Chapter 3 FASD awareness and prevention

3.1                   Fetal Alcohol Spectrum Disorders (FASD) are caused by prenatal exposure to alcohol. Prevention can only be effected by a woman choosing not to drink while pregnant. However, there are a number of factors influencing this decision, ranging from lack of awareness to misinformation, lack of support or alcohol dependency.

3.2                   This chapter discusses first the current national guidelines on alcohol and pregnancy, and their emphasis on making the safest choice of total abstinence. Current obstacles to promoting abstinence as the safest choice are considered, such as the low level of awareness among health professionals, low public awareness, and lack of support services for women with alcohol dependence or misuse.

3.3                   The chapter examines the factors claimed to be contributing to increasing alcohol consumption and in particular risky and anti-social patterns of consumption. These factors include alcohol availability, pricing and promotion.

3.4                   The chapter concludes by discussing health warning labels on alcohol containers as part of a campaign to improve community awareness of the harms of alcohol and the effects of alcohol on fetal development.

Prevention through education and support

3.5                   As outlined in the previous chapter, there are a number of factors which may influence a women’s decision to consume alcohol while pregnant. The following sections consider the role of health professionals in educating women about the risks of FASD and the national health guidelines on drinking and pregnancy.

3.6                   Raising public awareness of the risk of FASD posed by even small levels of alcohol consumption is critical to prevention. Currently a number of myths persist regarding a ‘safe’ level of alcohol consumption and in some instances this misinformation is perpetuated by poor media reporting. Essential to raising public awareness and supporting the behavioural change of pregnant women is an attitudinal change across the wider community.

3.7                   While FASD is not confined to a particular population group, those women who drink more heavily and more regularly place the developing fetus at greater risk of FASD. In situations where physical or emotional dependency on alcohol is an issue, there may be need for specialised support services.

The role of health professionals

3.8                   The role of health professionals is critical in providing information for those who are pregnant or planning pregnancies. It is also important that clear and consistent advice is provided, particularly to counteract the prevalence of alcohol in Australian society and the low level of current public awareness of the risk of FASD.

3.9                   Most women planning a pregnancy or newly pregnant will consult their general practitioner to seek advice regarding the health of the developing fetus and on managing their health during the pregnancy.

3.10               One of the key recommendations that should be provided to women at this time is that not drinking alcohol is the safest option for the developing fetus.

3.11               This recommendation comes from the Australian Guidelines to Reduce Health Risks from Drinking Alcohol (the Guidelines) which are a series of best practice ‘non-mandatory rules, principles or recommendations’ issued by the National Health and Medical Research Council (NHMRC).[1]

3.12               The Guidelines are not specific to pregnancy, but provide clear advice as the safest option for a woman who is pregnancy or planning a pregnancy:

 GUIDELINE 4

Pregnancy and Breastfeeding

Maternal alcohol consumption can harm the developing fetus or breastfeeding baby.

• For women who are pregnant or planning a pregnancy, not drinking is the safest option.
• For women who are breastfeeding, not drinking is the safest option.[2]

3.13               However, this has not always been the advice provided in the Guidelines.

3.14               The first set of Guidelines, issued in 1987, did not provide any advice or recommendations in relation to the consumption of alcohol while pregnant. The second version of the Guidelines, issued in 1992, included advice not to drink when pregnant.

3.15               In 2001 the third version of the Guidelines changed this advice and specified a limit of no more than seven drinks in a week and no more than two standard drinks per day. This was based on what was described as limited available evidence whilst indicating that more high quality research was needed.[3]

3.16               The 2001 Guidelines were in place for eight years. Current levels of public awareness (discussed further in later sections) suggest that many parts of the community still consider ‘moderate’ amounts of alcohol consumption to not pose harm to the developing fetus.

3.17               The current Guidelines were issued in 2009 following an extensive review of the 2001 Guidelines including a substantial literature review, a public consultation and both national and international peer review.

3.18               It is likely that the successive changes in the Guidelines from 1987 to 1994, 2001 and 2009 have resulted in a low level of awareness amongst health professionals and members of the public, and some confusion as to the reasons leading to the changed advice.

3.19               Although there has been some criticism of this changed approach[4] and the recommendation that women should not consume any alcohol when pregnant, there is general support for the ‘safest option’ approach of the current Guidelines.[5]

3.20               While the risk to the fetus from heavy drinking is well known, the evidence of fetal effects from low or moderate consumption is less well understood. Commentators such as Dr Colleen O’Leary have noted that it is important that women are informed that not all pregnancies exposed to alcohol, including heavy levels of alcohol, will necessarily be harmed. However, as there is no established knowledge as to the degree of risk from different levels of exposure, and how this may vary during stages of fetal development, health professionals need to take a pragmatic approach when advising women about the risks of alcohol during pregnancy.[6]

3.21               The Winemakers’ Federation of Australia (WFA) informed the Committee about recent studies into alcohol consumption by pregnant women investigating the effects of drinking in moderation. The WFA reported that in their opinion the results indicate that there is no significant risk of harmful effects and they argued that this should direct future guidelines and advice to pregnant women.[7] Their view is that:

Given that the evidence against very low levels of consumption is unclear or non-existent, public health campaigns should avoid alarmist statements about the impact of low levels of alcohol on fetal development with the goal of scaring women into abstinence.[8]

3.22               Dr Bernie Towler agreed that the evidence currently available suggests that at low levels of consumption there is low risk, but added that the individual factors of the woman and her pregnancy need to be taken into consideration.

In the absence of evidence, we do not really know how it is going to be one on one. So it is really the safest message and it is not uncommon to take that kind of preventative and cautious approach.[9]

3.23               To this end, the Guidelines for reducing health risks from drinking alcohol now include a section with practical advice for health professionals that states:

• the risk to the foetus is higher with high alcohol intake, including episodic intoxication, and appears to be low with low level intake
• it is impossible to determine how maternal and foetal factors will alter risk in the individual.[10]

3.24               However, research indicates that a number health professionals are not even aware of the advice provided in the Guidelines and so are not providing this information to women. Professor Elizabeth Elliott, a member of the working party to revise the 2001 Guidelines, informed the Committee that the previous Guidelines were not well known by health professionals. Research indicated only 12 per cent of health professionals were able to identify the components of the Guidelines that related to pregnancy.[11]

3.25               Over the three years since the new Guidelines have been in place, research suggests many health professionals are not aware of the changes and do not necessarily endorse the Guidelines as best practice. Although the Guidelines are clear on the ‘no alcohol during pregnancy’ message, a recent evaluation of the promotion of the Guidelines reported a low level of awareness of the Guidelines, with messages considered ‘unrealistic and confusing’.[12]

3.26               The Committee received evidence that some doctors and midwives continue to tell pregnant woman that moderate drinking while pregnant is safe and should not be a concern.[13]

3.27               Despite this alarming and irresponsible lack of awareness of the current Guidelines amongst some health professionals, evidence suggests that the changed Guidelines may be assisting to influence the consumption patterns of pregnant women. The Longitudinal Study of Australian Children: Annual statistical report 2010 reported that alcohol consumption of mothers from a cohort that was subject to the less stringent Guidelines was higher than mothers from a cohort where the Guidelines recommended that women not drink alcohol during pregnancy (although the study found that further investigation was required).[14]

3.28               Alongside concerning evidence regarding a lack of knowledge of the Guidelines amongst some health professionals, substantial evidence was provided to the Committee that health professionals often lack the skills or do not consider it relevant to discuss alcohol consumption with a woman who is pregnant.

