Evidence informing policy

Alcohol is more heavily advertised than the average product, resulting in widespread marketing that is impossible to avoid.^62,63 It is marketed and promoted in many settings, including across traditional channels such as broadcast, print and out-of-home media, at point of sale through price promotions and in-store placements, and at sporting and cultural events through sponsorship. Digital platforms have opened opportunities for alcohol companies to promote their products in a setting that is often described as ‘dark’ using highly targeted strategies. An Australian study examining the marketing tactics of harmful industries found that 97% of ads targeting users were considered “dark” to some degree. ‘Dark marketing’ can be defined as an advertisement which is solely visible to the intended target by the advertisers, are fleeting and are not published or trackable on the accounts of advertisers.⁶⁴

Many alcohol ads use themes that appeal to young people, such as humour and friendship, and many young Australians are regularly exposed to multiple forms of alcohol advertising in their daily lives.^65,66 For instance, half of all alcohol advertising on Australian television appears during children’s popular viewing times, which are not limited to times when child classification programs are broadcast. Alcohol advertising is also broadcast during televised sport programs on a weekend or public holiday and during live sport, meaning children are exposed to as much alcohol advertising as adults when viewing televised sport. ^67,68,69 Large numbers of children and young people are also exposed to alcohol marketing when attending or participating in live sport through alcohol sponsorship. Evidence shows that alcohol sponsorship of sport is linked to alcohol use and creates a positive association between sport and the alcohol brand.^70,71

Extensive research indicates that being exposed to and engaging with alcohol marketing has the propensity to influence beliefs, norms, consumption patterns and hazardous drinking, particularly among young people.⁷² Most investigations have been of incomplete restrictions on marketing, for example, an advertisement ban on television or another individual platform enabling the transfer of promotions to other channels. In this instance, the efficacy of restriction measures is impacted. Although, considering the strength of the evidence substantiating the causal relationship between alcohol marketing exposure and alcohol use as well as the findings of a single study which measured the effects of a complete ban on alcohol advertising, it is reasonable to deduce that a policy preventing population-level exposure to marketing would reduce alcohol use in the short and long term. ^66,73 Such effects can be attributed to the de-normalisation of alcohol products.⁷⁴

People who are experiencing alcohol dependency, or are at risk of dependency, are at increased risk when exposed to alcohol marketing, as they experience disproportionate harm from alcohol use and have increased susceptibility to alcohol marketing.⁷⁵ Alcohol companies use algorithms to explicitly target people who drink at high-risk levels, who are then regularly exposed to alcohol marketing. People in recovery have raised concerns about alcohol marketing acting as a trigger and posing a risk to their recovery.⁶³

As there is a dose-response relationship between alcohol use and cancer, people who drink at higher-risk levels are also at greater risk of alcohol-related cancer, and particular attention should be paid to policies designed to reduce their risks. There are currently no protections for people who may be vulnerable beyond the status quo for the general population.⁷⁶

Researchers have raised concern about alcoholic products claiming to be healthier, or ‘better-for-you’, by making claims about carbohydrate and sugar content, among others.⁷⁷ Evidence is building, however it appears that consumers view alcohol products with nutrition content and health-oriented claims as healthier and that the marketing of ‘better-for-you’ products may be misleading consumers.^78,79 Further, the presence of nutrition content claims on food and non-alcoholic beverages was shown to significantly decrease consumers’ attention to the nutrition information panel.⁸⁰ A meta-analysis of various labelling schemes, including nutrition content claims, found that consumers react positively to nutrition content claims, driving sales of unhealthy foods with claims on their labels.⁸¹

Systematic reviews investigating the impact of labelling claims on purchasing behaviours show that consumers are more likely to choose foods carrying claims than those that do not.^77,82 This has also been shown in the limited evidence on nutrition content claims on alcohol products.^83,78 Taken together, this demonstrates the influence that nutrition content claims are likely to have in increasing use of alcoholic beverages. It suggests that when faced with carbohydrate and sugar claims on alcohol products, consumers are less likely to refer to nutrition information panel to see the kilojoule content for a more accurate assessment of a product’s nutritional contribution.

Research with young Australians aged 15 to 17 years found that zero alcohol products are highly accessible to adolescents, potentially acting as a gateway to the use of alcoholic products.⁸⁴ Young people frequently report seeing zero alcohol products on shelves in supermarkets, and advertised across multiple media.⁸⁵ The findings also highlight that alcohol brand extension strategies, including zero alcohol products, may promote alcohol use and brand loyalty among underage young people.^86,87

Well-known alcohol brands have expanded their range to include zero alcohol products. These zero alcohol products share branding with their associated alcoholic products and are promoted via well-resourced marketing strategies. Zero alcohol products have been marketed as an alternative to sugary drinks as well as alcoholic products. The marketing for some of these products has promoted their use in places and instances where alcohol should not be used, for example when driving, using heavy machinery, or swimming.

