3rd National Alcohol Forum Conference

1. 3rd National Alcohol Forum
Conference
“The Best Available Evidence”
Supporting the Implementation of Local Solutions to Reduce
Alcohol Consumption and Alcohol Harms

2. Welcome
Chairperson Opening Address: Prof Thomas Collins

3. Minister for Health
Dr Leo Varadkar
Ministerial Address:

4. Dr Thomas Babor
“Looking Upstream : Evidenced based solutions for Alcohol – related
problems in the Community”

5. Looking Upstream: Evidenced based solutions for
alcohol-related problems in the Community
Thomas Babor
Dept. of Community Medicine
University of Connecticut
Farmington, CT, USA

6. Disclosure Statement
Listed below are all my commercial relationships during the
past year:
– None

7. Alcohol: No Ordinary Commodity
and
the Public Health Approach

8. Looking upstream
Ultimately, the value of
approaching alcohol problems
within a public health
framework is that it draws
attention to the ‘upstream’
sources of the damage as
opposed to attributing alcohol-
related problems exclusively to
the personal behavior of the
individual drinker.

9. ‘Upstream’ sources of the damage
• Affordable prices
• Easy availability
• A culture of universal heavy and episodic drinking
supported by aggressive marketing
• Lack of regulatory controls

10. Pricing and taxation measuresRegulating the physical availability of
alcohol
Modifying the drinking context
Drinking-driving countermeasures
Regulating alcohol promotion
Education and persuasion strategies
Treatment and early intervention services
Strategies and interventions to reduce alcohol-related harm upstream
and downstream
Upstream
Downstream

11. Pricing and Taxation
• People increase their drinking when prices are lowered, and decrease their
consumption when prices rise.
• Adolescents and problem drinkers are no exception to this rule.
• Increased alcohol taxes and prices are related to reductions in alcohol-related
problems, including crime, traffic accidents and mortality rates
• Alcohol taxes are thus an attractive instrument of alcohol policy because they can be
used both to generate direct revenue and to reduce alcohol-related harm.
• The most important downside to raising alcohol taxes is smuggling and illegal in-
country alcohol production.
• Political opposition from the alcohol industry and the hospitality industry, as well as
trade harmonization policies, make tax interventions difficult to implement and
maintain.

12. Other pricing measures
• Minimum prices
• Bans on happy hours
• Smart prices - taxation to shift consumption towards weaker
types of alcohol

14. Regulating Alcohol Availability
• Restrictions on availability can have large effects in nations or
communities where there is popular support for these measures.
• For young people, laws that raise the minimum legal drinking age
reduce alcohol sales and problems
• The cost of restricting alcohol availability is cheap relative to the
costs of health consequences related to drinking, especially heavy
drinking.
• Adverse effects include increases in informal market activities (e.g.,
cross-border purchases, home production, illegal imports)

15. Regulating Alcohol Availability Through Minimum Legal
Purchase Age (MPLA)
• In 1984 the US Congress passed the National Minimum
Purchase Age Act, which encouraged states to adopt the age
21 purchase standard
• The number of young people who died in a crash when an
intoxicated young driver was involved has declined by
almost 63%
• Could age restrictions be better enforced in Ireland and even
increased gradually?

16. Closing time: Effects on homicides in Diadema, Brazil
(1995-2005)

17. Regulating Alcohol Marketing
• The marketing of alcohol is a
global industry
• Promotion through:
Television, radio, billboards
print media, point-of-sale promotions,
the Internet, product placements in
movies and TV, sports sponsorships,
etc.

18. Drinking-Driving Countermeasures
Strategy or Intervention Effectiveness
Supporting
Research
Cross-National
Testing
Sobriety check points ++ +++ +++
Random breath testing +++ ++ ++
Lowered BAC limits +++ +++ +++
Administrative license suspension
++ ++ ++
Low BAC for young drivers (“zero
tolerance”)
+++ ++ ++
Graduated licensing for novice drivers
++ ++ ++
Designated drivers and ride services
0 + +
Severity of punishment 0/+ ++ ++

19. Modifying the Drinking Context
• Monitor or change the environments where alcohol is typically sold and
consumed (e.g., bars and restaurants)
– Such changes can reduce alcohol-related aggression and intoxication
• Options include training bar staff, imposing voluntary house policies to refuse
service, enforcement of regulations, community mobilization to influence
problem establishments

20. Treatment and
Early Intervention Services
• During the past 50 years there has been a steady growth in
high income countries in the provision of specialized
medical, psychiatric, behavioral and social services to
people with alcohol use disorders
• More than 40 therapeutic approaches have been developed
• Systems of specialized services are now typical of many
industrialized countries

21. Treatment and
Early Intervention Services
• In general, exposure to any treatment is associated with
significant reductions in alcohol use and related problems,
regardless of the type of intervention used.
• Randomized controlled trials (conducted in a variety of
settings) indicate that clinically significant changes in
drinking behavior and related problems can follow from
brief interventions with non-alcoholic heavy drinkers.

22. Education Strategies
• The impact of education and persuasion programs tends to be small at best.
• When positive effects are found, they do not persist.
• Among the hundreds of studies, only a few show lasting effects (after 3 years)
• Even comprehensive programs may not be sufficient to delay initiation of
drinking or sustain small reductions after program
• Programs with multiple interactive components that resemble family therapy
and brief intervention seem to have some potential
• Many programs shown to be ineffective continue to be used

23. Community action opportunities
• Advocate for minimum pricing policy
• Increase enforcement on alcohol laws – youth access, distance sales,
secondary purchasing, serving intoxicated customers, drink-driving
• Limit drinking in public places through local bye laws.
• Monitor compliance with industry marketing codes and advocate for
statutory regulations
• Support treatment and early intervention services
• Support the Public Health (Alcohol) Bill

24. Public Health (Alcohol) Bill
• Minimum pricing
• Regulation of alcohol marketing
• Health labelling of alcohol
products
• Enforcement powers in relation
to sale, supply and consumption
of alcohol products

25. Policy Environment Score and Adult Binge Drinking
Prevalence, U.S. States

26. Policy Environment Score and Youth Drinking
Prevalence, U.S. States

27. Public Health Model of
Corporate-borne Diseases
Agent: alcohol
industry
Environment: Where
exposure occurs
Host: Vulnerable
Populations

28. Political Factors
(Government)
Government
Policies
Corporations
Corporate decisions
aimed at profits
Conduits
(SAPROs)
Corporate pressures
on environment
Environment of
hosts- Retailers
Modified
environment
Hosts
Consumption and
profits
Hosts
Alcohol –related
problems; disability;
disease
The Epidemiologic Cascade Applied to Alcohol

29. Tobacco
Alcohol
Gambling
Industries
Public Good Chain
Politicians
Public
Consultation
Government
Officials

30. ADDICTION EDITORIAL: Diageo, University College Dublin and
the integrity of alcohol science
• On 6 April 2006 Diageo Ireland, a subsidiary of the world’s largest distributor of
alcoholic beverages, announced the awarding of a grant of 1.5 million euros to the
University College Dublin’s (UCD)
• As reported in the Irish Times, Diageo CEO Paul Walsh said the issue was, for
Diageo, a simple one –
the company did not want problems with binge drinking to lead governments to place higher taxes
on its products and thus eat into revenues. The UCD research funding is thus the perfect example
of “enlightened self-interest,” particularly in light of the taxes placed on alcopops over recent
years’.