3.29               The Telethon Institute for Child Health Research (Telethon Institute) provided research which indicated that health professionals infrequently ask about alcohol use in pregnancy and most feel ill-equipped to advise women about alcohol use in pregnancy or its potential adverse effects.[15]

3.30               They reported that a 2007 survey in Western Australian found that only half the health professionals who cared for pregnant women routinely asked women about alcohol consumption in pregnancy and only 33 per cent routinely provided information to pregnant women about the effects of alcohol use in pregnancy.[16]

3.31               A 2011 poll conducted by the Foundation for Alcohol Research and Education (FARE) found that less than half (42 per cent) of pregnant or breastfeeding women who were surveyed could say that a health professional discussed the risks of alcohol consumption.[17]

3.32               Professor Elliott claimed that there is reluctance on the part of health professionals to ask about alcohol use in pregnancy or to provide advice on not drinking in pregnancy.[18]

3.33               The Australian Wine Research Institute cited research that attributes lack of effective screening of pregnant women to:

… inadequate knowledge and skills among health care providers, including obstetricians, general practitioners, midwives and nurses, reinforced by limited education and training in medical school and in general practice, lack of time, and system barriers such as lack of intervention tools, protocol, referral or treatment resources.[19]

3.34               The Australian National Preventive Health Agency (ANPHA) clarified that some health professionals believe that they lack the necessary skills and tools to identify women and families at risk and thus to provide the necessary advice, support and referrals to bring about early intervention.[20]

3.35               At the Royal Women’s Hospital in Melbourne, maternity intake processes usually include measures of alcohol consumption. Staff told the Committee that they try initially to develop a rapport with women in order to facilitate this discussion.[21]

3.36               Tools are available to assist health professionals discuss the issue of alcohol consumption with a woman during any stage of a pregnancy.

3.37               Representatives from Commonwealth Government Departments, including the Department of Health and Ageing and the Department of Families, Housing, Community Services and Indigenous Affairs, discussed the recently revised Alcohol and Pregnancy Lifescripts Kit. This is a resource to aid primary healthcare professionals interview patients and discuss issues health and pregnancy management issues. The Lifescripts kit is informed by the NHMRC Guidelines.[22]

3.38               The advantage of the Lifescripts is that it enables the general practitioner (GP) to openly raise alcohol consumption during pregnancy and to advise, refer and treat a pregnant woman. It also serves to help GPs identify a woman who may have been drinking excessively during pregnancy and who may need additional support.

3.39               Dr Raewyn Mutch from the Telethon Institute advised that it is important for GPs and Child Health Nurses to be equipped and capable of asking about lifestyle risk factors, such as alcohol consumption, as these are the professionals closest to the families.[23]

3.40               Further discussion on the role of health professionals in screening women for alcohol consumption during pregnancy is provided in the following chapter as part of diagnosis and management of FASD.

Raising public awareness

3.41               It is apparent that across the field of health professionals, there are a number of practitioners who lack up to date information, who spread misinformation or who are reluctant to raise the topic of alcohol consumption with women who are pregnant or planning to become pregnant.

3.42               This is a serious failing and is no doubt a major contributor to the lack of public awareness of the risks of FASD, and to the myths and the misinformation that currently exist across the wider community.

3.43               Research indicates that although the risk of birth defects is greatest with high and frequent maternal alcohol intake during the first trimester, alcohol exposure throughout pregnancy can have consequences for the development of the fetal brain.[24]

3.44               The National Rural Health Alliance (NRHA) contended that the social norms governing drinking alcohol in Australian society may mean that women continue to drink when pregnant without being aware of the consequences of alcohol exposure to the fetus.[25]

3.45               The WFA considers that as alcohol is an accepted part of Australian culture, women will need to make the choice to consume alcohol when pregnant based on the best available information.[26] 

3.46               The National Alliance for Action on Alcohol (NAAA) considered that the community needs to be better informed that maternal alcohol consumption can result in a spectrum of harms to the fetus.[27]

3.47               Janet Falconer from the Langton Centre regularly encounters a lack of awareness of the harm of alcohol in pregnancy compared to illicit drugs: ‘What alcohol does to an unborn child is not out there. [Alcohol] is almost put into a different category because it is legal.’[28]

3.48               A Telethon Institute study found that pregnant women had some level of knowledge about not drinking too much. They had little idea, however, of the impact of alcohol and how it actually affected a baby’s development in either the early stages when they do not know they are pregnant or throughout their pregnancy.[29]

3.49               Professor Elliott told the Committee that a survey of women found that they wanted a clear message; they wanted to be advised of the safest option not to drink in pregnancy:[30]

• 80 per cent agreed that pregnant women should not drink alcohol
  
  
• 99 per cent said information about the effects of alcohol on the fetus should be readily available
  
  
• 97 per cent said health professionals should ask women about their alcohol use in pregnancy and 97 per cent said they should provide advice about alcohol use in pregnancy
  
  
• 91 per cent said that health professionals should advise women who are pregnant or thinking of becoming pregnant to give up drinking alcohol.[31]

3.50               Despite the desire for a clear and consistent message regarding the risks of alcohol consumption during pregnancy, community perceptions of the risk seem to vary greatly. Figure 3.1 provides a sample of comments from an article on drinking in pregnancy featured on a popular Australian news site.

Figure 3.1 Online comments on news article    

Ø The No alcohol in pregnancy message has nothing to do with telling pregnant women what to do. It is all about telling them what is the safest choice for the optimum health and development of their unborn child. Patricia, Adelaide Jul 11, 2012, 01:34PM

Ø But the research shows that the occasional glass of wine doesn't cause any harm - so why should people abstain because popular opinion is in conflict with the evidence that scientific studies have produced? Claire, Jul 11, 2012, 02:44PM

Ø Ridiculous. Pregnant women had a glass of wine if they felt like it in the seventies and no-one got paranoid about it. They also ate soft cheese, seafood and processed meats and gave birth - usually naturally - to healthy and intelligent children. I know because I did it and watched those children arrive and grow up into their forties. These idiotic rules forced on pregnant women are meaningless and utterly unnecessary. R.Ross, Jul 11, 2012, 03:41PM

Ø As a registrar at a major hospital in Darwin I see the terrible results of pregnancy and drinking. FAS is no joke, does happen and leaves a massive burden on families and the tax community who inevitably pick up the bill. So how much alcohol is OK during pregnancy? -zero. Once again for the dull. How much alcohol is OK during pregnancy? - zero. Sean, Jul 11, 2012, 03:45PM

Source L Malone, ‘”I can't serve you. You're pregnant"’, The Canberra Times, 11 July 2012.

3.51               This confusion as to the recommended approach, and an understanding that this recommendation is based on the safest option rather than a risk level was highlighted by media reporting of a limited Danish study into the effects of low alcohol consumption in early pregnancy.[32]

3.52               Results of the Danish study were released during the course of this inquiry and the findings of that study were reported alongside media coverage of this FASD inquiry.

3.53               It was reported that the results of the study showed significant effects were not observable from low to moderate alcohol consumption during pregnancy on executive functioning of children at the age of five years.[33]

3.54               These results were ‘translated’ in some media coverage with headlines such as:

• The Truth about Women and Alcohol[34]
• Moderate Drinking in Early Pregnancy Branded ‘Safe’[35]
• A Little Alcohol while Pregnant may be OK?[36]
• Pregnant Women can Binge Drink Safely, says Research[37]

3.55               The media reporting bore little resemblance to the findings of the study and the claims made in some media reports did not equate with the limited findings of the research. Further, this reporting indicated little understanding of the approach of the NHMRC Guidelines which is to recommend the safest option based on current best practice research evidence.

