, Vos T, Barker B, Stevenson C, Stanley L & Lopez AD (2007). The Burden of Disease 7 Livingstone, M. (2011) A longitudinal analysis of alcohol outlet density and domestic violence. Addiction. and Injury in Australia 2003. Canberra: Australian Institute of Health and Welfare. (excluding , , and 8 Liang, W., Chikritzhs, T. (2011) Revealing the link between licensed outlets and violence: counting 6 2 Gao, C., Ogeil, R.P., & Lloyd, B. (2014). Alcohol’s burden of disease in Australia. venues versus measuring alcohol availability. Australasian Professional Society on Alcohol and the Australian Capital Territory). Given less than half of Canberra: FARE and VicHealth in collaboration with Turning Point. other . 30,000 3 ibid. 9 Miller, P. (2015). Last drinks: A study of rural emergency department data collection to identify and target community alcohol-related violence. Deakin University on behalf of Australasian College of incidents are reported to police – and are often the most 4 Foundation for Alcohol Research and Education and Centre for Alcohol Policy Research, Emergency Medicine. 12 The range and magnitude of alcohol’s harm to others, Summary, 2nd Edition, February 2015. police reported incidents of severe cases – this figure likely under-represents the full 10 Morrison, C., & Smith, K. (2015) Disaggregating relationships between off-premise alcohol outlets 5 Australasian College for Emergency Medicine (2015). and trauma. Canberra: Foundation for Alcohol research and Education (FARE). alcohol-related domestic violence extent of alcohol-related domestic violence. 6 Laslett, A-M., Mugavin, J., Jiang, H., Manton, E., Callinan, S., MacLean, S., Room, R. (2015) The Hidden Harm: alcohol’s impact on children and families. Foundation for Alcohol Research and Education and Centre for Alcohol Policy Research. Improving regulation to better manage alcohol’s availability, marketing and promotion.

To prevent and reduce alcohol-related harm

St Vincent’s Health Australia supports a coordinated national approach to alcohol harm minimisation that is underpinned by strong partnerships across the government and non-government sectors and industry.

St Vincent’s Health Australia acknowledges there is no single strategy that can offer a ‘quick fix’ or ‘silver bullet’ to the prevention of harmful consumption of alcohol. Countless reviews have concluded that an integrated approach is required. Increase the price of alcohol to reduce

However, the following interventions have been identified as effective and enjoying quantifiable benefits. consumption and related harms.

We believe their introduction will allow us to meet our goal of reducing alcohol-related illness and injury by 20% by 2025. 1

Australia’s alcohol taxation system should be coherent, consistent and based on public health principles.

Evidence consistently shows that alcohol consumption and harm are influenced by price1. Alcohol taxation, as a means of increasing the price of alcohol, is one of the most effective policy interventions to reduce the level of alcohol consumption and its related problems. Evidence suggests that a 10 per cent increase in price is likely to lead to a five per cent decrease in consumption at population level.2

The Henry Review of Australia’s tax system (Australia’s Future Tax System) identified alcohol taxation as an appropriate measure for improving social outcomes because of the high costs imposed by excessive alcohol consumption.3

Alcohol products should be taxed on the basis of alcohol content/greatest level of harm (volumetric taxation) as recommended in the review.

A proportion of revenue from alcohol taxation should be directed towards initiatives that prevent alcohol-related harm (eg: an ‘Alco-line’ support hotline, similar to Quitline for smoking), provide support for people with alcohol-related problems, and conduct research into the prevention and treatment of alcohol- related harm.

The Commonwealth should regulate the minimum price (or floor price) of alcohol products.