31. Corporate Practices that Influence Alcohol
Misuse
Product design: increases alcohol content, “drinkability,” sales to
young people,
Marketing: increase sales to vulnerable groups such as women and
youth
Retail distribution: makes alcohol more accessible to consumers
Pricing: increases sales, profits, and market share
Political influence: affects the policy environment

32. The triangle
that moves the mountain
Relevant knowledge -
science
A Social Movement -
advocacy
Political support/
involvement

33. The Future of Community Action:
Global Health Policy Networks
(Schmitz, in press)
• Networks of individuals and organizations working at a global level
and linked by a shared concern for a particular health issue (e.g.,
tobacco addiction, polio, TB, alcohol misuse)
• Includes scientists, health professionals, policymakers, victim
groups, survivors, NGOs, faith groups, etc.
• Could play a crucial role in agenda-setting, issue framing, and
translating science into policy
• Begins with local community action, but is linked to national and
international initiatives

34. What is needed to build a stronger global alcohol health
policy network?
 A clear pro-active strategy to recruit new members, prioritize actions and frame
campaign goals
 Mobilize powerful membership organizations (e.g., AA, treatment organizations,
scientific societies, drink-driving groups, NGOs)
 Frame issues in ways that can be understood by civil society and policymakers (i.e.,
prevention of fetal damage, domestic violence, youth binge drinking, and relapse in
alcoholics)
 Build a broader coalition through strategic alliances with tobacco control, obesity
prevention, NCDs, etc.
 Financial support for core activities
 A positive message and proactive strategy, rather than just responses to aggressive
industry tactics that compromise or threaten public health globally

35. Conclusions
• Alcohol problems can be minimized or prevented using a coordinated,
systematic policy response.
• Alcohol policies that limit access to alcoholic beverages, discourage
driving under the influence of alcohol, reduce the legal purchasing age for
alcoholic beverages, limit marketing exposure and increase the price of
alcohol, are likely to reduce the harm linked to drinking
• In most countries, regulation of affordability, physical availability, and
alcohol promotions are the most cost-effective strategies, but enforcement
of drink driving laws and provision of treatment and early intervention are
also needed
• Effective interventions produce a favorable health return for cost incurred
in policy implementation

36. Mid-Morning Break
11:15 – 11:35

37. Prof David H. Jernigan
“Alcohol Marketing & Youth: Global Evidenceand Community
Response”

38. Alcohol Marketing and Youth:
Global Evidence and Community
Responses
David H. Jernigan Ph.D.
Associate Professor
Department of Health, Behavior and Society
and Director, Center on Alcohol Marketing and Youth
Johns Hopkins Bloomberg School of Public Health

39. Health

44. Alcohol’s role in the global burden of
disease for 15-24 year-olds
Source: Gore et al., Lancet 2011; 377:2093-2102

45. Alcohol and Youth in Ireland
• More than half of Irish 16 year-olds have been drunk, and one
in five is a weekly drinker (HBSC).
• 1 in 4 deaths among Irish youth is caused by alcohol
• The average age of first alcohol use in children decreased from
15 for those born in 1980 to 14 for those born in 1990.
.

46. The Consequences (US data)
• Young people who begin drinking before age 15 are five times more likely to
develop alcohol problems later in life than those who wait until they are 21. (OSG)
• They are:
• Four times more likely to develop alcohol dependence (Grant & Dawson, 1997)
• Six times more likely to be in a physical fight after drinking;
• More than six times more likely to be in a motor vehicle crash because of
drinking;
• Almost five times more likely to suffer from other unintentional injuries after
drinking. (Hingson et al, 2009)

47. Brain activity in 15 year-olds during a memory
task
Heavy use of alcohol during adolescence can impair brain development,
causing loss of memory and other skills.

48. Alcohol advertising and youth: adolescent
brain research
• Brain imaging research has found that teens with alcohol use
disorders show greater activity in areas of the brain previously
linked to reward, desire, positive affect and episodic recall in
response to alcoholic beverage advertisements.
• The highest degree of brain response was in youths who
consume more drinks per month and report greater desires to
drink. (Tapert et al., 2003)

49. Why do young people drink?
• In the USA, at the state level, highly correlated with adult
drinking
• Price and availability of alcohol
• Religious and cultural factors
• Exposure to alcohol marketing

50. Alcohol Advertising and Youth:
Published systematic reviews
• Anderson et al. 2009 (Alcohol and Alcoholism):
– 13 longitudinal studies following up more than 38,000 young people
– “Longitudinal studies consistently suggest that exposure to media and commercial communications on
alcohol is associated with the likelihood that adolescents will start to drink alcohol, and with increased
drinking amongst baseline drinkers”
• Smith and Foxcroft 2009 (BMC Public Health):
– 7 cohort studies following up more than 13,000 young people aged 10 to 26 years
– “…data from prospective cohort studies suggest there is an association between exposure to alcohol advertising or promotional activity
and subsequent alcohol consumption in young people. Inferences about the modest effect sizes found are limited by the potential
influence of residual or unmeasured confounding.”
Anderson et al., Alcohol Alcohol 2009:44:229-43

51. Alcohol Marketing
A Major Risk Factor for Underage Drinking
• Forms of alcohol advertising and marketing that predict drinking
onset among youth
– Alcohol advertisements in magazines
– Beer advertisements on television
– Alcohol advertisements on radio
– Alcohol advertisements on billboards
– In-store beer displays and sports concessions
– Alcohol use in movies
– Ownership of alcohol promotional items
• Alcohol companies have moved rapidly into social media – research
has not kept up
51
Collins et al., Journal of Adolesc Health 2007:40:527-34; Snyder et al.,Arch
Pediatr Adolesc Med 2006:160:18-24; Stacy et al., Am J Health Behav
2004:38:498-509
Pasch et al. J Stud Alcohol Drugs 2007:68:586-596; McClure et al., Am J Prev
Med 2006:30:277-83; Stoolmiller et al., BMJ Open 2012:Feb 20;2:e000543;
Sargent et al, J Stud Alcohol. 2006:67:54-65; Henriksen et al., J Adolesc
Health 2008:42:28-35

52. Published since 2008
52
• Eight longitudinal studies
• All found significant associations between exposure to, awareness of,
engagement with and/or receptivity to alcohol marketing at baseline, and
initiation of alcohol use, initiation of binge drinking, drinking in the past 30
days, and/or alcohol problems at follow-up
• Three RCTs (experimental)
• Two of three find immediate effects on drinking of exposure to alcohol
advertisements embedded in commercial breaks in films
• 23 cross-sectional studies
• All find significant associations between exposure to alcohol marketing and
youth drinking, but cannot address causality

53. Peer
Drinking
Peer
Approval
Intend to
Drink Beer
Next Year
Intend to
Drink Beer
Adult
Positive
Expectancies
Negative
Expectancies
Current
Drinking
Overall
Liking
Scaled 2 (795) = 899.36, p < .01
NFI = .85, Robust CFI = .96
RMSEA = .036
Exposure
Attention
Music
People
Story
Humor
.28
.18
.21
.13
.61
.15
.37.22
.24
.22
.49
.16
.13
.25
(R2=.73)
(R2=.60)
(R2=.41)
Effects of Alcohol Advertising
on Drinking Beliefs and Behaviors
(5th – 11th Graders)
Source: Grube et al., 2005

54. Music, people, story

55. Model of marketing receptivity
Source: McClure et al., ACER, 2013

56. Facebook
Brand Posts
Cumulative Posts by Brand
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Ju
n
-0
8S
ep-0
8D
ec-0
8M
ar-0
9Ju
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9S
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9M
ar-1
0Ju
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ep-1
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1Ju
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1S
ep-1
1D
ec-1
1M
ar-1
2Ju
n
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2S
ep-1
2D
ec-1
2M
ar-1
3
BUD LIGHT
SMIRNOFF ICE
BUDWEISER
SMIRNOFF VODKA
COORS LIGHT
JACK DANIELS
CORONA
MIKES
CAPTAIN
ABSOLUT
Source: CrowdTangle and Facebook

57. Facebook
Likes
Cumulative Likes by Brand
0
2000000
4000000
6000000
8000000
10000000
12000000
Jun-08
S
ep-08
D
ec-08
M
ar-09
Jun-09
S
ep-09
D
ec-09
M
ar-10
Jun-10
S
ep-10
D
ec-10
M
ar-11
Jun-11
S
ep-11
D
ec-11
M
ar-12
Jun-12
S
ep-12
D
ec-12
M
ar-13
BUD LIGHT
SMIRNOFF ICE
BUDWEISER
SMIRNOFF VODKA
COORS LIGHT
JACK DANIELS
CORONA
MIKES
CAPTAIN
ABSOLUT
Source: CrowdTangle and Facebook

58. Facebook
Likes
Average Number of Likes per Brand Post by Month
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
Jun-08
Aug-08
Oct-08
Dec-08
Feb-09
Apr-09
Jun-09
Aug-09
Oct-09
Dec-09
Feb-10
Apr-10
Jun-10
Aug-10
Oct-10
Dec-10
Feb-11
Apr-11
Jun-11
Aug-11
Oct-11
Dec-11
Feb-12
Apr-12
Month
AverageLikesperPost
BUD LIGHT
SMIRNOFF ICE
BUDWEISER
SMIRNOFF VODKA
COORS LIGHT
JACK DANIELS
CORONA
MIKES
CAPTAIN
ABSOLUT
Source: CrowdTangle and Facebook

59. Facebook
Shares
Cumulative Shares by Brand
0
100000
200000
300000
400000
500000
600000
700000
800000
900000
Jun-09S
ep-09D
ec-09M
ar-10
Jun-10S
ep-10D
ec-10M
ar-11
Jun-11S
ep-11D
ec-11M
ar-12
Jun-12S
ep-12D
ec-12M
ar-13
BUD LIGHT
SMIRNOFF ICE
BUDWEISER
SMIRNOFF VODKA
COORS LIGHT
JACK DANIELS
CORONA
MIKES
CAPTAIN
ABSOLUT
Source: CrowdTangle and Facebook