3.56               Professor Jane Halliday spoke generally about some of the issues with research supporting alcohol consumption when pregnant:

Anyway, there are methodological problems in a lot of these studies, and they are all conflicting, so I think the story is still not fully told and there is a lot more research that needs to be done to try to address what are the true risks associated with low and moderate levels of drinking, which is what we are focused on.[38]

3.57               The National Health Service in the UK commented that:

Coverage in the [UK] media was confusing, potentially misleading and damaging. Several papers, such as the Metro and the Mail, claim that binge and heavy drinking during pregnancy is safe, while the BBC and the Telegraph report that low or moderate drinking does ‘no harm’ to the child. The claim made by the Express and the Mail that pregnant women can safely consume 12 alcoholic drinks a week is particularly worrying.[39]

3.58               Dr Mutch noted that the Danish study was misrepresented in the media.[40] Commenting on the damage caused by such inaccurate media reporting, Dr David Reeve noted the numbers of people who read the newspaper and will take such claims as reliable information.[41]

3.59               Similarly Professor Elliott commented on the serious consequences of misinformation, and how the Australian media have represented alcohol consumption during pregnancy:

We have to be very careful and the media has to be careful of these issues that are potentially harmful. If you've got someone who does drink during pregnancy they will be reassured with that sort of message and they’ll think, ‘Oh, that’s fine. I can keep going.’ One of the problems that women tell us is that they get mixed messages. They get messages that it’s okay, not okay, one drink can hurt them, binge drinking is the only thing that hurts them. What we are saying is that the safest option – as the National Health and Medical Research Council and Department of Health and Ageing propose in their guidelines — is that women avoid alcohol during the period of pregnancy and when planning a pregnancy.  

3.60               It is clear that community awareness of the risks of FASD is low and community understanding of abstinence as the safest option is low. Ensuring health professionals undertake a more educative role is key to improving the knowledge and awareness of pregnant women. Clear and consistent public awareness campaigns are required for women to understand the risks involved and make choices to change their behaviour and not consume alcohol when pregnant.

3.61               It is necessary for these public awareness campaigns to inform all women of the risks posed to the developing fetus by prenatal exposure to alcohol, and also to target particular populations of women who, due to their higher levels of alcohol consumption, are placing the developing fetus at higher risk. This includes young women in the 18 to 24 year group, including those in metropolitan, regional areas, and Indigenous women. 

3.62               In addition, there is a need to raise the awareness of the broader community about the risks of FASD and the safest approach advocated by the Guidelines.

Community and family engagement

3.63               There was substantial evidence indicating a significant need to educate men about the harmful effects of alcohol on a pregnancy and for men to take an active role in helping partners to prevent FASD in their baby.[42]

3.64               The Western Australian Network of Alcohol and other Drug Agencies (WANADA) asserted that men should be aware of the dangers of drinking in pregnancy, highlighting that it is important that families, partners and the community are aware of why a woman may decide not to drink, particularly if she is planning a pregnancy or if she is pregnant.[43]

3.65               The Tasmanian Department of Health and Human Services argued that ‘women who are pregnant find it difficult not to drink if they have partners and networks of friends where alcohol is at the centre of socialisation’.[44]

3.66               The NRHA stated that men have been ‘let off the hook’ for too long in the FASD story:

Their understanding, support and assistance can be very valuable in the prevention, identification and management of FASD. It is critical not to see FASD as a women‘s issue.[45]

3.67               The NRHA further added that assistance for women to stop drinking during pregnancy may include assistance with other issues affecting their wellbeing. Their partners may also need to be encouraged to be supportive, even if this means to stop drinking themselves.[46]

3.68               The Australian College of Children and Young People’s Nurses raised their concern that not enough is done with young men around early intervention strategies for drinking. They contend that young men as well as young women need to be targeted.[47]

3.69               The National Drug Research Institute reported that male partners can affect a woman’s choice to drink when pregnant. Their study showed that 75 per cent of women who drank during pregnancy usually drank with their partner, with 40 per cent noting that their partner usually initiated drinking occasions.[48]

3.70               FARE told the Committee that partners who drink can foster an environment where alcohol use is tolerated and encouraged. They shared research which showed that 30.5 per cent of women would stop or reduce their drinking if their partner also stopped drinking for the duration of the pregnancy and 38 per cent would drink less if their partner encouraged them to stop or cut back.[49]

3.71               Dr Rosalie Schultz argued that a fundamental change in attitude is needed where society can accept that it is normal and healthy for pregnant women to abstain from alcohol. She considers that this will be a considerable challenge given that alcohol is present at almost all social events. Dr Schultz stated:

While only women drinking alcohol leads directly to foetal alcohol spectrum disorder, men drinking alcohol contributes to women drinking alcohol. Therefore interventions leading to reduction in alcohol-consumption across society are needed.[50]

Voluntary alcohol restrictions in Indigenous communities

3.72               A number of Indigenous communities have voluntary alcohol restrictions in place in order to reduce the harms of alcohol in their communities. This may include violence and social dysfunction as a result of excessive drinking, and the high rates of FASD which have been recognised in some Indigenous communities.

3.73               A leading expert in alcohol consumption in Indigenous communities, Dr Maggie Brady, said that:

… somewhat ironically, and unlike mainstream Australia with its national antipathy towards any (even implied) interference with our enthusiastic consumption of grog, Aboriginal people in some regions have embraced prohibition.[51]

3.74               In Queensland, 19 Indigenous communities have alcohol management plans that restrict the type and quantity of alcohol allowed into the community to varying degrees. In addition, the Queensland Government has set up a scheme that allows households in designated communities to choose to be ‘dry places’. Once designated as a ‘dry place’, anyone who drinks or has any type of alcohol in the home will be breaking the law and could be fined up to $2 090. These communities include Cherbourg, Hope Vale, Doomadgee and Palm Island.[52]

3.75               However, the Queensland Government announced a review of the alcohol management plans in October this year, raising concerns about a return to previous high levels of alcohol-related violence.[53]

 

Figure 3.2 The Lililwan Project               

Marulu: the Lililwan project is an innovative and highly successful community-led strategy developed to address FASD and early life trauma in the Fitzroy Valley of Western Australia. The community recognised that FASD threatens the very existence of Aboriginal culture in the Fitzroy Valley—where traditions, stories, and ways of life are passed from one generation to the next through oral communication. The strategy is guided by the community’s need to heal the pain of past alcohol abuse, to preserve their local culture and to ensure a bright future for their children.

June Oscar, Lililwan Project Chief Investigator, said: ‘This whole process of initiating the Lililwan Project and developing the overarching Marulu strategy by our community is something the community has been discussing and planning over a number of years.’ The project has three components: diagnosis and prevention of FASD, support for parents and carers of children with FASD, and advocacy and awareness-raising about FASD.

In partnership with experts in Indigenous health, paediatric medicine, human rights advocacy and child protection, the Lililwan project represents Australia’s first ever prevalence study of FASD. The project noted that past attempts to document the prevalence of FASD have been hampered by under-recognition and under-reporting. The unique data derived from the project will enable the community to advocate for improved health care, and community and education services.

Ms Oscar described the development of the strategy: ‘It all came to a head in July 2007 when the women in our community decided that it was time we took a strong stance on the way in which alcohol was devastating the lives of many in our community. We focused on pursuing alcohol restrictions which gave respite to the community and in the months that followed the women made FASD a priority area that we wanted to address from the community.’

Ms Oscar said: ‘We sought out the assistance of government and our current partners. We noted that we cannot do this alone as a community and government cannot do it on its own. It needs a whole network of people and hence we have come up with a collaborative model of how to pursue this issue.’

In Bunaba, a local language of the Fitzroy Valley in Western Australia, Marulu means ‘precious, worth nurturing’, while in Kimberley Kriol, Lililwan means ‘all of the little ones’. The Lililwan project has been extremely successful in addressing FASD locally and has provided valuable lessons for the development of strategies to address FASD elsewhere in Australia. In addition, the project has received international recognition at the United Nations for its considerable achievements.

Source: http://www.georgeinstitute.org.au/marulu/our-story and Ms June Oscar, Chief Executive Officer, Marninwarntikura Women’s Resource Centre, Lililwan Project Chief Investigator, Committee Hansard¸ Canberra, 24 November 2011, p. 2.

