Risky drinking among young Australians - PDF Document

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  1. Current issues in alcohol Risky drinking among young Australians Causes, effects and implications for GPs Amy Pennay Dan I Lubman Sarah MacLean There is considerable community concern relating to risky or ‘binge’ drinking among young Australians. Research demonstrates that adolescents are starting to consume alcohol at a younger age1 and that rates of risky drinking among young people have increased substantially over the past 2 decades.2 Particularly concerning is that almost one in 4 young people aged 14–19 years report consuming alcohol at levels associated with short term harm on a monthly or weekly basis,3 and over 40% of those aged 16–24 years report having consumed more than 20 standard drinks on a single occasion.4 Short term harms associated with risky drinking include alcohol overdose or poisoning; accidents such as road trauma, drowning and falls; blackouts and memory loss; and sexual risk taking and violence.5 Background Rates of risky drinking among young Australians have increased substantially over the past 2 decades, resulting in significant community concern. Objective To explore the social, cultural and economic contexts that underlie risky drinking among young people and the implications of these for general practitioners. Discussion Effective strategies for reducing alcohol related harm among young people must be developed in the context of the social and cultural forces to which risky drinking is inextricably linked. It is important that GPs not only play the role of health provider (by identifying risky drinking where possible and providing harm reduction advice), but also act as public health advocates, using their position as respected health experts to encourage a shift in alcohol policy, legislation, marketing and promotion. Social and cultural contexts of risky drinking Alcohol is deeply embedded in Australian culture, and as such, any discussion of risky drinking cannot occur without acknowledging the social, cultural and economic drivers of such practices. Alcohol plays a significant role in the social lives of Australians, and its historical roots can be traced back to colonisation.1 Experimentation with alcohol is a common feature of adolescent development, and there is even a popular view among some that excessive alcohol consumption is a necessary rite of passage for young people.6 Alcohol is used by young people for many of the same reasons that it is used by older age groups (relaxation, socialising and commiserating), but for young people drinking is also about experimentation – with altered states of consciousness, various aspects of adult lifestyle (including sexual behaviour) and identity exploration.7 Keywords: alcohol related disorders; youth; young adult; public health practice; general practice ‘Risky drinking’ versus ‘binge drinking’ in this article we choose to use the term ‘risky drinking’. Binge drinking is a term that is widely criticised for being emotive and definitively unclear. the term risky drinking also has some issues with varying definitions. the 2009 national health and medical Research council (nhmRc) Australian guidelines to reduce health 584Reprinted from AustRAliAn FAmily PhysiciAn Vol. 40, no. 8, AuGust 2011

  2. decreased.14 As young women’s social position changes, their drinking patterns have become more like those of young men. since 2002, the proportion of young women who engage in high risk drinking has increased more rapidly than the proportion of young men.4 Recent united Kingdom research15 shows that young women embody a ‘hyper sexualised’ femininity when drinking in licensed venues and use risky alcohol consumption as a way of managing both the increased visibility of sexualised behaviour and new ‘cultures of intoxication’. Research has also shown that of particular importance to young people is the sense of group identity and cohesion that occurs through drinking with people of the same gender.16 risks from drinking alcohol8 introduce the concept of progressively increasing risk of harm with the amount of alcohol consumed. Key drivers in the way that young people consume alcohol Changing life trajectories and increased emphasis on leisure over the past 3 decades, a number of social, cultural and economic changes have influenced the way that young people transition through adolescence to young adulthood. First, family structures have changed significantly during the past century. today, people stay in the family home for longer, and get married and have children later. second, young people are more likely to delay commitment to full time work. more young people are attending tertiary education or are engaging in other activities, such as overseas travel, often with high levels of disposable income.9 it has been argued that