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  1. TITLE Exploring the social and cultural contexts of risky drinking among young Australians: Implications for primary health providers KEYWORDS Alcohol, risky drinking, binge drinking, young people, primary care CONFLICT OF INTEREST None WORD COUNT 2800 (excluding abstract, figures and references) 1

  2. ABSTRACT Background: Rates of risky drinking among young Australians have increased substantially over the past two decades, resulting in significant community concern. Objective: To explore the social, cultural and economic contexts that underlie risky drinking among young people, as well as identify implications for primary health providers. 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. 2

  3. There is considerable community concern relating to risky or ‘binge’ drinking1 among young Australians. Research demonstrates that adolescents are starting to consume alcohol at a younger age (1) and rates of risky drinking among young people have increased substantially over the past two decades (2). Particularly concerning is that almost one in four young people aged 14-19 report consuming alcohol at levels associated with short-term harm on a monthly or weekly basis (3), and over 40% of 16-24 year olds 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; sexual risk-taking and violence (5). 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). A number of key drivers in the way that young people consume alcohol are discussed below. Changing Life Trajectories and Increased Emphasis on Leisure Alcohol has become an important component of young people’s contemporary leisure lifestyles. Over the past three decades, a number of social, cultural and economic changes have influenced the way that young people transition through adolescence to young adulthood. Firstly, family structures have changed significantly during the last century. Today, people stay in the family home for longer, and get married and have children later. 1We prefer the term risky drinking to binge drinking. Binge drinking is a term that is widely criticised for being emotive and definitively unclear. In recognition of this issue, the Australian National Health and Medical Research Council changed their terminology from binge drinking to risky drinking in 2009, when referring to single sessions of heavy drinking. 3

  4. Secondly, 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. As a consequence, young people experience a longer period of independence, often with high levels of disposable income (8). It has been argued that these changes result in young people experiencing an ‘extended adolescence’ (9). Thirdly, young people are part of a new generation. 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). These lifestyle changes have resulted in young people placing more emphasis on leisure and pleasure. Today, there is a greater emphasis on achieving a work/life balance, and, with fewer responsibilities and financial constraints (such as mortgages and families), young people have more disposable income to spend on alcohol (10). 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 (11). 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 (11). An Australian study (12) 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 re-living 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 4

  5. In recent years, women’s participation in the workforce has increased and the gap in the earning power of men and women has decreased (13). 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 UK research (14) 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 sex (15). 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 (16). 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 (16, 17). A second example of innovative alcohol marketing is the introduction of pre-mixed 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 fifteen years (16). The promotion of ‘shots’ or ‘shooters’ is another method employed by the alcohol market to encourage and support a culture of risky drinking (16). 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). 5

  6. The alcohol industry has also redesigned the physical space of licensed venues to maximise capacity and attract more young consumers. The night-time 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 (16). 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 licenses 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 two decades through a proliferation of alcohol outlets (18). 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, highlights the importance of delivering both preventative 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 colleagues (19) have suggested that such approaches should focus on (i) delaying the age of onset of experimentation; (ii) reducing the number of young people who progress to regular or problem use; and (iii) 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 (see 19), there are a number of key strategies that can be delivered by practitioners within primary care settings. Prevention Responding to evidence that young people who drink frequently during adolescence are at most risk of developing alcohol use disorders in early adulthood (20), as well as concerns that the developing brain may be more vulnerable to the effects of alcohol during adolescence (21), Australia’s National Health and Medical Research Council (NHMRC) 6

  7. recently recommended that not drinking alcohol is “especially important” for young people aged under 15 and that the safest option for those aged 15-17 is to delay alcohol initiation as long as possible (22). 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 (23). GPs 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 include parental modelling, disapproval of adolescent drinking, limiting availability of alcohol, general discipline, parental monitoring, improving parent-child relationship quality, parental support and general communication (23). Screening and Brief Intervention GPs 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, or 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 between 16 and 24 reported harmful use of alcohol (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 (24). Barriers to young people seeking treatment from their GP include cost, communication, compassion, confidentiality, inconvenience, fear, anxiety, shame and limited knowledge about the help that GPs can provide (25). 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) (26 - http://www.smartrecoveryaustralia.com.au/HealthProviderAUDIT.pdf), consisting of twelve questions that can be delivered in less than five 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 five-minute counselling session with the 7

  8. 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 (17). 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 kind. GPs 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 (see 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). Insert Table 1 about here 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. Another, more non-traditional role that could be played by GPs is the provision of alcohol- related health information within schools. Research has identified the need for GPs to be involved in more outreach programs that provide young people with information about the type of health care that GPs can deliver, and when it is appropriate to seek help. Such approaches might be effective in creating a sense of hope about the help that GPs can offer 8

  9. and also provide an opportunity for GPs to initiate relationships with young people that are distinct from parental or teacher/student relationships. A national program called ‘GPs in Schools’ operates across Australia, the major aim of whichis “to take the ‘face’ of general practice, into young people’s school environmentswhere GPs can be presented as friendly, non-threatening, non-judgemental, caring, and understanding” (25). Advocacy Given that young people attend primary care in small numbers, it is important for GPs to view their role not only as a health provider, but also as a health advocate, and 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 as young people are 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 providers can lobby for restrictions on the sale and supply of alcohol through peak bodies such as the Australian Medical Association (AMA) and the National Alliance for Action on Alcohol (NAAA), as well as developing an agenda for addressing alcohol-related harm within their local community (e.g. limiting new alcohol licenses). As explored in this paper, 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). GPs 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. 9

  10. 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 (19). 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 public health advocates, using their position as respected health experts to encourage a shift in alcohol policy, legislation, marketing and education. SUMMARY OF IMPORTANT POINTS Rates of risky drinking among young people have increased substantially over the past two 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 consumerism. 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. 10

  11. USEFUL RESOURCES FOR PATIENTS http://www.parentingstrategies.net provides practical parenting guidelines and a tailored web-based intervention to help parents delay or reduce their child's alcohol use. http://www.mhfa.com.au provides information about Mental Health First Aid, including guidelines on Helping Someone with Problem Drinking. http://www.somazone.com.au/ provides confidential advice and information for young people about drugs, sex, mental health, body image and relationships. http://au.reachout.com/ provides young people with the information, help, support, advice and connections they need to manage a range of issues including alcohol and other drug problems. http://www.counsellingonline.org.au provides confidential online counselling to people who might be unable to attend treatment, might be reluctant to access face-to-face counselling or who may find online counselling more suitable for them. http://www.ysas.org.au and http://www.turningpoint.org.au provide alcohol-specific treatment in Victoria, including counselling, medical services, detoxification services and outreach services. USEFUL RESOURCES FOR HEALTH PROFESSIONALS http://www.dacas.org.au is a specialist telephone consultancy services for health professionals that is provided by professional counsellors from Turning Point Alcohol and Drug Centre and addiction medicine specialists. 11

  12. TABLE 1: Practical tips for low-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 pre-packaged containers. Keep count of the number of standard drinks you consume. Drink beverages with lower alcohol content (i.e. light beer instead of full-strength beer). Never top up a drink before you have finished – as 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 non-alcoholic 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. *Adapted from Mental Health First Aid Guidelines: Helping someone with problem drinking (29). 12

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