 

3.76               In Fitzroy Crossing and Halls Creek in Western Australia, strong local women have led voluntary alcohol restrictions where responsible serving of alcohol is now being enforced. In these communities there has been a noticeable decline (between 20 and 40 per cent) in the number of alcohol-related crimes and alcohol-related admissions to hospitals.[54]

3.77               Since 1979, more than 100 Indigenous communities in the Northern Territory have used the restricted areas provisions under the Northern Territory Liquor Act 1978 to either ban or restrict the consumption and possession of alcohol in their communities.[55] Dr Brady noted that these provisions ‘vary according to local circumstances and expressed need’.[56]

3.78               Similarly to Queensland, the Chief Minister of the Northern Territory has suggested that alcohol bans could be lifted.[57] 

3.79               The Commonwealth Government has announced that, as part of the Stronger Futures in the Northern Territory initiative, minimum standards for Alcohol Management Plans will be introduced for all Indigenous communities in the Northern Territory. These standards are designed to help improve safety for Indigenous communities in the Northern Territory, and will support voluntary alcohol restrictions that are already in place. The Government is conducting consultations with Indigenous people and other stakeholders on these arrangements prior to the introduction of minimum standards.[58]

Specialised intervention and support services

3.80               Alcohol dependency, whatever the factors leading to this situation, poses particular problems in terms of supporting a woman not to drink during pregnancy. Where alcohol dependency exists, a woman is likely to have a history of regular and heavy alcohol consumption, which places the developing fetus at high risk of FASD.

3.81               In these instances, even awareness of the high risk may not be sufficient for a woman to cease or reduce her alcohol consumption. Specialised support and assistance is required.

3.82               Most hospitals that provide maternity services have some provision for women who drink heavily or use drugs. These services can often form a team of professionals that provide care and support for pregnant women with ongoing drug and alcohol issues.

3.83               The Committee visited the Women’s Alcohol and Drug Service at the Royal Women’s Hospital in Melbourne, which provides multi-disciplinary care for pregnant women with drug and alcohol issues and their infants.[59] The Committee also heard from the Chemical Use in Pregnancy Service which operates in the South East health region of New South Wales.

3.84               Research has found that illicit drug users generally tend to be truthful about their use when reporting in a research or clinical situation, however this is not necessarily the case when the drug user is pregnant. When pregnant illicit drug users were asked whether there had been recent illicit substance use only 2 per cent of the sample reported that they had, but 16 per cent tested positive in hair analyses.[60]

3.85               Neonatologist Dr Ju Lee Oei’s experience supports this research. She advised the Committee that ‘what we have also noticed in our work is that there is a reticence of admitting to alcohol or drug use, especially in the privately insured population’.[61]

3.86               Professor Elliott suggested that women not already known by community or social services to be drinking may slip through the net:

What we have not really explored is the number of people out in the general community who are not attached to [substance use] services who are drinking significant amounts and who potentially should be helped and who may be unaware of the potential harm that they are doing.[62]

3.87               WANADA stated that they saw a need for health professionals able to work with women who may find it difficult to give up alcohol during pregnancy:

… so that they are not turned away or forced to lie about their alcohol use but instead can be offered effective strategies to reduce their alcohol consumption during that time.[63]

3.88               Others raised concerns about mothers who continue to drink heavily through multiple pregnancies.  They may already have children diagnosed or suspected of having FASD and yet continue to drink during subsequent pregnancies.[64]

3.89               Professor Elliott explained that there was very little evidence to support what should be done when it is identified that a woman is drinking during pregnancy. She considers that more research is required to establish what services should be provided.[65]

3.90               The Public Health Association of Australia agreed that it is not as simple as just stopping drinking in all cases. They stated that if an individual has a serious drinking problem, that is a clinical issue which needs to be managed in the appropriate way. They highlighted the risk of harm to people through unsupported alcohol withdrawal.[66]

3.91               Many submitters to the inquiry suggested that brief interventions could be used where appropriate.[67] Interventions may take the form of voluntary residential care, alongside a range of therapeutic services and work across family and support networks to assist in changing behaviours and providing alternatives to the lifestyle of alcohol use. 

3.92               Such interventions would bring together drug and alcohol support services with maternity care providers to provide holistic approaches that optimise outcomes for the woman and the developing fetus. Many of these services are delivered by State programs, however it is essential that they are considered as part of an integrated national plan for FASD prevention.

Committee Comment

3.93               There is a perception amongst many in the community that low levels of alcohol consumption when pregnant do not pose a risk to the developing fetus. However, research has not established if there is any ‘safe’ level of alcohol consumption when pregnant. What is known is that even small amounts of alcohol have the potential to impact the healthy development of the fetus with lifetime consequences for the child.

3.94               The Guidelines are clear that the safest option for women is not to drink when pregnant or planning a pregnancy. The Committee is deeply concerned that this advice is not widely known, and the best practice approach of advocating the safest option is not widely understood.

3.95               Perhaps even more alarming is the low level of awareness of the Guidelines amongst health professionals and a lack of skills and training in discussing alcohol consumption with pregnant women. The Committee considers this a devastating failing in our health system.

3.96               The community relies on all types of health professionals to provide the most up to date and informed advice. Currently this is not being provided and the Committee recommends targeted training to ensure all health professionals are fully cognisant of the Guidelines and the risk posed by prenatal alcohol exposure.

3.97               FASD prevention starts with information. It is a simple message and health professionals play a vital role in advising and counselling pregnant women, and ensuring accurate information is provided to the community. The Committee recommends urgent action to ensure all health professionals fulfil this important role in regards to FASD prevention.

Recommendation 4

3.98

The Committee recommends that the Commonwealth Government work with the National Health and Medical Research Council and professional peak bodies to ensure that all health professionals are: fully aware of the National Health and Medical Research Council Guidelines that advise women not to drink while pregnant; have alcohol consumption impacts on pregnancy and the developing fetus incorporated into all general practice and midwifery training; trained in discussing the National Health and Medical Research Council Guidelines and alcohol consumption with women; and skilled in asking women about alcohol consumption and recognising and responding to women at risk. By 1 January 2014, all health professionals, including sexual health advisors, midwives, general practitioners and obstetric professionals should be promoting the consistent message that not drinking while pregnant is the safest option, in line with the National Health and Medical Research Council Guidelines.

3.99               The Committee recognises the need to collect data about women drinking while pregnant so consumption patterns may be identified, monitored and additional support or awareness programs can be targeted to where there is most need.

3.100           The Committee recommends that health professionals record the consumption of alcohol during pregnancy or at the time of birth for women who have not presented for prenatal care. This would inform future health planning and assist in FASD screening.

Recommendation 5
3.101	The Committee recommends that the Commonwealth Government establish mechanisms for health professionals to record women’s alcohol consumption during pregnancy, or at the time of birth for women who have not presented for prenatal care, and to ensure such information is recorded in midwives data collections or notifications across Australia.

3.102           Awareness of the risk posed by prenatal alcohol exposure can be radically improved by health professionals raising the issue with patients and providing clear advice in line with the NHMRC Guidelines. Knowledge about FASD needs to include both specialist medical advice and general public awareness.

3.103           FASD and the risks posed by prenatal alcohol exposure must become common knowledge. This must be achieved by widespread awareness initiatives run through media campaigns, health forums, pamphlets, posters and other forms of advertising.

3.104           The Committee commends the work of the Western Australian government in its series of advertisements encouraging women not to drink when pregnant, and encouraging friends and families to actively support this decision. However, more is needed nationwide to effect change. 

3.105           The lack of accurate information means women are not always able to make informed choices about their alcohol consumption, and may unknowingly be placing their child at risk. In addition, the lack of broader community knowledge can result in poor family and community support for women to stop drinking when pregnant.