these changes result in young people experiencing an ‘extended adolescence’.10 third, the external influences on young people of this generation are different to previous generations. young Australians report lower levels of religious affiliation than previous generations, and are raised by ‘baby boomers’, who are less authoritarian than the generation before them.1 young people place more emphasis on leisure and pleasure and alcohol has become an important component of this. they are more focused on achieving a work-life balance, and as they have fewer responsibilities and financial constraints (such as mortgages and families), they have more disposable income to spend on alcohol.11 Consumer culture young people operate in a contemporary consumer culture in which alcohol is a highly commodified product. the alcohol industry is responsible for a range of practices that encourage young people to drink more and in a heavy episodic fashion. the alcohol industry has developed sophisticated alcohol marketing campaigns designed to appeal to certain demographics and lifestyle choices. one example of innovative alcohol marketing has been the development of ‘alcopops’, which have several carefully considered advantages to young people. these include their palatability to the younger drinker, their convenient packaging (screw tops), easy portability and their high alcohol content.17 Alcopops are often labelled with tantalising brand names, bright colours, use provocative imagery and are combined with popular beverages such as energy drinks, furthering their appeal.17,18 A second example of innovative alcohol marketing is the introduction of premixed drinks with a higher alcohol content that are marketed as ‘designer’ drinks. it has been suggested that the strength of alcohol products has increased up to 50% over the previous 15 years.17 the promotion of ‘shots’ or ‘shooters’ is another method employed to encourage and support a culture of risky drinking.17 in addition, by sponsoring many sporting events, as well as music festivals and concerts, alcohol companies have been able to create a strong association between alcohol and popular leisure pastimes.6 the alcohol industry has also redesigned the physical space of licensed venues to maximise capacity and attract more young consumers. the night scene is no longer clearly separated into traditional drinking spaces such as pubs and nightclubs. instead, a growing bar scene has emerged that includes café bars, dance bars and themed bars catered to different demographics, thereby offering drinking opportunities to diverse social groupings of young people.17 Finally, the alcohol industry has effectively lobbied for the liberalisation of alcohol licensing, which has resulted in many bars and clubs (as well as bottle shops) applying for licences to stay open for longer, in some cases 24 hours. As such, alcohol has become increasingly accessible and available to young people over the past 2 decades through a proliferation of alcohol outlets.19 Sociability and belonging Alcohol plays an important role in the social world of young people. Alcohol is most often consumed by young people in social contexts, and is commonly used to enhance social occasions. Alcohol enhances opportunities for socialising by reducing inhibition, increasing confidence and facilitating conversation and humour. Alcohol has also been noted to facilitate group inclusion and belonging, which is particularly important for young people.12 Alcohol has symbolic power by marking the boundaries of inclusion and group membership. indeed, social conformity has been found to be one of the primary drivers of young people’s alcohol use.12 An Australian study13 demonstrated that opportunities for socialising created by alcohol include drinking before a particular event, during the event, as well as creating further social opportunities after the occasion (in the form of discussing the event and reliving memorable moments). thus, alcohol is a key resource to achieve social competence, acceptance and belonging among young people, and not drinking, and/or refusing to engage in similar practices of drinking among friends is associated with social exclusion within some social circles. Alcohol and gender in recent years, women’s participation in the workforce has increased and the gap in the earning power of men and women has Reprinted from AustRAliAn FAmily PhysiciAn Vol. 40, no. 6, july 2011585