60. Facebook
Shares
Source: CrowdTangle and Facebook
Average Number of Shares per Brand Post by Month
0
500
1000
1500
2000
2500
3000
3500
Ju
n
-0
9A
u
g
-0
9O
ct-0
9D
ec-0
9Feb-1
0A
pr-1
0Ju
n
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0A
u
g
-1
0O
ct-1
0D
ec-1
0Feb-1
1A
pr-1
1Ju
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1A
u
g-1
1O
ct-1
1D
ec-1
1Feb-1
2A
p
r-1
2Ju
n
-1
2A
u
g-1
2O
ct-1
2D
ec-1
2Feb-1
3
BUD LIGHT
SMIRNOFF ICE
BUDWEISER
SMIRNOFF VODKA
COORS LIGHT
JACK DANIELS
CORONA
MIKES
CAPTAIN
ABSOLUT

61. Facebook
User Engagement
Source: CrowdTangle and Facebook
User Photos
0
1000
2000
3000
4000
5000
6000Ju
n
-0
9S
ep-0
9D
ec-0
9M
ar-1
0Ju
n
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0S
ep-1
0D
ec-1
0M
ar-1
1Ju
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1S
ep-1
1D
ec-1
1M
ar-1
2Ju
n
-1
2S
ep-1
2D
ec-1
2M
ar-1
3
BUD LIGHT
SMIRNOFF ICE
BUDWEISER
SMIRNOFF VODKA
COORS LIGHT
JACK DANIELS
CORONA
MIKES
CAPTAIN
ABSOLUT

62. Facebook
User Engagement

63. Behavior and consumption
• Is there evidence that alcohol promotion in digital media (either specifically branded
or not) influences behaviour or increases consumption?
– Seven documents identified
– All of them reported primary data; all find in favour of hypothesis that exposure to alcohol
marketing in digital media is associated with a greater risk of earlier initiation or more drinking
– None longitudinal or controlled so direction of causality cannot be established
– One presents evidence that digital marketing can undermine regulations that restrict traditional
(e.g. TV) advertising

64. Promotional methods used
• What methods of promotional marketing are used, and what are the extent of and
trends in their use?
– 19 studies reporting nature and magnitude of promotional alcohol marketing on digital media
– “These interactions make brands a part of everyday conversations on Facebook and allow [the
brands] to become part of the continuous ‘flow’ of content in the news feeds of their followers.
With each interaction, brand content appears in the news feeds of their followers’ friends.”

65. Exposure of specific populations
• Is there evidence that specific population groups are targeted or attracted? And is
there quantitative evidence of their exposure levels?
– Nine studies were found which gave evidence of high levels of exposure to digital alcohol
marketing in certain age groups
– There is a shortage of direct evidence showing that youth or, particularly, underage consumers
are specifically targeted.
– Brand owners state that they target young adults, and the material they provide is designed to
appeal to that age group

66. Marketing code violations
• Is there evidence of marketing code violations and especially of underage access to
alcohol marketing promoted through digital media?
– Ten papers provided evidence of various forms of code violation.
– All of these papers give evidence that under-age users are gaining access to alcohol advertising
through digital media, in violation of voluntary code provisions
– Particular platforms are especially problematic, e.g. YouTube
– Industry innovation and movement of youth audiences across platforms pose challenges for
regulation

67. CAMY Survey: Research Questions
• Research Question 1: What proportion of youth ages 13 to 20 recall
being exposed to alcohol promotion on television, radio, in magazines,
on billboards or public displays, and on the internet, and how frequently
do they recall being exposed? How does this compare with adults ages
21 and older?
• Research Question 2: What proportion of youth ages 13 to 20 report
engagement with alcohol in social media, including viewing, endorsing
or “liking”, sharing, and posting?

68. Recruitment methods
• Adults: from pre-recruited Internet panel of 50,000 (18+)
adults and 3,000 teens (13-17)
• Panel members invited on average 4 times per month to
complete surveys
• Teens recruited by contacting adults in the panel, securing
parental permission
• Due to brevity of survey (<10 minutes), no incentives for
adults, $5 gift for teens

69. Response Rates
• Teens:
– 2,376 adults contacted; 49% provided permission
– Of these, 66% of teens completed the survey
• 18-20 year-olds:
– 1003 invited, 41% completed the survey
• Adults 21+:
– 2,113 invitations sent
– 53% completed the survey

70. Weighting and IRB
• Weights adjusted for gender, age, race/ethnicity, census region,
household income, home ownership status, metropolitan area,
and household size
• Survey approved by Johns Hopkins Bloomberg School of Public
Health Institutional Review Board

71. Sample Characteristics
YOUTH (%) ADULT (%)
Total 1192 1124
Male 550 (46.1) 562 (50)
Female 642 (53.9) 562 (50)
Non-Hispanic White 723 (60.8) 843 (75)
Black non-Hispanic 112 (9.4) 86 (7.7)
Hispanic 232 (19.5) 125 (11.1)
Other 123 (10.3) 70 (6.2)
Internet access yes 1137 (95.4) 925 (82.3)
Internet access no 55 (4.6) 199 (17.7)

72. Findings: exposure to alcohol advertising in
past 30 days
Youth Adults
TV 69.2% 61.9%**
Radio 24.8% 16.7%***
Magazines 35.7% 36.4%
Billboards 54.8% 35.4%***
Internet 30% 16.8%***
*p<.05;**p<.01;***p<.001, proportions weighted

73. Findings: seeing content on the internet
(ever)
Youth Adults
Alcohol advertisements 468 (40) 278 (25.3)***
Celebrities using alcohol 422 (36.1) 227 (20.8)***
Celebrities wearing alcohol-branded
items
325 (27.7) 175 (15.9)***
Friends/peers using alcohol 346 (29.5) 334 (30.6)
Friends/peers showing negative effects
of alcohol use
187 (16.1) 148 (13.6)
*p<.05;**p<.01;***p<.001, proportions weighted

74. Findings: interacting with content on the
internet (ever)
Youth Adults
Alcohol advertisements 114 (9.7) 78 (7.1)
Celebrities using alcohol 126 (10.7) 63 (5.7)**
Celebrities wearing alcohol-branded
items
109 (9.3) 54 (4.9)**
Friends/peers using alcohol 165 (14.1) 111 (10.1)*
Friends/peers showing negative effects
of alcohol use
110 (9.4) 53 (4.8)**
*p<.05;**p<.01;***p<.001, proportions weighted

75. DESPITE RESTRICTIONS, YOUNG PEOPLE ARE
APPARENTLY ON SOCIAL MEDIA – HOW?

76. Findings: deception

77. What is an advertisement?
• In September 2012 the Australian Advertising Standards Bureau
determined that (i) a brand's Facebook page is a marketing
communication tool, and (ii) all contents on the page fall under the
industry's self-regulatory code of ethics, including consumer-created
content such as user-generated comments and photos.
• The Alcohol and Tobacco Tax and Trade Bureau in the United States has
made a similar finding.

78. Alcohol industry self-regulation
• Beer advertising and
marketing materials
should not depict
Santa Claus.

79. Alcohol industry self-regulation
• Beer advertising and
marketing materials
should not portray,
encourage, or
condone drunk
driving.

80. “Beverage alcohol advertising and marketing materials should not contain any lewd or indecent
images or language.”
Photo Credit: Skyy Vodka- Cosmopolitan, January 2011

81. DISCUS Code of Responsible Practices
Beverage alcohol advertising
and marketing materials
should not contain the name
of or depict Santa Claus.
Brand photos on Captain Morgan Facebook Page

82. Alcohol industry self-regulation
– Distilled Spirits Council of the United States (DISCUS) Code:
• Beverage alcohol advertising and marketing materials should not imply
illegal activity of any kind.

83. Alcohol industry self-regulation
DISCUS code
• Beverage alcohol advertising and
marketing materials should not depict
situations where beverage alcohol is
being consumed excessively or in an
irresponsible manner.
• “Limit” is as much as five times the
U.S. dietary guideline for women.