1 Osterberg, E. 1995 “Do alcohol prices affect consumption and related problems” in H. Holder & G. Edwards (eds.) Alcohol and Public Policy: Evidence and Issues, Oxford University Press, Babor, T., R. Caetano, S. Casswell, G. Edwards, N. Giesbrecht, K. Graham, J. Grube, P.J. Gruenevald, L. Hill, H. Holder, R. Homel, E. Osterberg, J. Rehm, R. Room and I. Rossow (2003) Alcohol: No Ordinary Commodity – Research and Public Policy, Oxford University Press, Oxford. Chisholm, D., J. Rehm, M. Ommeren & M. Monteiro (2004) “Reducing the global burden of alcohol use: A comparative cost-effectiveness analysis” Journal of Studies on Alcohol, 65:782-793 Loxley, W., J. Toumbourou and T. Stockwell (2004) The Prevention of Substance Use, Risk and Harm in Australia: A Review of the Evidence, Australian Government DOHA Canberra Coate, D. and M. Grossman (1988) “Effects of alcoholic beverage prices and legal drinking ages on youth alcohol use” Journal of Law and Economics, 31:145-171 Chaloupka, F., M. Grossman and H. Saffer (2002) “The effect of price on alcohol consumption and alcohol-related problems” Alcohol Research & Health, 26:22-34. 2 Wagenaar, A. et al (2009) Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction (2009);104(2):179-190 105 Gallet, C.A. (2007). The demand for alcohol: a meta-analysis of elasticities. The Australian Journal of Agricultural and Resource Economics. 51: 121 – 135. 3 Henry, K. Australia’s future tax system: Report to the Treasurer. Commonwealth of Australia 2010; 2009 Dec. Use liquor licensing laws to ensure the responsible sale of alcohol.

In addition to curbing the economic availability of of legislation are important statements about the alcohol, its physical availability can be regulated by manner in which decisions should be made by 2 restricting the trading hours of on and off licence licensing authorities. They may empower authorities premises, the density of these outlets in a given to take into account the wider health implications locality, and the range of places in which it is sold. of administrative decisions. There is strong national and international evidence National guidelines need to be developed on that extending the trading hours of alcohol outlets alcohol outlet density and opening hours based Increase restrictions around the advertising, results in increases in alcohol-related problems and on harm minimisation principles, evidence-based that the reduction in these hours can contribute to a marketing and promotion of alcohol, with a focus research and with input from local communities reduction in these same problems. to guide liquor licensing agencies, planning on the welfare of young people. In this context, there is a need to reassess departments and local government. Liquor approaches to the physical alcohol availability of licensing laws should also be exempt from alcohol which is regulated by state and territory National Competition Policy. 3International and national research has shown governments through liquor licensing legislation. that exposure to repeat high-level alcohol Alcohol should not be sold in pubs and clubs promotion inculcates pro-drinking attitudes and Liquor licensing laws may be used by governments after 3am. All existing 24 hour liquor licenses increases the likelihood of heavier drinking. to encourage and ensure the responsible sale of should be abolished, with 10pm introduced alcohol, and implement public health objectives. as the latest time for packaged liquor sales There is also moderate but consistent evidence Objects or purpose clauses which include or (including from supermarket outlets). to suggest that point of sale promotions are emphasise public health, harm minimisation or likely to affect the overall consumption of alcohol-related as an objective underage drinkers, binge drinkers and regular drinkers. Ownership of alcohol-branded merchandise among non-drinking children and adolescents also predicts both early initiation to alcohol use and . St Vincent’s Hospital Sydney (SVHS) – which has within Young people are exposed to too many Improve alcohol product its catchment the greatest number of licensed premises in instances of alcohol marketing, promotion and labelling at points of sale and Australia – has played a leading role in advocating for tighter advertising and research shows it has a great regulations to reduce alcohol-related harm and violence. impact on the age they start drinking. consumption to reduce harm. We support ending all in The hospital played a major part in convincing the NSW Government to introduce measures free-to-air TV sporting broadcasts, as well Pictorial health warning labels should be mandated on all alcohol products designed to curb alcohol-fuelled violence, particularly in Sydney’s CBD and Kings Cross, as on government owned infrastructure (eg: 4and their packaging in Australia. The warnings should be developed in February 2014. buses, shelters, sporting grounds). independent of the alcohol industry, tested and frequently varied, and contain SVHS’s experience of the laws – which include the statewide closure of bottle shops at 10pm Alcohol sponsorship of music events aimed information on alcohol treatment and advice services. and 3am last drinks within the city of Sydney’s entertainment precinct – is compelling: at young people should be phased out as One label should specifically relate to the risks of drinking alcohol during • In the year following the introduction of the regulations, there was a 25% drop in seriously with alcohol sponsorship of sport, clubs or pregnancy. Health warning messages should be preceded by the text injured patients accessing the hospital’s emergency department during the busiest period programs and the placement of alcohol brands, ‘HEALTH WARNING’. (6pm Friday to 6am Sunday). logos, slogans or related images on any • The frequency at which people present at the hospital’s Emergency Department with sporting or other merchandise. Alcohol producers should be prohibited from including any positive health alcohol-related issues – and the severity of those issues – has declined, with only three claims on their products, including representations of products as ‘low’ in An independent panel should monitor clear admissions to the hospital’s Intensive Care Unit, and no deaths, from the entertainment alcohol or calories. and consistent standards in relation to all forms precinct over two years. of alcohol advertising and promotion – including An independent examination must be held into the benefit of restrictions SVHS’s experience has been supported by independent evidence gathered by the NSW online and social media – with penalties for on packaging and product design of alcohol products, including alcohol-plain Bureau of Crime Statistics and Research’s (BOCSAR) showing a 45% reduction in assaults significant breaches. packaging laws similar to those introduced for tobacco in Australia. in Kings Cross and a 20% reduction in the CBD.