3.106           Key to preventing FASD is raising community awareness of the Guidelines, and changing societal expectations so that it is the norm that women do not drink when pregnant or when planning a pregnancy.

3.107           It is the view of the Committee that partners, families and the community at large all play a role in ensuring that a pregnant woman is not placed in a position where she is coerced or made to feel that the only option available is to have a drink.

3.108           This social change will require a range of targeted nationwide campaigns that raise awareness across the community, not just among women. Specific campaigns should be developed to raise awareness in Indigenous communities and amongst youth who are more likely to engage in risky levels of alcohol consumption and be in situations where the social expectation is to engage in drinking alcohol.  

3.109           However, it is important that these awareness campaigns promote the message that FASD is a risk for the baby of any woman who drinks at any level while pregnant, and the risk of FASD is not confined to a particular population group or to particular levels of alcohol consumption.

Recommendation 6

3.110

The Committee recommends that the Commonwealth Government implement a general public awareness campaign which promotes not drinking alcohol when pregnant or when planning a pregnancy as the safest option, consistent with the National Health and Medical Research Council Guidelines. Specific awareness campaigns should be developed to target youth and Indigenous communities. Nationwide campaigns should be started no later than 1 July 2013.

3.111           As part of these nationwide awareness raising initiatives, the Committee concurs with the Western Australia parliamentary committee’s recommendation that the Guidelines regarding alcohol and pregnancy be printed on pregnancy testing and ovulation kits.[68]

3.112           Women who are planning a pregnancy or who consider they may be pregnant are likely to purchase pregnancy and ovulation testing kits. Requiring these products to display information about the risks of drinking while pregnant will assist in providing a targeted message to women who may become pregnant.

3.113           These labels should be consistent with information provided through the public awareness campaign and will enable women to receive clear advice about the risks posed by consuming alcohol.

Recommendation 7
3.114	The Committee recommends that the Commonwealth Government mandate a health advisory label advising women not to drink when pregnant or when planning a pregnancy to be included on the packaging of all pregnancy and ovulation testing kits. These labels should be in place by 1 October 2013.

3.115           The Committee acknowledges that high levels of alcohol consumption has been a feature of many Indigenous communities, and many of these communities have been proactive in taking steps to control the use of alcohol within communities. Some state and territory governments have introduced measures to assist Indigenous and other communities restrict the accessibility of alcohol.

3.116           However, recent moves in some states and territories have suggested the lifting of alcohol restrictions and abolishment of alcohol management plans.

3.117           The Committee considers that these community endorsed approaches are vital in changing patterns of consumption and creating a space where women, families and communities can make positive choices around their use of alcohol.

3.118           The Committee welcomes the recent announcement by the Commonwealth Government in regards to draft minimum standards for Alcohol Management Plans in the Northern Territory, and the consultation process being undertaken with Indigenous communities.[69]

3.119           FASD is disabling the children of many Indigenous communities. It is the role of Government to provide a concerted education program on the risks of prenatal alcohol exposure and, where an Indigenous community wishes to institute an alcohol management plan, to support this initiative.

3.120           The Committee urges state and territory governments to show leadership and acknowledge the self-determination and decision making capabilities of Indigenous communities who want restrictions on alcohol. Government should support these important measures as part of the national strategy to eliminate FASD which in turns supports a strong Indigenous people. 

Recommendation 8
3.121	The Committee recommends that the Commonwealth Government raise with the States and Territories the critical importance of strategies to assist Indigenous communities in managing issues of alcohol consumption and to assist community led initiatives to reduce high-risk consumption patterns and the impact of alcohol.

3.122           The Committee acknowledges that for some women not drinking when pregnant is difficult due to other life circumstances. These women will require specialised assistance and support.

3.123           The reasons why a woman in this situation may continue to drink, despite knowledge of the risks posed to the fetus, are rarely simple. It is critical that women are able to engage with the health system without fear or judgement.

3.124           The Committee considers that voluntary intervention and support services across remote, regional and metropolitan Australia are essential for women with alcohol dependency issues. Services must be culturally appropriate in their response to women and families, and able to provide a range of options to assist women manage their life circumstances and ensure the best health for the developing baby.

Recommendation 9
3.125	The Committee recommends that the Commonwealth Government work with State and Territory governments to identify and implement effective strategies for pregnant women with alcohol dependence or misuse.

Prevention through reforms of alcohol sales and labelling

3.126           FASD prevention and better support for those with FASD and their carers is the focus of the inquiry. However substantial evidence was received regarding the wider range of harms caused by alcohol. The changes in alcohol consumption patterns in Australia were often linked to changes in the accessibility and marketing of alcohol.

3.127           Michael Thorn from FARE told the Committee that the issue of managing the risky consumption of alcohol can be triangulated around price, availability and promotion.[70] Others stated that strategies for general alcohol harm reduction were critical to FASD prevention, and this required changes to the physical availability and price of alcohol.[71]

3.128           The following sections consider the pricing, availability, promotion and labelling of alcohol in Australia, and the contribution of these factors to social attitudes and behaviours around alcohol consumption.

Pricing and availability

3.129           There is a volume of research on the harms of the misuse of alcohol, the associated social and economic costs of these harms, and the effect of pricing on consumption patterns when combined with a culture of heavy drinking. 

3.130           Amongst the research providing detailed empirical evidence linking price changes to alcohol harm reduction is the 2009 World Health Organization (WHO) paper Evidence for the Effectiveness and Cost–effectiveness of Interventions to reduce Alcohol-related Harm which states that:

There is indisputable evidence that the price of alcohol matters. If the price of alcohol goes up, alcohol-related harm goes down. Younger drinkers are affected by price, and heavy drinkers are more affected than light drinkers; in fact, if a minimum price were established per gram of alcohol, light drinkers would hardly be affected at all.[72]

3.131           Further, many submitters to the inquiry provided evidence as to the benefits of price increases on reducing excessive drinking patterns and fostering a more informed and responsible attitude to alcohol consumption.

3.132           For example, the NAAA cited international scientific evidence which consistently shows that alcohol consumption and harm are influenced by price.[73]

3.133           Todd Harper from the NAAA stated that there is good modelling to suggest that a 10 per cent increase in pricing leads to a 5 per cent decrease in consumption.[74]

3.134           The Western Australia Drug and Alcohol Office referred to research that shows women are more likely to reduce their alcohol consumption due to price increases than men. This suggests that increasing the price of alcohol may be amongst effective measures for reducing drinking by pregnant women.[75]

3.135           Some submitters argued that price increases unfairly target responsible drinkers and do not impact on risky drinking behaviours. The WFA contend that the abuse of alcohol by high risk consumers does not change as price goes up. They suggested that while overall national alcohol consumption may decrease with price changes, those consumers who represent the high end users have an ‘inelastic demand’ for alcohol.[76]

3.136           Similarly, the Australian Hotels Association Western Australia (AHAWA) argued that pricing measures may punish the overwhelming majority of Australians who consume alcohol in a way which does not impose risks for themselves or others. They noted that increases in pricing may force some at-risk drinkers from the market but does not address the key issue at hand.[77]

3.137           These claims have been disputed by a number of independent studies and reports. For example Professor Ian Webster provided evidence from Canadian studies on the effectiveness of minimum pricing. These studies showed that the consumption of alcohol across all groups fell when the minimum price was increased, contradicting the position taken by the alcohol industry that those who are heavy drinkers are not affected by pricing policies.[78]

3.138           These results are consistent with those published by the WHO[79] and by research commissioned by FARE[80].

3.139           Recognising the impact of pricing, the Commonwealth Government has tasked ANPHA with developing the concept of a public interest case for a minimum (floor) price of alcohol, ‘to discourage harmful levels of consumption and promote safer consumption.’[81] The final report is due in December 2012.

3.140           Several submitters raised the need for reviewing approaches to pricing, and in particular questioned the current tax and excise regime and the alcohol pricing inequities it creates.