  3. Risky drinking among young Australians – causes, effects and implications for GPs FOCUS Strategies for addressing risky drinking the high rate of risky drinking among young Australians, as well as evidence of developmental harm as a result of adolescent drinking,5 highlights the importance of delivering both preventive and early intervention approaches within health settings. such approaches need to be developed with an understanding of the strong social and cultural forces that shape risky drinking practices. lubman and colleagues20 have suggested that such approaches should focus on: • delaying the age of onset of experimentation • reducing the number of young people who progress to regular or problem use, and • encouraging current users to minimise or reduce risky patterns of use. While this requires a multifaceted whole-of-government approach, incorporating a range of strategies (universal, indicated and targeted interventions) throughout childhood and adolescence,21 there are a number of key strategies that can be delivered by practitioners within the primary care setting. (the most common substance use disorder), only 7% of males and 18% of females with a 12 month substance use disorder accessed any type of treatment over the past year.23 Barriers to young people seeking treatment from their GP include24: • cost and inconvenience • concerns about communication and compassion • concerns about confidentiality • fear, anxiety and shame, and • limited knowledge about the help that GPs can provide. As young people are unlikely to present to their GP with alcohol related problems, screening should be offered opportunistically whenever they present for other general ailments. the most widely used screening tool is the Alcohol use Disorders identification test (AuDit)25 (see Resources), which consists of 12 questions that can be delivered in less than 5 minutes (or in the waiting room). if the young person screens positive for risky drinking, then a brief intervention should be conducted. Brief interventions essentially involve a 5 minute counselling session with the young person about their current drinking patterns, the prevalence of risk behaviours, the risks and harms associated with risky alcohol consumption and the provision of alcohol related information. such approaches have been found to be effective when delivered to young people within primary care settings.26 in particular, discussing previous experiences of behaving in a regrettable way (or the experiences of friends who have behaved in a regrettable way) when inebriated is a useful starting point. While screening and brief intervention are important strategies in addressing risky drinking, such approaches often do not address the social and cultural influences that underpin such behaviour. As such, GPs are likely to face substantial barriers when attempting to deliver interventions of this type. General practitioners should therefore consider offering advice to young people that resonate with their personal experiences, particularly around the social conformity issues associated with drinking, as well as gender specific information. For example, GPs should avoid abstinence focused messages that do not correlate with the experiences of young people and should instead consider providing practical tips to young people to promote drinking in safer ways (Table 1). Given the social aspect of drinking, young people should also be encouraged to share these practical tips with peers whose drinking they are concerned about (as well as support them to get professional help), or in an attempt to reduce risky drinking practices as a group.27 in addition to these low risk drinking tips, GPs should provide alcohol related information that is likely to resonate with young people. For example, young people are unlikely to be concerned about liver cirrhosis or alcohol poisoning. more resonant messages for women might include information about the high calorie content in alcoholic beverages or the link between drinking (and smoking) and developing wrinkles. For men, a discussion of the role that alcohol plays in sexual dysfunction might be particularly salient. Prevention Responding to evidence that young people who drink frequently during adolescence are at most risk of developing alcohol use disorders in early adulthood,21 as well as concerns that the developing brain may be more vulnerable to the effects of alcohol during adolescence,5 the nhmRc recently recommended that not drinking alcohol is ‘especially important’ for young people aged under 15 years and that the safest option for those aged 15–17 years is to delay alcohol initiation as long as possible.8 Engaging parents in a discussion about alcohol is central to implementing such recommendations, and builds on a strong evidence base highlighting the critical influence that parents have on adolescent patterns of drinking, particularly before alcohol use commences.22 General practitioners are ideally placed to raise the topic of alcohol with parents of both preteens and adolescents, and to suggest parenting strategies that have been shown to delay the onset of adolescent drinking or reduce risky drinking among young people. Parenting strategies that can be used to reduce their adolescent’s alcohol consumption include22: • parental