Under the current alcohol taxation system in Australia, alcohol products are taxed according to their volume or value, with a range of tax rates depending on the type of beverage packaging, alcohol strength, place of manufacture, and the method or scale of production.

Currently, the tax payable per standard drink (i.e., 10 grams of alcohol) for different types of alcoholic products varies considerably. Information on the alcohol tax paid per standard drink of alcohol in Australia (as of August 2014) can be viewed here.

The Wine Equalisation Tax (WET) is of particular concern from a public health perspective.⁸⁸ As the WET is based on the wholesale price of wine, not its alcohol content, it incentivises the production of lower value wine products, which has contributed to an oversupply of cheap wine products in Australia.⁸⁹ These cheaper products include high alcohol volume cask wine. Abolishing the WET will simplify the alcohol taxation system and reduce the cost of administration for Government.⁹⁰ Moving wine products to the excise system will likely result in higher prices per standard drink for certain wine products, such as cask wine, which will decrease total alcohol use and remove incentive for manufacturers to produce a high volume of low-cost wine products, in turn, minimising harms from alcohol in the community.⁹¹

Research has consistently shown that increases in the price of alcohol lead to reductions in alcohol use. It has been estimated that a price increase of 10% reduces alcohol use by an average of 5%.^91,92 This reduction in use applies to all groups of drinkers, including high risk drinkers.⁹³ Therefore, increasing the price of alcohol has potential to reduce alcohol-related cancer risk on a population basis, particularly in view of the dose-response relationship between alcohol use and cancer.⁹⁴

A minimum (floor) price for alcohol sets a price per standard drink below which alcohol cannot be sold. It is set at a level that raises the cost of the cheapest alcohol products at the bottom end of the market, which are often the cause of most harm. A floor price would not increase the cost of alcoholic products sold above the ‘floor’; drinks bought at pubs, clubs, or restaurants are generally already priced above that threshold. A floor price for alcohol is being used increasingly by communities around the world to reduce the disproportionate harms caused by very cheap alcohol products.⁹⁵ A floor price is complementary to alcohol taxation and can be introduced by state and territory governments.

Evidence from the Northern Territory, Scotland and Canada shows that a floor price can save lives, reduce hospital admissions, and cut crime. In the Northern Territory, a floor price set at $1.30 per standard drink, as part of a suite of measures, resulted in significant benefits to the community including reductions in alcohol sales, alcohol-related assaults, emergency department presentations, ambulance attendances, hospital admissions, and road crash injuries and fatalities.^96,97,98 Similar benefits have been experienced by other communities around the world who have used similar measures. In Scotland, a five-year review of the floor price policy found that the measure reduced deaths due to alcohol by 13%, hospitalisations by 4%, and population-wide alcohol use by 3%.⁹⁹

A floor price is a simple and sensible measure that has significant potential to reduce the harms our families and communities experience.

Australian research has shown that cancer warnings on alcohol products constitute a potential means of increasing awareness about the link between alcohol use and cancer.¹⁰⁰ While evidence is continuing to develop on the effectiveness of warning labels in reducing alcohol use and the design features to optimise effectiveness, researchers from Canada found a significant reduction in purchasing of alcohol following an intervention that saw large bright yellow and red warning labels being placed on alcohol products sold in liquor stores, which temporarily replaced previous pregnancy warning labels.^101,102,103 Total per capita retail alcohol sales decreased by 6.3% during the intervention, and an even larger reduction occurred after the intervention when the pregnancy warning labels were reintroduced.¹⁰³

A 2020 poll found that one in two Australians (51%) believe that alcohol use causes cancer, while 15% do not believe alcohol use causes cancer and 34% are undecided.¹⁰⁴

Examples of effective public education campaigns can be found within Australia. The Alcohol. Think Again ‘Spread’ campaign increased awareness of the link between alcohol and cancer and was ranked as the most motivating for reducing alcohol use among 82 other campaigns from around the world.^105,106 This highlights that when done well, public education campaigns can be an effective tool in informing communities about harms from alcohol and supporting positive behaviour change. Public education campaigns and other approaches to building knowledge about alcohol harms can also help to create an environment conducive to evidence-based policy measures.¹⁰⁷