BOCSAR also found most areas within easy reach of the entertainment precinct showed no increase in violence. Improve early intervention for Early intervention, treatment and alcohol use disorder. taking a national approach.

5 Despite the significant prevalence of harms associated with heavy drinking across the Australian community, early intervention and management Significantly increase funding for treatment of problematic alcohol consumption services to meet demand. compares poorly with other chronic disease conditions or lifestyle issues.

There is strong evidence that early and Only 1-in-10 Australians with alcohol dependence Treatment and withdrawal services for alcohol short-term interventions have a high level 6 receive treatment in any given year. There is also an dependence should be provided at all major hospitals of efficacy in reducing alcohol-related estimated gap of around 20 years from the onset of and in specialist alcohol and drug services. The increased harm. Brief interventions, particularly problem-drinking to seeking care for treatment. availability of such services will allow primary care in primary healthcare settings, are very doctors to more readily refer people with alcohol use effective – especially with early high risk Australian governments must commit more funding disorder for help. drinkers – and have been demonstrated to expand treatment services to meet unmet needs, to reduce alcohol consumption by about particularly among those facing the most significant Treatment services need to offer stepped care as six standard drinks per week, as well as barriers to accessing help, such as people in rural and well as reflect the diversity of people’s needs and cultural being cost and time effective. regional areas, Aboriginal and Torres Strait Islanders, backgrounds. Stepped care begins with low-intensity, pregnant women, young people and prisoners. low-cost treatments through to more intensive and Brief interventions conducted with individuals who have been affected comprehensive treatment where necessary. by alcohol and presented at Emergency Departments have also shown to be effective.

A range of strategies to help prevent and delay the onset of alcohol use disorder should be funded from a levy A national strategy to reduce alcohol-related harm. on alcohol products, including: • training for doctors and nurses – 7 when in medical and nursing school There is a pressing need for the Commonwealth to take We support the development of a whole-of-government – in the detection and management national leadership on reducing the harm from alcohol. national framework to address alcohol’s role in family violence. of alcohol use disorder; A first step would be to develop a national strategy to For example, such a framework would assist local and

• primary care nurses and GPs should reduce alcohol-related harm, with actions funded from an state governments to work together to change liquor be trained and incentivised to screen increase in alcohol taxation. licensing laws so family violence could be considered in and conduct brief interventions; planning applications for bottle shops, hotels and other We believe a national strategy – supported by a alcohol outlets. • investment in research and innovation performance measurement framework – would assist to deliver early interventions through to build the evidence-base through data collection and It would also improve integration and collaboration between new technology (eg: online, telehealth) coordination of research. Evidence-based initiatives to services providing treatment for people with alcohol use to reach more people, earlier; tackle alcohol-related harms could then be prioritised, disorder and other related services, including family and improving the cost-effectiveness of national efforts. domestic violence and child protection programs. • evidence-based alcohol-related health promotion and prevention strategies, The accountability of all governments in reducing harms Finally, a National Summit on Reducing Alcohol-related including information for parents on from alcohol must be improved, including developing and Harm and Violence – led by the Commonwealth how to explain the risks and harms of measuring progress against national targets. and supported by the states and territories – would be alcohol use to their children; and a beneficial way of starting a broad national conversation A national strategy should also encompass alcohol’s role in • funding for health education diversion about alcohol’s role in our society and charting a family violence. programs for alcohol-related offences, new way forward. particularly with under-age drinkers It’s estimated that in some parts of Australia, two-thirds of who come to police attention. family violence incidences reported to police involve alcohol. Alcohol sales data is an essential component in providing a comprehensive picture of alcohol consumption and informing evidence-based There is a need for accurate, timely and comprehensive public policy decisions. indicators and monitoring of alcohol-related harms at a