84. What is an ad? Conversations With Joose

85. Center on Alcohol Marketing and Youth  Johns Hopkins Bloomberg School of Public Health  85
Conversations With Joose (continued)

86. Joose
2014…
• ….should not depict
situations where beer is being
consumed rapidly,
excessively…
• Models and actors should
be…a minimum of 25 years
old

87. User-generated content?

88. User uploaded…

89. Industry self-regulation: Placement
• Alcohol industry trade associations have voluntary codes to ensure their marketing goes to primarily
adult audiences
– 71.4% minimum for adult audiences (28.4% maximum for youth audiences)
– Covers everyone under 21
– Magazines only measured 12 and up, radio 5 and up, TV 2 and up
• Existing industry standards permit disproportionate exposure of the group at risk of underage drinking
(ages 12-20)
• 2003: National Research Council and Institute of Medicine recommend moving towards a tighter 15%
maximum for audiences ages 12-20
• 2011: In comments to the FTC, 24 state and territorial AGs endorse this standard as well

90. Industry self-regulation:
Actual placement data
• Magazines 2011:
– Compared to adults 21+, youth ages 12-20 saw per capita 7% more beer ads, 11% more alcopop
ads, 82% fewer wine ads
• Radio 2009:
– 32% of ads on programming with disproportionately youthful audiences
• Television 2012:
– 19% of 350,868 ads aired at times when youth 12-20 per-capita exposure exceeded that of adults
21+
– Average exposure for 12-20s in 2009: 366 ads

91. Youth Exposure in Local Media Markets,
2010
• 25 of 26 largest TV markets in the U.S.
• 10 programs most popular with youth in four categories: broadcast
sports, broadcast non-sports, cable sports, cable non-sports
• Used local ratings data
• Nearly 1 in 4 ads played to underage audiences greater than 30%

92. Industry self-regulation: summary
• Self-regulation of content is subjective and largely
unenforceable
• Self-regulation of placement is not protective of youth
– Youth are still seeing disproportionate amounts of alcohol
advertising, even when the industry meets its self-regulatory
standards

93. Importance of Monitoring at Brand Level
A small percentage of alcohol brands is responsible for
half of youth exposure
Medium Year
Total number
of brands advertising
Brands responsible for half of
youth exposure
Magazines 2008 333 16 (5%)
Television 2009 151 12 (8%)
Radio 2009 77 3 (4%)

94. The importance of brands
• Alcohol marketing is branded.
• Different products or brands clearly target different audiences
• Half or more of youth exposure to alcohol advertising comes from less than
10% of brands advertising
• Putting all brands together can wash out effects on young people
– Diageo: Smirnoff Ice; Johnnie Walker; Ciroc
– AB/Inbev: Bud Light; Tilt; Beck’s
– Pernod Ricard: Absolut; Chivas; Malibu

95. Filling the brand gap
• First-ever national study of youth alcohol consumption by
brand
• Internet-based survey of 1,031 young people ages 13-20
• Asked specifically about 898 brands
• Also collected wide range of other data to enable controlling
for other variables

96. Rank Male (%) Female (%)
1 Bud Light (28.1) Bud Light (27.7)
2 Budweiser (17.0) Smirnoff Malt Beverages (22.7)
3 Jack Daniels Whiskeys (14.2) Mikes (14.4)
4 Coors Light (13.7) Smirnoff Vodkas (13.3)
5 Heineken (13.2) Bud (12.2)
6 Captain Morgan Rums (13.1) Coors Light (11.7)
7 Smirnoff Vodkas (12.2) Absolut Vodkas (11.3)
8 Smirnoff Malt Beverages (11.6) Corona Extra (11.2)
9 Corona Extra (11.3) Bacardi Malt Beverages (10.3)
10 Blue Moon (10.2) Jose Cuervo Tequilas (9.5)
RESULTS
Top 10 Youth Brands By Gender
(Percent of Population Consuming This Brand)
Siegel et al., J Substance Use, 2014

97. Common arguments against the influence of advertising on
youth drinking
• “Kids drink what adults are drinking”
• Survey found several brands much more commonly consumed by youth than by
adults: Corona Extra Light (9.3 times more popular)
– Bacardi Malt Beverages (8.0 times)
– Smirnoff Malt Beverages (6.7 times)
– Mike’s (4.4 times)
– Jack Daniel’s Cocktails (43.8 times)
– Malibu Rums (2.6 times)
– Natural Ice (2.3 times)

98. Common arguments against the influence of advertising on
youth drinking
• “Kids drink whatever is cheapest”
– Survey found is a general relationship between lower price and youth
brand choice BUT
– The most commonly consumed brands are not the cheapest
• Only one of the top 25 youth brands (Keystone Light) is among the 88
cheapest brands

99. Common arguments against the influence of advertising on
youth drinking
• “Since kids report they drink what others give them, advertising doesn’t
matter.”
• Survey found that regardless of source of alcohol, youth brand preferences are
consistent
• Nine of the top 10 youth brands were even more popular among youth who
made their own brand choices
• 7 of top 15 youth brands repeatedly showing up in analyses:
– Smirnoff Malt Beverages, Jack Daniel’s Whiskey, Mike’s, Absolut Vodkas, Heineken, Bacardi
Malt Beverages, and Malibu Rums

100. Greater ad exposure predicts youth alcohol consumption
by brand
• Youth were three times more likely to consume a brand if exposed
to its television advertising
• Analysis controlled for:
– Demographic characteristics
– Magnitude of alcohol consumption
– Parental drinking
– Risk-taking behavior
– Media use patterns
– Autonomy of brand choice
– Brand-specific prices
– Overall brand market share
Ross et al., ACER 2014

101. Media providers
• Require age for access
– Twitter, YouTube
• Tighten age-gating procedures
– Affirmation is not sufficient
– Verification is feasible (BudTV, tobacco)

102. Parents
• Be aware that young people lie about their ages in social media
to get where they want to go
• They are seeing the ads – need to talk to them about them
• Demand stronger action from companies, government

103. Alcohol Companies
• Monitor social media feeds and remove inappropriate content
– Including user-generated content
• Refrain from placing ads on social media (YouTube) that could
not be aired on television

104. Goverments? A global problem…
• Globally, alcohol sales are worth approximately $1 trillion per year
• Five companies alone report US$5.5 billion in measured marketing
(just traditional advertising) spending in 2010
• These five are among the top 100 marketers in the world

105. WHO Global Strategy Recommendation
• Set up regulatory or co-regulatory frameworks, preferably with a legislative basis,
and ways they could be supported when appropriate by self-regulatory measures,
for alcohol marketing by:
– regulating the content and the volume of marketing;
– regulating direct or indirect marketing in certain or all media;
– regulating sponsorship activities that promote alcoholic beverages;
– restricting or banning promotions in connection with activities targeting young people;
– regulating new forms of alcohol marketing techniques, for instance social media

106. WHO Global Strategy Recommendation
• Develop effective systems of:
– surveillance of marketing of alcohol products;
– administrative and deterrence systems for infringements on
marketing restrictions can be set up.
• WHO marketing tool lays out policy options in detail

107. Why not just self-regulation?
• Alcohol industry self-regulation
– 47% of reporting countries indicate no regulation of alcohol marketing, leaving it
entirely to alcohol industry self-regulation
– Multiple studies in multiple countries have found alcohol industry self-regulation
ineffective, both in terms of content and in terms of placement
– Industry interpretations of the codes tend to be far more lenient than layperson
or public health interpretations

108. What is marketing?

109. Partnership?
The conflict of interest
Alcohol industry self-regulatory (voluntary) codes:
Distilled Spirits Council of the U.S. (“DISCUS”):
“DISCUS members encourage responsible decision-making regarding drinking,
or not drinking, by adults of legal purchase age, and discourage abusive
consumption of their products.”
Beer Institute (U.S.):
“Brewers strongly oppose abuse or inappropriate consumption of their
products.”

110. What is “abusive consumption”?
• The alcohol industry will never define this.
• In the U.S., “binge consumption” is defined as:
– 5 or more drinks (70g) in two hours for males
– 4 or more drinks (56g) in two hours for females

111. Binge drinking dominates the alcohol market
• More than half of adult consumption in the U.S. is in the form
of binge drinking (CDC)
• At least 2/3 of youth consumption in the U.S. is in the form of
binge drinking

112. Even if we limit “abusive consumption” to DSM-IV
criteria and underage drinking…
The alcohol market in the U.S.:
– Value of underage drinking: $22.5 billion
– Value of abusive and dependent drinking (DSM-IV criteria): $25.8
billion
– Total combined loss to industry if underage and pathological drinking
eliminated: $48.3 billion, or 37.5% of sales (Foster et al. 2006)

113. The Conflict of Interest
• If everyone in the US drinks in a safe and responsible manner:
– Alcohol companies face a market less than half the size of what we
have today
– Alcohol companies lose at least a third of their profits.
– No publicly-traded company can intentionally lose this much of their
market and survive.
– The alcohol industry has a conflict of interest with safe and
responsible drinking.