Communities and the environments in which Australians live should support health and wellbeing. Yet, the number of liquor licences, licensed premises and alcohol trading hours have increased dramatically in recent decades. These increases have resulted in alcohol becoming more readily available than ever before.¹¹⁰

Restricting the availability of alcohol via reduced hours of sale is one of three ‘best buy’ policies recommended by the World Health Organization to reduce the harmful use of alcohol.¹¹¹

Packaged liquor makes a significant contribution to harms associated with alcohol use.^112,113 Packaged alcohol outlet density is positively associated with chronic diseases, and rates of assault, domestic violence and very heavy episodic drinking.¹¹⁴

To support public health, it is essential that alcohol regulations are evidence-informed and appropriately restrict the availability of alcohol. Cancer Council’s position is informed by the WHO’s SAFER framework and supports the National Alcohol Strategy 2019-2028 goal to reduce opportunities for alcohol availability. ^115,116

Current practices for the online sale and delivery of alcohol are putting the community at risk, especially children, people with an alcohol dependence, and people experiencing violence in the home.¹¹²

Alcohol delivery is used to extend drinking sessions and people report receiving deliveries while intoxicated.^117,118 People who drink at higher risk levels are more likely to use rapid or same day delivery companies, order higher volumes of alcohol, and place and receive orders while intoxicated.¹¹²

Alcohol companies do not consistently verify age or check for intoxication when selling and delivering alcohol.¹¹⁹ Research into alcohol home delivery companies found the current regulatory approach inadequate to address the risks of these companies.^117,118

Alcohol is an established carcinogen which means that alcohol causes cancer.¹²⁰ Ethanol in alcoholic beverages, and its toxic metabolite acetaldehyde, are both known to cause cancers in the oral cavity, pharynx, larynx, esophagus (squamous cell carcinoma), liver, colorectum and female breast.¹²¹ A study examining alcohol use and cancer incidence among adults aged 45 years and over in NSW showed that there is a 10% increase in the risk of developing an alcohol-related cancer with every seven standard drinks consumed per week.¹²² It was found that drinking more than this increases the risk of liver cancer by 48%, breast cancer by 15% and bowel cancer by 14%. Additionally, the pattern of drinking was linked to breast cancer with a greater risk observed among women who drink 14 or more standard drinks on 1 to 3 days per week compared to those who drink the same amount over a longer duration (4 to 7 days per week).¹²²

Alcohol use accounts for a considerable 6.6% of breast cancer cases among postmenopausal women, and 12.6% of cases among premenopausal women in Australia.¹²³ Further, drinking alcohol is associated with 10% of all breast cancer deaths, with this number as high as 18-20% in regions with higher alcohol intake such as Australia.¹²⁴

Smoking and alcohol together have a compounding effect on the risk of oesophageal, stomach and small intestine cancers as well as head and neck cancers, meaning the combined effects greatly exceed the risk from either one alone.¹²⁵ It has been estimated that over 75% of cancers of the head and neck in developed countries can be attributed to this effect. Studies have found a threefold increased risk of developing cancers of the head and neck at relatively high intake levels (>60g/day).¹²⁶

Alcohol has an independent effect on the risk of oral, pharyngeal, laryngeal and oesophageal cancers, but it is its compounding effect with smoking that is most significant.¹²⁷ Both risky alcohol consumption and smoking are more prevalent among Aboriginal and Torres Strait Islander people than in the non-Indigenous population and may be contributing factors to the higher incidence rates of liver and lung cancer observed among Aboriginal and Torres Strait Islander people.¹²⁸

See the Tobacco control section of the National Cancer Prevention Policy for more information.

Alcohol use may indirectly increase cancer risk by contributing to obesity and overweight, which are linked by convincing evidence to 13 types of cancer. ^129,130 The relationship between alcohol use and body fat is complex and appears to vary with sex and drinking pattern.¹³¹ From a nutritional viewpoint, alcoholic drinks represent ‘empty kilojoules’, meaning they are high in energy (kilojoules) but low in nutritional value, especially when added to sugary mixer drinks.

If people drink alcohol in addition to their normal dietary intake – that is, without a compensatory reduction in energy intake – they are at risk of gaining weight. Alcohol provides extra kilojoules and slows fat and carbohydrate oxidation. On the other hand, if drinking replaces healthy eating habits, it can lead to nutritional deficiencies and serious illness.¹³²

See the Obesity in the National Cancer Prevention Policy for more information.