modelling • disapproval of adolescent drinking • limiting availability of alcohol • general discipline • parental monitoring • improving parent-child relationship quality, parental support and general communication. Screening and brief intervention General practitioners can play an important role in reducing risky drinking through the routine screening of drinking practices and the provision of brief interventions. however, many young people do not seek treatment, or may delay seeking treatment, and very few young people view GPs as a source of help for alcohol and other drug problems. While the 2007 national survey of mental health and Wellbeing revealed that around 9% of Australians aged 16–24 years reported harmful use of alcohol Outreach and advocacy Given that young people attend primary care in small numbers, it is important for GPs to view their potential role not only as a health provider 586Reprinted from AustRAliAn FAmily PhysiciAn Vol. 40, no. 8, AuGust 2011

  4. Risky drinking among young Australians – causes, effects and implications for GPs FOCUS providers can lobby for restrictions on the sale and supply of alcohol through peak bodies such as the Australian medical Association (AmA) (see Resources) and the national Alliance for Action on Alcohol (nAAA) (see Resources), as well as developing an agenda for addressing alcohol related harm within their local community (eg. limiting new alcohol licences). As explored in this article, the alcohol industry is responsible for sophisticated marketing strategies that target young people. in particular, alcohol is branded so that is appealing to young people, and is promoted at sporting and other popular leisure events. it is important that local, state and federal governments take a stand on alcohol related advertising. At the very least, they should be encouraged to label alcoholic drinks with messages about harms and safer consumption.6 General practitioners are ideally placed to lobby with other health professionals for changes in the marketing and promotion of alcohol in Australia to ensure we have a comprehensive approach to reducing risky drinking. Table 1. Practical tips for lower risk drinking Know how much alcohol is in a standard drink. Be wary of different sizes of glasses and different strengths of alcohol products Know how many standard drinks are in prepackaged containers Keep count of the number of standard drinks you consume Drink beverages with lower alcohol content (ie. light beer instead of full strength beer) Never top up a drink before you have finished – you will lose count of how many standard drinks you have had Always make sure you have food with alcohol Always make sure you drink water when consuming alcohol Make sure you alternate each alcoholic drink with a nonalcoholic drink such as water or softdrink Avoid getting into ‘rounds’ or ‘shouts’ and keeping up a quicker drinking pace than you are comfortable with Avoid playing drinking games Do not consume more than one drink at a time Always put down your drink between mouthfuls Avoid ‘skolling’ or ‘chugging’ your drink Conclusions and recommendations Effective strategies for reducing alcohol related harm among young people must be developed in the context of the social and cultural forces to which risky drinking is inextricably linked. For example, attempts at reducing alcohol related harm have not been as successful as attempts at reducing tobacco use because there has not been a comprehensive, all encompassing approach that includes mass media campaigns, education campaigns targeting parents, school based education, consistent and targeted treatment approaches and significant changes to marketing, price and other regulatory controls. instead, the alcohol industry has continued to influence the way that young people drink through promotion, marketing, availability, cost and access. thus, young people are faced with conflicting messages about the social acceptability of alcohol and given the many social and cultural influences on alcohol consumption, it is unsurprising that young people are engaging in risky drinking.20 it is therefore important that GPs not only play the role of health provider (by identifying risky drinking where possible and providing harm reduction advice), but also as public health advocates, using their position as respected health experts to encourage a shift in alcohol policy, legislation, marketing and education. Adapted from Mental health first aid guidelines: Helping someone with problem drinking29 within a practice, but also outside the practice as a health educator and advocate. Research has identified the helpful role that GPs can play in outreach programs that provide young people with information about the type of healthcare that GPs can deliver, and when it is appropriate to seek help.24 such approaches might be effective in creating a sense of hope