114. Marketing policy options
• Total ban
– Easiest and least expensive to implement
– Research in well-resourced countries shows will have an effect,
especially on youth drinking
– Will generate significant alcohol industry opposition
• Will claim hurts competition
• In fact, current high marketing spend creates high barriers to entry that
already hurt competition
• Currently exists in at least 21 countries

115. Marketing policy options
• Partial bans
– Content-specific
– Time-specific
– Audience-specific
– Beverage-specific
– Medium- or channel-specific
– Location-specific
– Event-specific

116. THE LEE LAW PROJECT

117. THE LEE LAW PROJECT: OVERVIEW
• Focus is on alcohol
advertising restrictions in
Lee Law
• Organized and led by youth
• Toolkit available at
http://www.fridaynightlive.org/wp-
content/uploads/FNL-Lee-Law-toolkit-
draft_v2.pdf

118. • Counter-advertising
– Marketing activity designed to decrease interest in a product
• Often uses people’s familiarity with the product ads to promote recall of the counter
advertising message
– Effective in tobacco control
– May be effective in reducing youth alcohol use but little evidence and few experiments exist
Alternatives to Regulation

119. Countering “Blast”

120. The counter-ads

121. Alcohol advertising reform: global
• France has one of the strongest anti-alcohol advertising laws among the wealthy
countries:
– No advertising is allowed on television or in cinemas;
– No sponsorship of cultural or sport events is permitted;
– The law has been upheld by the European Court of Justice
• Thailand passed a new Alcoholic Beverage Control Act in 2008:
– Prohibits sales of alcoholic beverages to anyone under 20
– Bans consumption or sale of alcohol on government premises, schools, hospitals, petrol
stations, parks
– Bans alcohol advertising that in any way includes pictures of a product or encourages
drinking – leaves only “corporate” advertisement and advertising originating outside of
Thailand
• South Africa considering a complete ban; Australia and Thailand buying out sports
sponsorships

123. Thank you very much!
www.camy.org
www.twitter.com/CAMYJHU
www.facebook.com/JHU.CAMY

124. Dr Ann Hope
“Tackling Our Alcohol Problems: What can Communities Do?”

125. Tackling alcohol problems in Ireland – what
can communities do?
Dr Ann Hope,
Research Associate,
Department of Public Health and Primary Care,
Trinity College, Dublin.
Alcohol Forum National Conference
Croke Park, April 22nd2015

126. Firstly,
We need to understand -why we are
where we are now?

127. 0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Litresofpurealcohol
Alcohol consumption per capita adult (15+) 1975-2014
Total Beer Spirits Wine Cider

128. Affordability
• “Increasing economic growth in Ireland will lead to a
disproportionate increase in alcohol consumption” (ESRI for DOH
alcohol policy, 1996)
• No increase in alcohol taxes (1994-2001)
• Tax increase on spirits (Dec budget 2002)
• Affordability of alcohol increased by 50% between 1996 and
2004 (RAND, 2009)
• Below cost selling of alcohol (2006)
• Tax decrease (2009), Tax increase (2012, 2013)

129. Availability
• Increased opening hours
– Extensions for late nights (65% increase btw 1994 and 2006)
– Increased in normal pub opening hrs, (from 11.30pm to 12.30am),
“plus 30 mins drinking up time” (2000)
– Increased in early morning opening for off-licences (7.30am)
• Free movement of Licences (2000)
• Greater density of outlets in towns and cities
• Increase in number of outlets selling alcohol

130. Pub licences, 8,414
Off-spirits, 1,746
off-wine, 3,370
0
2000
4000
6000
8000
10000
12000
14000
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
nooflicences
On and Off-licences, 1993-2013
Pub licences, 10,190
Off-wine 368

131. The drink question in Ireland - not a new problem
(1886)
The figures “afford a clear indication
that as public-houses become more
numerous, more drink will, as a
consequence, be consumed; and that,
following on an increased consumption
of drink, crime, disorder, and misery,
become intensified as a natural and
inevitable consequence”
“Legislation can do a great deal to
remove temptation”

132. Drink Driving policies
478
396
162
190
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Numberofdeaths
Road deaths, 1990-2013
Penalty points
system Oct 2002
BAC .08
BAC .05
RBT introduced

133. Secondly,
What can communities do?

134. Learning - Futures Ireland
“We need to create a learning society.
• The evidence shows that we have only a
very partial system of innovation and
learning....
• These cannot flourish without profound
changes to our organisational system
• Local learning can help to re-cast
policies”
Ireland at Another Turning Point,
NESDO foresight report, 2009

135. Community Action on Alcohol
Community action is based on the premise that
public policies need to change to reduce alcohol
problems
regulation, enforcement, laws and systems change

136. Public policies at the local level
• Local Council
– Planning, bye-laws
• Joint Policing Commission
– Decisions on alcohol issues shared and discussed
• Local /Regional Drug and Alcohol Task Forces
– Valuable expertise, national network
• The Health Services
– GPs, hospital staff, treatment, family support, EHO and others
• Valuable community networks
– Residents, school/colleges, sporting organisations etc
• Business Community
– Ensure business practices enable and support reduction in alcohol problems

137. Reduce availability
• Map the number, type and density of outlets selling alcohol
• Increase enforcement on alcohol laws through a systems
approach
– Limit drinking in public places through local bye laws
– Examine current licensing laws and propose changes to benefit your
community safety
– Youth access, secondary purchasing, serving intoxicated customers,
drink-driving
• Advocate for minimum pricing policy
• Examine potential to reduce cheap discounts at local level

138. Reduce marketing
• Reduce exposure of children to alcohol
marketing
• Stop alcohol advertising in public places
• Advocate for meaningful statutory regulation to
protect children
• Advocate for third party verification of age on
industry/social network sites where alcohol is
marketed

139. Intervene early and provide treatment
• Provide alcohol screening and brief advice in key settings
• Identify and develop local pathways for alcohol treatment
services at the individual and family level
• Ensure a range of treatment options within community (eg.
town or county)
• Ensure local community are aware of how to
access alcohol treatment services & are
encouraged to do so.
“Living with a problem drinker affects the
whole family, like ripples in a pond”
Scottish front line staff member

140. Raise awareness
• Increase understanding of
– Range of alcohol problems in community
– Benefits of reducing alcohol related problems
– What works and what does not work in reducing
problems
– That protecting children is
everyone’s responsibility.
“Grown-ups like drinking
because then they don’t
think the world is as it is”
Miki, aged 10
“They should say it on the news, that
things don’t get any better because
you drink”
Dorthea age 8

141. Monitor and Evaluate
• Undertake a community audit, identify needs and priorities for
your community
• Build awareness that everyone has a role to play
• Put a monitoring system in place
• Evaluation interventions that reduce availability, cheap
alcohol, less alcohol advertising and increase alcohol
screening and brief advice
• Ensure regular roundtable discussions - important collective
process

142. We need to Build a Healthy and Sustainable Society

143. Dr Stephan Stewart
“Preventing alcohol-related problems – a hepatologist’s perspective”

144. PREVENTING ALCOHOL-RELATED PROBLEMS
AN HEPATOLOGIST'S PERSPECTIVE
Dr Stephen Stewart
Mater Misericordiae University Hospital
April 2015

145. PLAN
• What are the alcohol-related harms I see?
• How are Irish livers doing?
• Why are they doing so badly?
• What can we do about it?

147. CirrhosisNormal

149. PLAN
• What are the alcohol-related harms I see?
• How are Irish livers doing?
• Why are they doing so badly?
• What can we do about it?

150. MORTALITY DUE TO CIRRHOSIS IN IRELAND

153. PLAN
• What are the alcohol-related harms I see?
• How are Irish livers doing?
• Why are they doing so badly?
• What can we do about it?

154. ALCOHOL

155. IRELAND’S ALCOHOL CONSUMPTION COMPARED TO OTHER
EUROPEAN COUNTRIES

156. PLAN
• What are the alcohol-related harms I see?
• How are Irish livers doing?
• Why are they doing so badly?
• What can we do about it?

157. Hepatocellular cancer
surveillance
Relapse prevention
Screening and brief interention
Pricing
AvailabilityPro
motion

158. DRIVERS
• Alcohol is more affordable
• Alcohol is more available
• Alcohol is more acceptable

159. PRICE V CONSUMPTION

160. DRIVERS
• Alcohol is more affordable
• Introduce a minimum unit price
• Alcohol is more available
• Restrict time and place of sale
• Alcohol is more acceptable
• Restrict promotion

161. Alcohol Consumption per Adult 1986 -2006

164. Day Devoted to Hoisting Guinness Starts to Leave a Bitter
Taste

165. Arthur’s Day axed: Guinness confirms celebration will not be returning
However, the company says the decision was NOT related to the backlash against the event.