3.141           Currently, wine is subject to a tax while other forms of alcoholic beverages incur an excise. The tax on wine (known as the Wine Equalisation Tax) is calculated based on wholesale value. In contrast, in most instances excise is based on the proportion of alcohol content, and varies across beverage type. Beer is subject to a different excise calculation again.

2.1                   These variations result in cheaper wine attracting less tax and in some cases alcoholic beverages are cheaper than bottled water or milk. A number of submitters expressed concern at the impact of this pricing structure.[82]

2.2                   A volumetric approach to pricing alcohol would resolve these inequities, as outlined in the FARE commissioned report:

Alcohol taxation reform would improve the efficiency of the Australian taxation system and improve the resource allocation efficiency by removing current distortions in favour of cheap wine. AS recommended by the Henry Tax Review, this involves shifting all alcohol taxation to a volumetric basis. Importantly an increase in alcohol taxation would reduce consumption and the associated adverse externalities.[83]

3.142           The report also notes that:

Ideally, a full and comprehensive assessment of alcohol taxation reform needs to be multi-faceted and examine the benefits, costs and their distribution of each major component including:

• The reduction in direct externalities (i.e., direct harms to others);
• The reduction in indirect externalities including the cost of health harms to drinkers subsidised/paid for by others via Australia’s tax, welfare and health systems;
• The correction of private consumption decisions which are ill-informed, irrational or not based on the full incremental costs of the drinking decision;
• Changes in tax efficiency; and
• Changes in the efficiency of resource allocation, recognising the short-term disruption to business and suppliers.[84]

3.143           In addition to sale pricing reforms, several witnesses noted the increased number of alcohol retail outlets and the expansion of venues at which alcohol is sold. An increase in lower priced alcoholic beverages over the last few years has been accompanied by an increase in the sale points of alcohol. Many argued that it was not just the cheap acess of alcohol but the physical availability of alcohol which must be addressed as part of harm reduction strategies.[85]

3.144           The increased number of sale points for alcohol is caused to a large degree by the deregulation of liquor control laws.[86]

3.145           Liquor licensing laws and regulations in most states and territories have been relaxed over the past decade, due in part to the requirements of National Competition Policy.[87]  One result of this has been the increase in the number of new licensed premises in some jurisdictions. For example, the number of outlets in Victoria has increased from around 4 000 to 16 000 from 1986 to 2006.[88]

3.146           In addition, there has been an increase in the numbers of premises with extended trading hours, the numbers of licences to sell packaged liquor and an increased concentration of licences held by just a few businesses.[89]

3.147           The Alcohol and Other Drugs Council of Australia detailed the link between outlet density and the increase in violence and assaults.[90] Others proposed that the substantial and wide-ranging effects of liquor stores on alcohol-related harms may have been underestimated in the literature and by policy makers.[91]

3.148           The NAAA contend that there is a need for national guidelines on alcohol outlet density and opening hours. They consider there is a lack of cohesive policy guidance among liquor licensing agencies, planning departments and local government over the relationship between alcohol outlet density, opening hours and alcohol-related problems and on how this relationship should inform decision making.[92]

Promotion

3.149           A number of concerns were raised regarding the promotion of alcohol to younger people and the contribution of these strategies to the growing harms of alcohol and the risk of FASD.

3.150           The American Medical Association (AMA) has noted the changing communications landscape and the greater exposure to alcohol marketing that occurs across a range of technologies. They note that:

This is particularly true of young people who use digital technologies and are exposed to alcohol marketing on mobile phones, online video channels, interactive games, and social networks such as Facebook and Twitter. Marketing of alcohol is increasingly sophisticated and multidimensional, integrating online and offline promotions with the sponsorship of music and sporting events, the distribution of branded merchandise, and the proliferation of new alcoholic brands and flavours.

3.151           A number of submitters expressed concern at the marketing techniques being employed by some sectors of the alcohol industry.

3.152           For example, the NAAA referred to the range of products and promotions which are directly designed to appeal to young people.[93]

3.153           The McCusker Centre for Action on Alcohol and Youth (McCusker Centre) expressed apprehension about the growing range of alcohol products which appear to be designed, packaged and promoted specifically for young people and for young females in particular.[94]

They noted a range of promotions where the alcoholic beverage and the associated give-aways appear specifically targeted to teenage girls or young women:

… they taste sweet, they come in a range of bright colours and we have seen examples where lip gloss or nail polish are offered as gifts with purchase.[95]

3.154           As a peak body the AHAWA have adopted a strong position against what it considers to be irresponsible marketing promotions. They stated that retailers offering these types of promotions were in the minority, and emphasised that the AHAWA had raised with the Western Australian government instances where product marketing was inappropriate.[96]

Our very public, strong view is that alcohol is a product of adult choice. It is a drug. It is a drug of adult choice that needs to be regulated and sold responsibly. If we do not sell it responsibly and ensure that we do that in an effective manner, we will ultimately lose the right of the privilege to dispense and sell that product. So we need to take a commercial and responsible approach to it as well as a community and social approach.[97]

3.155           The advertising, marketing and promotion of alcohol are regulated by the Alcohol Beverages Advertising Code. This is a quasi-regulatory system for alcohol advertising whereby guidelines for advertising have been negotiated with government, consumer complaints are handled independently, but all costs are borne by industry.

3.156           It would appear this regulatory approach has not kept pace with the options for alcohol marketing across new technologies. This is concerning, given that marketing across new technologies and social media can target a younger audience.

3.157           In September 2012 the AMA conducted a national summit on alcohol marketing to young people. The AMA summit featured public health and non–government organisations, law enforcement bodies, youth associations and experts in alcohol and leading academics and researchers in the field.

3.158           The AMA summit recognised the emergence of new technologies and how these were being utilised in new forms of marketing techniques that may not be adequately covered by existing regulations. It concluded that there were significant issues with how alcohol is marketed to young people, across traditional advertising forms as well as newer digital technologies and social media. In relation to the regulatory approach to alcohol advertising, it found that:

The current policy regime is totally inadequate in protecting young people from continued exposure to alcohol marketing. Industry self-regulation is deeply ineffective and has failed. It is time for a robust regulatory response that is independently and impartially applied, and which carries the force of meaningful sanctions.[98]

3.159           A key outcome of the AMA summit was the recommendation for an analysis of alcohol advertising and promotion directed at children and teenagers. The Summit found that a comprehensive inquiry into the marketing and promotion of alcohol should:

• include a substantial focus on marketing techniques in digital platforms and in new and emerging social media, and the extent to which these platforms and media are targeted;
• include a focus on alcohol industry sponsorship of sporting and youth cultural and music events and alcohol promotion targeting tertiary education students; and
• use its powers to require leading alcohol companies and their communications agencies to table their annual expenditure, and to provide research and planning documents on alcohol promotion and marketing.[99]

Labelling

3.160           The issue of advisory or warning labels on alcoholic beverages was raised by a number of witnesses and the topic continues to attract media attention.[100] Industry advocates cited the success of the voluntary scheme currently in place and disputed the need for a mandatory approach to warning labels.

3.161           Others disputed this claim and provided detailed research on the importance of warning labels as a public education tool targeting not just FASD prevention, but a range of alcohol related health consequences.

Current voluntary labelling initiatives

3.162           In the 2011 review of food labels, Labelling Logic: Review of Food Labelling Law and Policy (2011) (the Blewett Report), four key recommendations were made to the Commonwealth Government concerning alcoholic beverage labelling and packaging. This included the following two recommendations:

• Recommendation 24: That generic alcohol warning messages be placed on alcohol labels but only as an element of a comprehensive multifaceted national campaign targeting the public health problems of alcohol in society.
• Recommendation 25: That a suitably worded warning message about the risks of consuming alcohol while pregnant be mandated on individual containers of alcoholic beverages and at the point of sale for unpackaged alcoholic beverages, as support for ongoing broader community education.[101]

3.163           The Legislative and Governance Forum on Food Regulation (the Forum), which comprises of Ministers from the Commonwealth, States and Territories and New Zealand, agreed that warnings about the risks of consuming alcohol while pregnant should be pursued.