about the help that GPs can offer and also provide an opportunity for GPs to initiate relationships with young people that are distinct from parental or teacher/student relationships. A program called ‘GPs in schools’ operates in new south Wales, the major aim of which is ‘to take the ‘face’ of general practice, into young people’s school environments where GPs can be presented as friendly, nonthreatening, nonjudgmental, caring, and understanding’.24 General practitioners are also encouraged to engage in a range of broader public health strategies to address the social and cultural influences of risky drinking. there are a number of alcohol policies that have been shown to significantly reduce levels of alcohol consumption and subsequently reduce alcohol related harm among young people. this includes limiting the availability of alcohol through restrictions on the hours and days of sale of licensed premises, as well as reducing outlet density (of both bottle shops and licensed venues). there is also good evidence that increasing the cost and taxation of alcohol products results in reduced consumption, especially in young people as they are particularly sensitive to the price of alcohol.28 Despite the strong evidence for these policies, they are currently not implemented in Australia for a range of political and economic reasons. health Summary of important points • Rates of risky drinking among young people have increased substantially over the past 2 decades. • Risky drinking practices are influenced by a range of social, cultural and economic factors, including changing family structures, the desire for social belonging, gender influences and consumer culture. • A comprehensive strategy for addressing risky drinking is needed, which includes prevention, early intervention and broader public health approaches. • GPs should routinely screen for risky drinking, but should also use their role as ‘health experts’ to engage in a range of advocacy activities. 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  5. Risky drinking among young Australians – causes, effects and implications for GPs FOCUS Resources for patients • Practical parenting guidelines and a tailored web based intervention to help parents delay or reduce their child’s alcohol use: www.parent- ingstrategies.net • Information about Mental Health First Aid, including guidelines on helping someone with Problem Drinking: www.mhfa.com.au • Confidential advice and information for young people about drugs, sex, mental health, body image and relationships: www.somazone. com.au • Information, help, support, advice and connections for young people on a range of issues including alcohol and other drug problems: http://au.reachout.com • Confidential online drug and alcohol counselling to people who may be unable to attend treatment, may be reluctant to access face-to- face counselling or who may find online counselling more suitable for them: www.counsellingonline.org.au • Alcohol specific treatment in Victoria, including counselling, medical services, detoxification services and outreach services: www.ysas. org.au and www.turningpoint.org.au. young people: exploring meaning and social context. health Educ Res 1997;12:311–22. national health and medical Research council. Australian guidelines to reduce health risks from drinking alcohol. canberra: nhmRc, commonwealth of Australia, 2009. Available at www.nhmrc.gov.au/_files_nhmrc/publica- tions/attachments/ds10-alcohol.pdf [Accessed 15 july 2011]. Wyn j, White R. Rethinking youth. st leonards, nsW: Allen & unwin, 1997. 10. Valentine G, skelton t, chambers D. cool places: an introduction to youth and youth cultures. in: skelton t, Valentine G, editors. cool places: geographies of youth cultures. london: Routledge; 1998. 11. Parker h. consumption beyond control: the centrality of heavy social drink- ing in the lifestyles of English youth. in: jarvinen m, Room R, editors. youth drinking cultures. Aldershot: Ashgate Publishing, 2007. 12. Percy A, Wilson j, mccartan c, mccrystal P. teenage drinking cultures. Belfast: Queen’s university, 2011. 13. Borlagdan j, Freeman t, Duvnjak A, lunnay B, Bywood P, Roche A. From ideal to reality: cultural contradictions and young people’s drinking. Adelaide: national centre for Education and training on Addiction, Flinders university, 2010. 14. hartnett R, thom B, herring R, Kelly m. Alcohol in transition: towards a model of young men’s drinking styles. j youth stud 2000;3:61–77. 15. mackiewicz A. Femininities and alcohol consumption: exploring the discur- sive constructions of female extreme drinkers (‘FEDs’). 37th Annual Alcohol Epidemiology symposium of the Kettil Bruun society; melbourne, Australia, April, 2011. 16. De crespigny c, Ask A, Vincent n. young women’s social drinking in context – pub style. A study of decision making and social drinking of young women in urban south Australia. contemp Drug Probl 1999;26:31–46. 