166. Ministers Fitzgerald, Reilly and White announce Measures to Deal with Alcohol Misuse
Minimum Unit Pricing and Regulation of Advertising and Sponsorship to be provided for in a
Public Health Bill
Thursday 24 October 2013

169. MORTALITY DUE TO CIRRHOSIS IN IRELAND

170. CONCLUSIONS
• Alcohol has numerous health harms
• Cirrhosis mortality is increasing
• There are numerous intervention points on the pathway to end-stage liver
disease
• We are in the middle of a public health revolution

171. Lunch 13:00-14:00
Viewing of Poster Presentations:
Dr Helen McMonagle: Alcohol Related Brain Injury: A Whole System Approach to
Rehabilitation.
Christina McEleney: Alcohol and Pregnancy
Eimear Murphy & Ian O’Sullivan: Alcohol Consumption-Research: Impact of Drinking
in the home on Youth Behaviours
Debbie McDonagh: Drug and Alcohol Family Support Needs Analysis. WRDTF
Martin Davoren: Types of Alcohol Consumption Among Young Adults – A Narrative
Synthesis

172. Ms Evelyn Smith
“Prescription For a Healthy Pregnancy – Addressing Maternal Alcohol
Consumption”

173. Letterkenny General Hospital
Evelyn Smith
ADON/M/Service Manager Women & Childrens Services
Letterkenny General Hospital Donegal April 2015

174. PRESCRIPTION FOR A HEALTHY
PREGNANCY
Addressing Maternal Alcohol Consumption
Practice Change Initiative
Letterkenny General Hospital

175. Introduction
• Context & Evidence Base - wider hidden harm agenda
• The Project Road Map –
• Partnership; Process; Permissions
• Aims Objectives and Hoped For Outcomes
• Current status
• Evaluation

176. Short life group established April 2013

177. Partnerships
• Mutidisciplinary/Multiagency Group including
• Maternity Services LGH
• Antenatal Clinic
• Health Promotion Services LGH
• Alcohol Forum
• Donegal Education and Training Board ETB
• HSE Drug and Alcohol Service

178. Risks of alcohol use in pregnancy
“Of all the substances of abuse including
cocaine, heroin, and marijuana, alcohol produces by far the most serious
neurobehavioral effects in the foetus resulting in life-long permanent
disorders of memory function, impulse control and judgment”
INSTITUTE OF MEDICINE Report to Congress, 1996 (U.S)

179. Numbers so affected…lets (guess) estimate
• No reliable evidence currently of incidence
of FASD in UK
• England and Scotland: data only collected
on FAS and not on the whole spectrum of
FASD
– 128 FAS cases England (2002-3) (DH Hospital
episode stats)
– 10 FAS cases Scotland 2004
• No available data for NI or Wales or ROI
• World wide incidence estimated at 0.97
cases per 1000 live births (Alcohol culture/ one of
highest consumers alcohol Europe
• EUROPEAN AVERAGE OF 0.4
PER 1000 LIVE BIRTHS
• FAS although not a common
condition is regarded as the
leading cause of non-genetic
disability in western world.

180. WHO European Charter
All children have the right to grow up in an environment protected from the
negative consequences of alcohol consumption

181. A pregnant pause….
• The proportion of women of child-bearing age in the Ireland who drink
over 11 standard drinks of alcohol per week has increased in recent
years.
• National Drinking Surveys 2006 & 2010 Worryingly shows:
• Females of child bearing age (18-49 years) 47% of women engaged in regular
hazardous drinking
• Child bearing women: Coombe Study 63% of woman surveyed drank
alcohol during pregnancy
6/26/2015

182. Steering Group Report On a National Substance Misuse Strategy
February 2012
Action 11 (chapter 3) prevention chapter states:
“Given the concerns about Fetal Alcohol Spectrum Disorder (FASD), a
comprehensive awareness campaign on a national and community level is
needed to increase public knowledge regarding the risks and impacts of
drinking during pregnancy and to discourage the consumption of alcohol
during pregnancy.”

183. Ascertaining Alcohol Use in Pregnancy
• Ascertaining the true prevalence and extent of alcohol
consumption in pregnancy is difficult due to:
• Under reporting.
• Lack of understanding of what constitutes a standard drink and
therefore low to moderate use. (P.18 toolkit)

184. The Chief Medical Officer advises…
Given the harmful drinking patterns in Ireland and the propensity
to binge drink, there is a substantial risk of neurological damage
to the foetus resulting in Foetal Alcohol Spectrum Disorders
(FASD). Therefore, it is in the child’s best interest for a pregnant
woman not to drink alcohol during pregnancy

185. Child protection
• Alcohol use alone may not be an indicator for a child protection report or
notification
• However child protection is a consideration in all alcohol interventions for
pregnant women. Legislation requires that the safety and well being of the
child is paramount.
• From a child protection perspective, regular daily or nearly daily use and
binge use are of most concern.

186. Screening for alcohol AUDIT
•The AUDIT is a validated screening tool and although not
designed specifically for during pregnancy it is useful in
identifying lower levels of drinking that may still be
harmful during pregnancy.

187. Women’s fears
• Automatically referred to social work
• Baby taken into care
• Confusion over damage use will cause to foetus
• Blamed if anything goes wrong with pregnancy
• Unfit or uncaring if can’t stop or reduce use
• Feeling guilty and blaming self re: baby’s withdrawal

188. What we are doing together:
• Multidisciplinary multi-agency approach can provide pregnant
women with:
–Information on the risks associated with use.
–Assessment of alcohol related problems in pregnancy.
–Advice
–Discussion of treatment and care options with mum.
(see Scottish document re: Integrated Care Pathways)

189. Alcohol and Pregnancy: Key Messages (1)
• Significant rise in the number of
women of child bearing years who
drink heavily
• Link between alcohol consumption
and unplanned pregnancy
• FASD completely preventable through
the elimination of drinking during
pregnancy
• Benefit to the infant can be obtained if
alcohol is withdrawn at any stage of
gestation
• The level and pattern of alcohol
consumption and the stage of pregnancy
when consumed are important determinants
of the outcome of an alcohol affected
pregnancy (Binge drinking/alcohol culture) p.1 BMA 2007
• Particular vulnerability of fetus to alcohol in
first and third trimester
6/26/2015

190. Many women will not know they are
pregnant during the early part of 1st
trimester and continue to drink in their
pre-pregnancy fashion with no awareness
of the risks to their unborn child
Consequently, the foetus is most likely
to be exposed to alcohol in the first
trimester, before pregnancy
recognition
These findings suggest that alcohol
consumption during pregnancy is an
important public health issue.
First national practice change initiative
in the area of maternal alcohol
consumption
6/26/2015
Alcohol and Pregnancy: Key Messages (2)

191. Health Promotion and Advice (BMA2007p.14-15)
“In antenatal settings there is a responsibility to
provide on-going advice and support to expectant
mum’s (including) information of the risks of
maternal alcohol consumption that is up to date
consistent and evidence based.”

192. BMA continued…
• This health advice should be supplemented with take home printed
information.
• The combination of verbal guidance together with printed information is found
to decrease alcohol consumption levels in pregnant women.
• Supported in recent research by John Sheehan - brief advice is just as
effective as brief intervention.

193. Road Map to project at LGH
• Review of literature /evidence base
• Draft Project Descriptor (indicating need for a response)
• Application for ethical approval
• Meet with Ethics Committee May 2013
• Ethical Approval Granted June 2013
• Resource pack developed September 2013
• Staff Training September 2013
• Road Blocks – flooding of LGH and October start date postponed until the new year
• 20th February 2014
• AUDIT C screening integrated in DR Nandini Ravikumar’s Booking in clinic in LGH
• TOOLKIT Official Launch April 3rd 2014 (AAW)
• Master Class Alcohol and Pregnancy as part of CPD
• Evaluation – Commenced March 2015

194. Project Descriptor
Local multidisciplinary multi-agency response to maternal alcohol
consumption thereby providing pregnant women with information on
the risks associated with use; early assessment of alcohol related
problems in pregnancy; appropriate advice on use in pregnancy;
and treatment and care options. (Scottish document re: Integrated Care Pathways).