We strongly encourage state and territory governments to continue, national and local level. 8 or to initiate, the collection of wholesale and retail sales data to monitor national levels of alcohol consumption, as well as consumption patterns Australia must begin collecting nationally standardised data on alcohol-related harms 9 associated with specific population groups and beverage choices. and make them available in the public domain. Such data should be available in the public domain. This should include increasing the collection of information about alcohol’s involvement with emergency services (eg: police, ambulances), emergency department and hospital admissions, and justice and community services (including family and domestic violence programs).

Gathering evidence to support our There is no national data on the prevalence of Foetal Alcohol understanding of alcohol-related harm Spectrum Disorder (FASD) in Australia which must be addressed and efforts to reduce its impact. through the development of a national repository that encourages the collection and sharing of standardised data.

10 FASD should be formally recognised as a disability and identified as an issue that affects the whole community.

Given the higher rate of FASD among Aboriginal and Torres Strait Islander peoples, greater effort must be made to tailor evidence-based education campaigns for these groups about the risks of alcohol consumption during pregnancy, in consultation with the communities themselves.

Since being established in 1964, St Vincent’s Hospital Melbourne’s Department of Addiction Medicine has been one of Australia’s leading centres in terms of prevention and treatment for people experiencing alcohol dependency.

The department’s work includes direct patient treatment, research, education, training and policy development.

Its services include DePaul House – a 12-bedroom medical residential withdrawal unit where more than 500 patients a year from across undergo short-term medically supported withdrawal – as well as offering outpatient clinics, drink-driving education, and support and education to alcohol-dependent young people in custody.

Currently the department is exploring treatments by trialling new medications for managing alcohol withdrawal symptoms; and dosing thiamine to prevent Wernicke-Korsakoff syndrome – a condition caused by thiamine deficiency and which is common among long-term alcohol users. Reduce alcohol-related illness and injury in Australia by 20% by 2025, including: National Targets Alcohol-related emergency department Hospital admissions Alcoholic presentations for alcohol use disorders liver disease deaths

Recognition that combatting Australia’s problem with alcohol what’s needed? will require a nationally co-ordinated response based on constructive dialogue between governments, businesses, the community and health sectors, and the broader public.

Improving Early intervention, treatment Gathering evidence to support action points alcohol regulation and taking a national approach our understanding of alcohol-related harm and efforts to reduce its impact

Increase the price of alcohol to reduce Improve early intervention for alcohol Alcohol sales data is an essential component consumption and related harms. use disorder. in providing a comprehensive picture of alcohol 1 5 8 consumption and informing evidence-based public policy decisions. Use liquor licensing laws to ensure the Significantly increase funding for treatment 2 responsible sale of alcohol. services to meet demand. There is a need for accurate, timely and 6 comprehensive indicators and monitoring of 9 alcohol-related harms at a national and local level. Increase restrictions around the advertising, marketing and promotion of alcohol, with a focus A national strategy to reduce alcohol-related harm. 3 on the welfare of young people. 7 There is no national data on the prevalence of Foetal Alcohol Spectrum Disorder (FASD) in 10 Australia which must be addressed through Improve alcohol product labelling at points the development of a national repository 4 of sale and consumption to reduce harm. that encourages the collection and sharing of standardised data. serving, seeing and striving for something greater

Founded by the Sisters of Charity 176 years ago, St Vincent’s Health Australia is the nation’s largest Catholic not-for-profit health and aged care provider and the largest non-government provider of public hospital services. Over 17,000 employees provide more than 1,000,000 episodes of compassionate, high quality care every year.

As a Catholic health care service we bring God’s love to those in need through the healing ministry of Jesus. We are especially committed to people who are poor or vulnerable.

Together, we are serving, seeing and striving for something greater.

Photo Credits Page 3: Man drinking at cricket Stephen Harman/Newspix Woman assisting drunk man Wesley Monts/Newspix Man on gurney Gordon McComiskie/Newspix Woman in bus shelter Gordon McComiskie/Newspix Page 6: Crowd on footpath Mark Calleja/Newspix Page 7: Police making arrest Marc Robertson/Newspix

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