3.164           The Forum noted the voluntary steps that industry had taken in this area and gave industry the opportunity to introduce appropriate labelling on a voluntary basis for a period of two years before deterring whether to regulate for this change.[102]

3.165           The voluntary labelling period commenced in late 2011 and is to last for two years. Some parts of the industry claimed a wide uptake of the labels. The Distilled Spirits Industry Council of Australia (DSICA) told the Committee that they were anticipating approximately 75 per cent of their members’ containers to be labelled by the end of 2013.[103]

3.166           However, an independent audit of the DrinkWise Australia warning labels has found that a full year after the voluntary initiative was launched, fewer than one in six (or 16 per cent) of alcohol products carry the consumer information messages.[104]

3.167           Currently there is a range of different symbols, advisory labels and warning labels that can appear on alcoholic beverages. There is no direction as to the size, colouring, positioning or prominence of the labels. These decisions are at the discretion of the manufacturer. The labels or icons appear on the beverage container itself and not on any associated packaging or promotional material or advertising of the beverage.

3.168           A number of the symbols and labels have been developed by DrinkWise Australia, a not-for-profit organisation which describes itself as being focused on promoting change towards a healthier and safer drinking culture in Australia. The alcohol producers who contribute to DrinkWise Australia account for approximately 80 per cent of all alcohol sales by volume in Australia.[105]

3.169           Some voluntary labels refer people to the DrinkWise Australia website which provides information on topics such as:

• Kids and Alcohol Don’t Mix;
• Is Your Drinking Harming Yourself or Others?; and
• It is Safest Not to Drink While Pregnant.[106]

3.170           The WFA, the Brewers Association of Australia and the DSICA indicated their support for the work of DrinkWise Australia and the voluntary approach to labelling.[107]

3.171           While supportive of warning labels on alcoholic beverages, most submitters to the inquiry were critical of the voluntary labelling scheme. Generally it was regarded as having a low uptake and featuring labels that were largely hidden from sight and designed for minimum exposure.  

3.172           The Department of Health and Human Services, Tasmania asserted that many academics and experts in the Public Health and alcohol and other drugs field consider these industry warnings weak in the messages they portray around alcohol.[108]

3.173           Even DrinkWise Australia refer to the labels as consumer information messages, rather than warnings. Further, the most commonly occurring DrinkWise Australia message is the innocuous and uninformative slogan ‘Get the facts—visit DrinkWise.org.au’.

3.174           A May 2012 research paper into alcohol warning labels provides a comprehensive review of responses to the DrinkWise Australia labelling from leading researchers across a range of fields. It provides an extensive analysis of the failings of the DrinkWise Australia labels and concludes that:

If alcohol warning labels are to have any chance of spurring positive changes in drinking behaviours, then the messages they convey need to be, firstly, arresting (similar to tobacco warning labels) and, secondly, varied reasonably frequently. It is debatable whether the DrinkWise Australia consumer information messages meet the first of these criteria.[109]

3.175           Similarly a FARE commissioned survey found the DrinkWise Australia labels to be lacking and the voluntary scheme to be ineffective. Participants in the survey were asked to select the best labels from DrinkWise Australia and FARE against a set of criteria including:

• noticeability;
• comprehensibility of the message;
• capacity to raise awareness and prompt conversations about alcohol-related harms; and
• impact on alcohol consumption.[110]

3.176           It was found most DrinkWise Australia messages have low visibility, with 98 per cent of the messages taking up less than 5 per cent of the label or face of the packaging.[111] The FARE developed labels were considered superior on all measures. Figures 3.3 and 3.4 provide examples of the labels from DrinkWise Australia and FARE.

Figure 3.3 DrinkWise Australia consumer information label

Source Foundation for Alcohol Research and Education, Alcohol Health Labelling: Community perceptions of the FARE and DrinkWise model alcohol labels, 2011, p. 11.

Figure 3.4 FARE health warning labels

Source Foundation for Alcohol Research and Education, Alcohol Health Labelling: Community perceptions of the FARE and DrinkWise model alcohol labels, 2011, p. 13.

3.177           FARE has criticised the format of the voluntary labels in use, claiming they ambiguous, contain a weak message, and are small in size and difficult to locate on the alcohol product. As the labels are voluntary, FARE notes there is no certainty that all alcohol producers will adopt these labels.[112]

Mandating health warnings

3.178           Various representatives from the alcohol industry claimed that there is no evidence to demonstrate that warning labels on alcohol beverages are effective. 

3.179           Gordon Broderick from DSICA stated that an extensive survey of the situation in America shows that labelling has raised awareness but has not made any impact on behaviour.[113]

3.180           The Wine Research Institute of Australia supported this by citing the results of studies undertaken after the introduction of alcohol warning labels in the US. These showed an increase in awareness of the label but did not show changed consumer behaviour particularly in ‘at risk’ groups.[114]

3.181           The WFA and the DSICA suggested that warning of the dangers associated with alcohol during pregnancy has the potential to alienate and worry women who may be at very low risk.[115] The WFA raised concerns that advisory labels such as those prepared by FARE could negatively impact on pregnant women and stated that:

There is also the possibility of some pregnancies ending in termination before actual harmful effects of alcohol have been adequately assessed. Some expectant mothers may be so concerned or in such a state of depression and guilt as to terminate the pregnancy based on their expectation that the foetus has been damaged.[116]

3.182           WFA’s claims of possible negative effects of warning labels resulting in terminations or pregnant women experiencing undue anxiety and guilt are based on anecdotal stories, and misrepresentation of some media commentary.[117] Further, graphic warnings indicating the harm caused by tobacco to the developing fetus have not ceased due to any claimed anxiety caused to pregnant women or claims of terminations due to fears caused by warnings.  

3.183           The DSICA expressed concern that labelling could go too far:

… if there were to be mandatory labelling, those people who oppose the industry would want to go down the tobacco road. The lettering would not be big enough; the wording would not be big enough; the pictures would not be horrific enough; and before we know it we would have our labels looking like a bottle of angostura bitters or a page out of the white telephone book.[118]

3.184           The Committee notes that each of these claims against mandated warning labels claims has been clearly refuted and substantial evidence cited to the contrary in FARE’s detailed paper ‘Booze before Babies—Analysis of alcohol industry submissions to the FASD inquiry’. The FARE paper cites international moves to regulate warning labels in Europe and acknowledgement by the United Kingdom Department of Health that ten years of self-regulation has not resulted in an effective labelling program.[119]

3.185           Alcohol industry advocates claim that warning labels are ineffective in changing behaviours. International and FARE research finds that the limited alcohol warnings of the type favoured by industry are indeed weak and ineffective.

3.186           Contrasting this, FARE cite substantial evidence confirming the effectiveness of warning regimes when that regime is based on best practice principles.[120] According to this research, health warning labels can create behaviour change and the labels should:

• be mandatory so the label appears on all products
• be applied consistently across all products so they are visible and recognisable
• be developed by health behaviour and public health experts
• include the text ‘HEALTH WARNING’
• involve rotating messages on a range of harms, including during pregnancy and
• be accompanied by a national public education campaign.[121]

3.187           Similarly, a wealth of research confirming the effectiveness of warning labels as part of an broader alcohol health campaign is reviewed in the Parliamentary library paper ‘Alcohol Warning Labels – do they work?’.[122]

3.188           The evidence reviewed in these papers is consistent with further evidence provided by a number of other submitters, and finds warning labels effective in raising awareness and changing consumption patterns.