195. Practice Change Aims (1)
Promotion of screening and Brief Intervention of pregnant women at risk of
maternal alcohol consumption for a 6 month period within Dr. Nandini’s
antenatal clinic LGH.
In this time to establish care pathways for women at high risk of an alcohol
affected pregnancy
To develop or source appropriate alcohol and pregnancy health promotion
materials for use within the antenatal (perinatal) setting

196. Practice Change Aims (2)
To develop or source an alcohol toolkit for use within the antenatal setting
•To provide training to midwives on screening and brief intervention for maternal alcohol
consumption in line with the national standard (Saor Model)
•In line with the Department of Health and Children’s Chief Medical Officer, this practice change
initiative will ensure that women are provided with all the relevant information for a safe and
successful pregnancy.
•It is anticipated that the results will inform phase two re; systems wide practise change.

197. Hoped for
outcomes
To increase awareness of hidden harm
To support and build upon good clinical
practise
To promote earlier intervention
To offer practical tools to engage with
mums
A reduction ;
• of alcohol use in pregnant woman
• in negative birth outcomes and medical
costs
An improvement in ;
• access to a range of services.
• outcomes for children in line with the
Hidden Harm Agenda

198. The How?
• Integrate AUDIT screening within booking clinic in LGH re; maternal alcohol
consumption to
• Identify alcohol use among pregnant women along the continuum from alcohol use to dependency
• Adapted SAOR Model for use within antenatal setting
• Onward referral
• Provision of printed information and screening to first time mums at 12 weeks
up to 20 weeks (to include late bookings)
• Follow up at the 28 week antenatal appointment re: impact of intervention.

199. Cohort targeted
• Based on previous 12 month period figures for Booking Clinics:
• 1 Booking Clinics per week x 10 potential participants attending each clinic. x
6 month period a potential cohort of (40x6) = 240 targeted.

200. TOOLKIT CONTENT
•Review & adaption of SOAR model
•Links with National Screening & Brief
Interventions (SBI)
200

201. The Screening
Tool
201

202. Midwives Handbook
Prescription
For a
Healthy Pregnancy
The SOAR Model
LETTERKENNY GENERAL HOSPITAL
2013
Screening and Brief Intervention (SBI) for Alcohol Misuse in
Pregnancy Practice Change Initiative
Evi Muggli Senior researcher and
Jane Haliday (PHD)
The Royal Children's Hospital,
Victoria, Australia
Links now created with National SBI project
Adapted from Life Script’s
202

203. The Prescription
203

204. The “take home”
information leaflet
204

205. 6/26/2015

206. SAOR MODEL
•Support
•Ask
•Offer Assistance
•Refer
(page 10 of Midwives Handbook)

207. Risk Level Intervention AUDIT score
Low risk
Alcohol Education by midwife:
Reinforce advice that there is NO safe drinking level
Give out Alcohol Focus Scotland Leaflet
0 – 3
Risky
Simple Advice as above
Ascertain feelings about stopping
Ascertain confidence level
Refer to consultant obstetrician
4-5
Risky/High Risk
Simple Advice plus
Refer to consultant obstetrician >6
Scoring Audit refer to page 19 Midwives Handbook
Message: NO alcohol in pregancy
Positively reinforce where the mother no longer consumes alcohol

208. 28 week follow up questions
1. Did you read the leaflet “Alcohol and Pregnancy Don’t Mix”? Y/N
2. Before you read the leaflet, did you know that the recommendation is
not to drink at all when pregnant? Y/N
3. Did you find the leaflet useful? Y/N
4. If yes in what way was it useful?
5. Do you think this leaflet should be available to all pregnant women?
Y/N
Any other comments/suggestions?

209. Evaluation Report Pending …
May 2015
Quantitative Measures:
• Number of screenings completed
• Number of brief advice offered
• Number of follow-up at 28 weeks on the benefits/impact of the same.
• Number of referrals to specialist services
Qualitative measures:
Mother’s experience: information and advice at 12 weeks – follow-up at 28 weeks on the
benefits/impact of the same.
• Consultant/ Midwives experience of training
• Consultant / Midwives experience of delivery in practise
• Consultant / Midwives experience of toolkit

210. Master class on Alcohol and Pregnancy
3RD APRIL 2014
M O U NT E R R I G A L HO TE L
L E TTE R KE NNY
6. 30 P M – 9. 00 P M

211. International Interest in the Pilot Project
An Expression of interest has been received from Professor Jane
Halliday,
PhD Group Leader, Public Health Genetics
Genetics Royal Children’s Hospital Australia to share our findings
and results.

212. Real investment in our future
Our children are our
greatest treasure.
They are our future.
Nelson Mandela

213. Thank you

214. References
• National Substance Misuse Steering Group Report 2012:
• RCOG Statement 5 March 2006 UK;
• Prevalence, predictors and perinatal outcomes of peri-conceptional alcohol exposure- retrospective cohort study in an urban obstetric
population in Ireland (2011);
• Chief Medical officer Guidance;
• European Charter on Alcohol (1995).
• Alcohol and Pregnancy: Information for Midwives (No-FAS UK 2004) : BMA 2007; Drug Scope Substance Misuse in Pregnancy ;
• Alcohol and Pregnancy Patient Information Leaflet (Alcohol Focus Scotland);
• integrated care pathways Guide 8: Drug Misuse in pregnancy and Reproductive Health) ; www.ichr.uwa.edu.au/alcoholand pregnancy;
• Babor et al The Alcohol, Use disorders Identification Test Guidelines for Use in Primary Care WHO (2001);
• Sheehan et al The effectiveness of a Brief Intervention to reduce alcohol consumption in pregnancy: a controlled trail HSE (2013);
• Children First: National Guidance for the Protection & Welfare of Children (2011)
• National Institute for Health and Clinical Excellence (2008) Antenatal Guidelines
• NSW Clinical Guidelines
• SOAR Model for the Introduction of Screening and Brief Intervention (SBI) for Hazardous Harmful Use of Alcohol in the Emergency
Department, HSE 2009

215. Eimear Murphy & Ian
O’Sullivan
“Alcohol Consumption: Does the Apple fall far from the tree?”

216. Alcohol Consumption: Does the
apple fall far from the tree?
Eimear Murphy & Ian O’Sullivan

217. • Alcohol plays a complex role in Irish society
• Recent figures from the World Health Organisation (WHO) highlight
that the European Region (E.U.) is the heaviest drinking region in the
world. Noteworthy the Irish population consume more alcohol when
compared to the E.U. average

218. • In European countries adolescents report increased levels of alcohol
consumption
• In Ireland, young adults report being drunk more often than those in
most other European countries.

219. • The majority of individuals typically start using alcohol at some point
during adolescence or early adulthood. A number of factors influence
this:
• Peers
• Societal
• Parental

220. Previous research on the subject of parent child relationship and
alcohol use have found inconclusive or weak evidence.
Thus the aim of this current research is to investigate the relationship
between parental attitudes and alcohol consumption and adolescent
alcohol consumption

221. Methodology
• Survey Design
• A cross-sectional survey was undertaken. This involved distributing a questionnaire
to a representative sample of second-level students in the Kanturk-Mallow local
electorate area.

222. • Sampling
Our sample consisted of fifth and sixth year students from the Kanturk-Mallow local electorate
area.
The area has a spread of socioeconomic classes and incomes. The locality contained eight
secondary schools all of which were sampled.
This gave us a sample size of 982 fifth and sixth year students. We received a response from
360 pupils and their parents. This gave us a response rate of 37%.

223. • Questionnaire
• A number of existing validated instruments were used to create the
questionnaire used in this research. Topics included in this survey were:
• Alcohol use,
• Self- reported height and weight
• Smoking status
• Mental health and well-being

224. • Data Analysis
• The data was entered in an excel document and transferred to IBM SPSS
Statistics 20 for statistical analysis.
• Analysis included descriptive analysis, frequency analysis and binary logistic
regression analysis

225. Results Male Female Total
Adolescent Gender Male 159 (44.2%)
Female 201 (55.8%)
Hazardous Drinking Non-Hazardous 96 (60.4%) 141 (70.1%) 237 (65.8%)
Hazardous 63 (39.6%) 60 (29.9%) 123 (34.2%)
School Year Fifth year 99 (62.3%) 114 (56.7%) 213 (59.2%)
Sixth year 60 (37.7%) 87 (43.3%) 147 (40.8%)
BMI Categories Normal weight 141 (88.7%) 172 (85.6%) 313 (86.9%)
Overweight 15 (9.4%) 20 (10%) 35 (9.7%)
Obese 3 (1.9%) 9 (4.5%) 12 (3.3%)
Smoked Yes 17 (10.8%) 16 (8%) 33 (9.2%)
No 141 (89.2%) 184 (92%) 325 (90.8%)
Currently Current Smoker 9 (56.2%) 14 (100%) 23 (66.7%)
An ex- smoker 7 (43.8%) 0 (0%) 7 (23.3%)
Minimum Maximum Mean
Age 15 19 16.89
Well-being Score (/80) 13 80 61.75