17. measham F, Brain K. ‘Binge’ drinking, British alcohol policy and the new culture of intoxication. crime, media, culture: An international journal 2005;1:262–83. 18. Pennay A, lubman Di, miller P. combining energy drinks and alcohol: a recipe for trouble? Aust Fam Physician 2011;40:104–7. 19. livingston m, chikritzis t, Room R. changing the density of alcohol outlets to reduce alcohol-associated problems. Drug Alcohol Rev 2007;26:557–66. 20. lubman Di, hides l, yucel m, toumbourou jW. intervening early to reduce developmentally harmful substance use among youth populations. med j Aust 2007;187:s22–5. 21. Bonomo y, Bowes G, coffey c, carlin jB, Patton Gc. teenage drinking and the onset of alcohol dependence: a cohort study over seven years. Addiction 2004;99:1520–8. 22. Ryan sm, jorm AF, lubman Di. Parenting factors associated with reduced adolescent alcohol use: a systematic review of longitudinal studies. Aust n Z j Psychiatry 2010;44:774–7. 23. Reavley n, cvetkovski s, jorm AF, lubman Di. help-seeking for substance use, anxiety and affective disorders among young people: results from the 2007 Australian national survey of mental health and Wellbeing. Aust n Z j Psychiatry 2010;44:729–35. 24. Wilson cj, Fogarty K, editors. the GPs in schools Program: Building bridges to General Practice. youth in mind conference, national Alliance of General Practice; 2002; Brisbane, Australia. 25. saunders jB, Aasland oG, Babor tF, De la Fuente jR, Grant m. Development of the Alcohol use Disorders identification test (AuDit): Who collaborative Project on Early Detection of Persons with harmful Alcohol consumption-ii. Addiction 1993;88:791–804. 26. Bein th, miller WR, tonigan js. Brief interventions for alcohol problems: a review. Addiction 1993;88:315–36. 27. Kingston Ah, jorm Ah, Kitchener BA, et al. helping someone with problem drinking: mental health first aid guidelines – a Delphi expert consensus. melbourne: the mental health First Aid training and Research Program, orygen youth health Research centre, the university of melbourne, 2009. 28. chikritzhs t, Gray D, lyons Z, saggers s. Restrictions on the sale and supply of alcohol: evidence and outcomes. Perth: national Drug Research institute, curtin university of technology, 2007. 29. mental health First Aid. helping someone with problem drinking. melbourne: the mental health First Aid training and Research Program, orygen youth health Research centre, the university of melbourne, 2009. 8. 9. Resources for health professionals • Specialist telephone consultancy service provided by professional counsellors from turning Point Alcohol and Drug centre and addiction medicine specialists: www.dacas.org.au • The Alcohol Use Disorders Identification Test (AUDIT) is available at www.smartrecoveryaustralia.com.au/audit.html • Australian Medical Association: http://ama.com.au • National Alliance for Action on Alcohol (NAAA): www.vichealth.vic. gov.au/en/media-centre/media-Releases-by-topic/Alcohol-and-drugs/ new-national-Alliance-formed-to-reduce-harm-from-alcohol.aspx. Authors Amy Pennay BA(hons), is Research Fellow, turning Point and Drug centre, Eastern health and monash university, melbourne, Victoria. amy.pennay@turningpoint.org.au Dan i lubman Bsc(hons), mBchB, PhD, FRAnZcP, FAchAm, is Director and Professor of Addiction studies, turning Point Alcohol and Drug centre, Eastern health and monash university, melbourne, Victoria sarah maclean PhD, is Research Fellow, turning Point Alcohol and Drug centre, Eastern health and university of melbourne, melbourne, Victoria. conflict of interest: none declared. References 1. Roche A, Bywood P, Borlagdan j, et al. young people and alcohol: the role of cultural influences. Adelaide: national centre for Education and training on Addiction, Flinders university, 2007. 2. chikritzhs t, Pascal R. trends in youth alcohol consumption and related harms in Australian jurisdictions, 1990–2002. national Alcohol indicators Bulletin no. 6. Perth: national Drug Research institute, curtin university of technology, 2004. 3. Australian institute of health and Welfare. 2007 national Drug strategy household survey: detailed findings. Drug statistics series no. 22. cat. no. PhE 107. canberra: Australian institute of health and Welfare, 2008. 4. Victorian Drug and Alcohol Prevention council. 2009 Victorian youth Alcohol and Drug survey. Final Report. melbourne: Victorian Drug and Alcohol Prevention council for the Department of health, 2010. 5. lubman D, yucel m, hall WD. substance use and the adolescent brain: a toxic combination? j Psychopharmacol 2007;21:792–4. 6. Bonomo y. Adolescent alcohol problems: whose responsibility is it anyway? med j Aust 2005;183:430–2. 7. Pavis s, cunningham-Burley s, Amos A. Alcohol consumption and 588Reprinted from AustRAliAn FAmily PhysiciAn Vol. 40, no. 8, AuGust 2011