3.189           The Uniting Church in Australia stated that a comprehensive review of the effects of alcohol warning labels concluded the use of warning labels did raise awareness.[123]

3.190           The McCusker Centre provided evidence that multiple expert groups have recommended health warning labelling of alcohol products with clear, specific messages as an important component within a wider strategy to raising awareness of the risks to health of alcohol consumption. Warning labels related to the risks of alcohol consumption during pregnancy have been specifically recommended as part of this approach.[124]

3.191           The Women’s Christian Temperance Union made the point that poisons are labelled and prescription drugs have leaflets explaining their effects and possible side effects. They stated that the public has the right to the latest information regarding alcohol and the health of a developing fetus.[125]

3.192           The AMA advocates that:

Alcohol products should have simple and clearly visible front-of-pack labels that warn of health risks of excessive consumption, and urge pregnant women not to consume alcohol.[126]

3.193           The Tasmanian Department of Health and Human Services considers that mandatory labelling of alcohol with generic health warnings and specific pregnancy warning messages is urgently needed. They believe that this will help to change the perceptions of the community about alcohol and ensure that alcohol is not considered an ‘ordinary’ household product.[127]

3.194           NAAA considers that it is not appropriate to leave policy development in this vital area to the alcohol industry. They advocate Government adopting the recommendations from the Blewett Report and the many other expert reports which support warning labels.[128]

3.195           Along with others, NAAA argues it is critical that any implementation of health warning labels is accompanied by a comprehensive public education campaign, using various forms of media to reinforce the messages of the health warning labels.[129]

Committee Comment

3.196           It is the view of this Committee, informed by experts and the response of the alcohol industry itself, that current regulation and voluntary programs regarding alcohol labelling are not functioning effectively and are unlikely to ever do so given the commercial realities of the alcohol industry.

3.197           Consequently the Commonwealth Government must mandate greater controls to ensure responsible attitudes to alcohol labelling and sales, and mechanisms to reduce the easy access to alcohol that promotes harmful levels of drinking.

3.198           In particular, the issue of warning labels on alcoholic beverages advising women not to drink while pregnant was a contentious one through the inquiry.

3.199           The Committee was frustrated by some within the alcohol industry. While claiming to support responsible marketing and sales of alcohol, some industry advocates provided widely inflammatory and unfounded claims to the Committee.

3.200           The Committee considers that Australians have a right to be fully informed around the impact of choices they make to consume alcohol and it is the role of governments to employ a range of mechanisms to ensure public health messages are widely disseminated.

3.201           Research indicates a low level of public awareness regarding the risks posed by prenatal exposure to alcohol. Providing warnings on alcohol products is an essential step in raising awareness amongst women, and fostering community support for women’s decision to not drink while pregnant.

3.202           While some parts of the alcohol industry claim to support labels advising women not to drink while pregnant, the Committee notes that large sectors of the industry have not adopted the voluntary labelling scheme. Furthermore, in many instances where a warning icon is present on the label, the icon is small, in faint colours, and placed in the least visible part of a label. Some labels took up less than 0.1 per cent of the container’s surface area.

3.203           The Committee disputes wild claims made by some in the alcohol industry about early terminations due to women’s fears of having consumed alcohol while pregnant. There is no credible evidence to support such claims.

3.204           Conversely, there is a volume of credible evidence to indicate that health warnings on alcohol containers are effective as part of a wider strategy to raise awareness and enable people to make informed choices around their consumption patterns.

3.205           Recognising the range of harms that can be attributed to alcohol, the Committee recommends that a comprehensive warming label regime reflect this range of harms. FASD disabling babies is just one serious consequence of irresponsible alcohol consumption. In addition, there are a range of other health consequences and social harms which may be attributed to alcohol and patterns of alcohol consumption. Further, best practice research indicates that a rotating range of health warnings are more effective in raising awareness.

3.206           The Committee recommends that the appropriate format and design of health warning labels be determined by 1 March 2013. This will enable the alcohol industry to be fully prepared for the implementation of mandated health warning labels by 1 January 2014. The introduction of the labelling scheme should be accompanied by a comprehensive public awareness campaign.

Recommendation 10

The Committee recommends that the Commonwealth Government seek to include health warning labels for alcoholic beverages, including a warning label that advises women not to drink when pregnant or when planning a pregnancy, on the Legislative and Governance Forum on Food Regulation’s December agenda. The Commonwealth Government should determine the appropriate format and design of the labels by 1 March 2013, to assist the alcohol industry in adopting best practice principles and preparing for mandatory implementation.

Recommendation 11

3.207

The Committee recommends that the Commonwealth Government mandate the range of health warning labels for alcoholic beverages as decided by the Legislative and Governance Forum on Food Regulation. The warning labels should consist of text and a symbol and should be required to be displayed on all alcohol products, advertising and packaging by 1 January 2014; The minimum size, position and content of all health warning labels should be regulated; and The introduction of mandated warning labels should be accompanied by a comprehensive public awareness campaign.

3.208           Anecdotal evidence was received regarding trends to mix high caffeine drinks with alcohol, sales of alcohol to under-age drinkers and service of alcohol to intoxicated customers. The range of harms caused across the community from binge drinking amongst young people and other forms irresponsible alcohol consumption is concerning and must be addressed.

3.209           A review of regimes around the availability, pricing and promotion of alcohol is essential to reduce the wider harms of alcohol as well as to eliminate FASD in Australia.

3.210           A more comprehensive review of this nature is beyond the capacity of this Committee and the scope of the inquiry terms of reference. While actions to eliminate FASD in our population must commence immediately, studies on broader alcohol reform are needed and appropriate regulatory responses developed.

3.211           It is the clear view of this Committee that widespread reforms are required to address the harms of irresponsible alcohol consumption and that these reforms are best achieved through public information accompanied by appropriate controls on alcohol pricing, availability and marketing.

3.212           Accordingly, the Committee recommends that two independent studies are commissioned by the Commonwealth Government, and that the findings of these studies are used to inform a National Alcohol Sales Reform Plan.

3.213           The first study should consider how the availability and pricing of alcohol is contributing to changes in alcohol consumption patterns across different sectors of the population and in different regions. The Committee notes that ANPHA is reporting on a minimum pricing of alcohol, and the study should take this work into account.

3.214           The second study should consider marketing strategies for alcohol. The Committee is concerned that changes in technology may be enabling forms of alcohol advertising and promotion that are not addressed by existing regulations. The Committee recommends a study into current alcohol marketing strategies, with a focus on the marketing of alcohol to young people through the use of new technologies.

3.215           In addition, this study should focus and the relationships and impact of linking on the sport sponsorship and success with alcohol consumption.

3.216           These two studies should provide the platform for the Commonwealth Government to develop a National Alcohol Sales Reform Plan. These reforms, while part of a broader plan to reduce harms of alcohol, will form a critical element in the national FASD prevention strategy.

Recommendation 12
3.217	The Committee recommends that the Commonwealth Government commission an independent study into the impacts of the pricing and availability of alcohol and the influence of these factors in the changing patterns of alcohol consumption across age groups and gender. The study should be completed by 1 October 2013.

Recommendation 13

3.218

The Committee recommends that the Commonwealth Government commission an independent study into the impacts and appropriateness of current alcohol marketing strategies directed to young people. The study should have regard to these strategies and the volume and frequency of alcohol consumption amongst young people, the links being made between alcohol and sport, the efficacy of efforts to promote responsible drinking behaviours, and the adequacy of current regulations to respond to marketing through digital platforms such as the internet, social media and smartphones. The study should be completed by 1 October 2013.

Recommendation 14
3.219	The Committee recommends that, following the completion of the study into the pricing and availability of alcohol and the study into alcohol marketing strategies, the Commonwealth Government develop a National Alcohol Sales Reform Plan aimed at reducing the harms caused by irresponsible alcohol consumption across Australia.