226. Parent Father Mother
Gender 268 (100%) 339 (100%)
Hazardous Drinking Non-Hazardous 134 (50%) 179 (52.8%)
Hazardous 134 (50%) 160 (47.2%)
Education Status Primary Level 23(6.4%) 9 (2.7%)
Second Level 196 (54.6%) 140 (41.3%)
Third Level 140 (39%) 190 (56%)
Marital Status Single 5 (1.9%) 13 (3.8%)
Cohabiting 8 (3%) 13 (3.8%)
Married 245 (91.4%) 280 (82.6%)
Separated 7 (2.6%) 13 (3.8%)
Divorced 2 (0.7%) 10 (2.9%)
Widowed 1 (0.4%) 10 (2.9%)
Smoked Yes 125 (47%) 156 (46.3%)
No 141 (53%) 181 (53.7%)
Currently Smoker 38 (29.5%) 50 (31.5%)
An ex- smoker 91 (70.5%) 109(68.6%)
BMI Category Normal weight 86 (32.1%) 208 (61.4%)
Overweight 138 (51.5%) 87 (25.7%)
Obese 44 (16.4%) 44 (13%)

227. Fathers attitudes Mothers attitudes
Child’s drinking pattern
Hazardous
drinking
Non-
hazardous
drinking
p-value Hazardous
drinking
Non-
hazardous
drinking
p-value
It’s ok for my
adolescent to get
drunk sometimes
Disagree/Neutral 76 (85.4%) 173 (97.2%) P=
<0.001
112 (94.1%) 214 (98.6%) P=
0.020Agree 13 (14.6%) 5 (2.8%) 7 (5.9%) 3 (1.4%)
Getting drunk is
part of having
fun
as an adolescent
Disagree/Neutral 77 (86.5%) 171 (96.1%) P=
0.004
108 (90.8%) 212 (97.2%) P=
0.009Agree 12 (13.5%) 7 (3.9%) 11 (9.2%) 6 (2.8%)
Adolescents
should not drink
at all
Disagree/Neutral 42 (47.7%) 72 (40.4%) P=
0.259
63 (52.5%) 80 (36.7%) P=0.005
Agree 46 (52.3%) 106 (59.6%) 57 (47.5%) 138 (63.3%)
I set a good
example for my
adolescent
through my own
drinking
Disagree/Neutral 26 (29.2%) 42 (23.6%) P=
0.321
18 (15.1%) 34 (15.6%) P=0.909
Agree 63 (70.8%) 136 (76.4%) 101 (84.9%) 184 (84.4%)
I teach my
adolescent to
drink responsibly
at home
Disagree/Neutral 40 (44.9%) 99 (56.6%) P=0.1 44 (36.7%) 116 (53.2%) P=0.004
Agree 49 (55.1%) 79 (44.4%) 76 (63.3%) 102 (46.8%)

228. It’s okay for
adolescents to
drink on
special
occasions
Disagree/ne
utral
31 (34.8%) 125 (70.2%)
P=<0
.001
45 (37.5%) 146 (67%)
P=<0
.001Agree 31 (34.8%) 58 (65.2%) 75 (62.5%) 72 (33%)
It would be ok
for another
parent to
provide my
adolescent
with alcohol
Disagree/Ne
utral
60 (67.4%) 161 (91%) P=<0.00
1
80 (67.8%) 191 (88%) P=<0.00
1
38 (32.2%) 26 (12%)
Agree 29 (32.6%) 16 (9%)
It’s a good
idea to
introduce
alcohol in the
home
Disagree/
Neutral
58 (65.2%) 129 (72.9%) P=
0.194
72 (61%) 155 (71.8%) P=0.044
Agree 31 (34.8%) 48 (27.1%) 46 (39%) 61 (28.2%)
I wouldn’t be
concerned if
my adolescent
drank 4 pints
once a month
Disagree/
Neutral
67 (76.1%) 155 (87.6%) P=
0.017
85 (32.6%) 192 (88.9%) P=<0.00
1
Agree 21 (23.9%) 22 (12.4%) 32 (27.4%) 24 (11.1%)

229. Father OR 95% CI
Hazardous drinker 2.91 1.70-4.96
OK with teen getting drunk 5.92 2.04-17.19
Agrees that getting drunk is part of
having fun as a teen
3.81 1.44-10.05
Agrees that teenagers should not
drink at all
0.74 0.45-1.24
Thinks that he sets a good example
through his own drinking behaviour
0.75 0.43-1.38
Introduces alcohol in a controlled
home environment
1.54 0.92-2.56
Thinks it’s OK for teenagers to drink
on special occasions
4.44 2.57-7.59
Thinks its ok for another parent to
supply alcohol to their teen
4.86 2.47-9.59
Thinks it’s a good idea to introduce
alcohol to u18’s in the home
1.44 0.83-2.48
Wouldn’t be concerned if their teen
drank four pints once a month.
2.21 1.14-4.29

230. Mother O.R 95% CI
Hazardous Drinker 1.56 1.00-2.44
Agrees that its ok for their adolescent to
get drunk sometimes
4.46 1.13-17.58
Agrees that getting drunk is part of having
fun as an adolescent
3.6 1.3-9.99
Thinks that adolescents shouldn’t drink at
all
0.52 0.33-0.82
Thinks that she set a good example
through their own drinking behaviours
1.04 0.56-1.93
Introduces alcohol to their adolescent in a
controlled home environment
1.96 1.24-3.10
Thinks that it’s ok for an adolescent to
drink on special occasions
3.38 2.12-5.38
Thinks that it would be ok for another
parent to provide their adolescent with
alcohol
3.49 1.99-6.13
It is a good idea to introduce alcohol to
adolescents in the home
1.62 1.01-2.61
Wouldn’t be concerned if their adolescent
drank four pints of beer once a month
3.01 1.67-5.42

231. Parental Factors which influence hazardous adolescent alcohol
consumption in order of most importance:
O.R. 95% CI
Hazardous drinking by the father 3.15 1.63-6.11
The father allowing their adolescent to drink alcohol on special
occasions
3.83 1.89-7.73
The father believing that it is ok for their teenager to get drunk
sometimes
3.74 1.01-13.90
The mother allowing their adolescent to drink alcohol on
special occasions
3.17 1.57-6.41
Poor well-being of the father 0.98 0.96-0.99

232. Discussion
• We found that 47% of parents who returned the survey were
hazardous drinkers, similar to recent findings reported by the Health
Research Board.
• However, we found that it is a father’s alcohol consumption which
effects alcohol misuse amongst adolescents.

233. • Introducing alcohol at home on special occasions may be causing
increased levels of consumption among adolescents in later life.
• This was also noted if the father of the adolescent was ‘okay with
their teenager getting drunk sometimes’. Fathers well-being is closely
related to child hazardous drinking which has been previously noted
in similar international research.

234. Policy recommendations
• Previous research has noted the importance of a minimum age for
consumption. Research has shown that exposure to alcohol in
adolescence can have detrimental effects on brain development and
intellectual capabilities and increases the likelihood for later alcohol
dependence.

235. • However, the current study notes that the majority of hazardous
adolescent drinkers (68.2%) were under the legal age of consumption. It is
against the law for alcohol to be sold to adolescents under the age of 18.
• The promotion of alcohol in areas such as sport and music is becoming
increasingly prevalent and these same lifestyle areas are where adolescents
learn social engagement, independence and self-expression.

236. • Alcohol sports sponsorship is especially topical right now and well-
established evidence shows alcohol marketing increases likelihood
that adolescents will start to drink and will drink more if they are
already using alcohol.

237. We would also suggest that a minimum unit price for alcohol should be
brought in as adolescents often don’t have a lot of money and will only drink
when they can afford it. Another suggestion is to start a social norms
campaign to alter people’s attitudes to alcohol consumption and what
constitutes hazardous drinking

238. Conclusion
• This study has found there to be a significant correlation between
parental attitudes and alcohol consumption and adolescent alcohol
consumption. It notes that the majority of hazardous adolescent
drinkers (68.2%) were under the legal age of consumption.
• In particular the influencing nature of the father is noteworthy. In the
future we would recommend that any action plans to tackle
adolescent drinking behaviours should also be aimed at tackling
father’s well-being, attitudes towards and consumption of alcohol.

240. Q & A Session
14:40 – 15:00

241. Choice of Masterclass
Dr Thomas Babor
Or
Prof David H. Jernigan

242. Summation and Closing Remarks
Conference Chair: Prof Tom Collins

243. Thank You!