Alcohol and hepatitis B virus infection may exert a joint effect on cancer of the liver. Alcohol exacerbates the effects of chronic viral hepatitis and tobacco use, causing liver cancer.¹³³ This is of particular concern in Aboriginal and Torres Strait Islander communities, where prevalence of chronic hepatitis B is four times higher than among non-Indigenous people.¹³⁴ In addition, data suggest that liver cancer incidence and mortality rates are 2.4 times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people in Australia.¹³⁵ Research shows that alcohol is a factor in over half of liver cancer cases among Indigenous people and over one-third of liver cancer cases among non-Indigenous people, while liver cancer secondary to chronic hepatitis B infection occurs among Indigenous people about 2.5 times more frequently than non-Indigenous.¹³⁶ In addition, clustering of co-factors (alcohol and hepatitis B) is significantly more common among Aboriginal and Torres Strait Islander people, indicating this is an important area for further investigation and action.

See Liver cancer in the National Cancer Prevention Policy for more information.

Australians continue to drink at levels that are considered risky for their health. In 2022-2023, the National Drug Strategy Household Survey reported that 42% of young people aged between 18-24 years consumed alcohol in ways which put their health at risk.¹³⁷

In 2022-2023, alcohol was consumed daily by 5.2% of people aged 14 years or older, a significant decline from 6% in 2016. The most commonly consumed alcoholic products among recent drinkers in 2019-20 were bottled wine (42%) and regular strength beer (35%), followed by bottled spirits (21%).¹³⁸

Self-reported surveys can result in underestimates of alcohol use, and this has been particularly demonstrated in those who describe themselves as less frequent drinkers, with males who said they drank alcohol less than once a month, estimated to be drinking 2.45 times more frequently than was self-reported. For females who drink alcohol, this ratio was 2.78.¹³⁹

Ongoing and regular surveillance of alcohol consumption among young people and adults is important for preventing and mitigating the occurrence of related harms and will assist with monitoring changes in drinking practices over time. This currently occurs through the Australian Secondary School Students Alcohol and Drug survey (ASSAD). The current evidence alludes to poor short and long-term consequences associated with early initiation of alcohol use, including the development of harmful and risky drinking behaviours, alcohol use disorder and associated health problems later in life.^139,140,141

Drinking patterns within and between Aboriginal and Torres Strait Islander communities vary greatly.¹⁴² Aboriginal and Torres Strait Islander peoples are less likely to drink alcohol compared to non-Indigenous Australians, however those who do drink are more likely to drink at risky levels and experience greater harms from alcohol.¹⁴³ Notably, the proportion of Aboriginal and Torres Strait Islander peoples who consume alcohol in ways that put their health at risk has decreased from 48% in 2010 to 33% in 2022-2023.¹³⁷

Risky alcohol use among Aboriginal and Torres Strait Islander populations does not take place in isolation. It occurs in the wider Australian context in which supply of alcohol contributes to that harm, and for most Aboriginal and Torres Strait Islander peoples, availability, price, and industry strategies to promote alcohol use are determined in the wider political and economic arena.¹⁴⁴ In addition, alcohol use among Aboriginal and Torres Strait Islander peoples and health disparities need to be understood within the social and historical context of colonisation, dispossession and exclusion.¹⁴⁵ Self-determination through significant input to alcohol policies and other areas is crucial, and research has found that the importance of policy development on a foundation of human rights, which includes self-determinations, cannot be understated. In addition, advocacy successes have highlighted the need for and importance of Aboriginal and Torres Strait Islander and non-Aboriginal groups working together to counter commercial interests by employing strategies that included championing Aboriginal leadership and elevating the voices of community Elders in the media.¹⁴⁶

Indigenous-led approaches to addressing alcohol-related harm promote holistic well-being and refers to the healing qualities inherent in Aboriginal culture. This also serves as an effective method for mitigating intergenerational trauma and interrelated harms from alcohol. Healing within communities and trauma-informed approaches to care can circumvent barriers such as racism which prevent Aboriginal and Torres Strait Islander peoples accessing necessary health and social support systems.¹⁴⁷ Aboriginal Community Controlled Health Organisations (ACCHOs) have made significant contributions to improving the health of Aboriginal and Torres Strait Islander peoples through the delivery of culturally sensitive health care, for example, the provision of tailored alcohol services. ACCHSs should be considered in the development of prevention or reduction strategies for alcohol related harm including changes in the availability of alcohol.¹⁴⁸ However, sustained funding and resourcing is required to reinforce and extend culturally appropriate healing approaches that incorporate both traditional practices and components of western methodologies.¹⁴⁹

Alcohol use among children and young people is significant in a cancer context because the more alcohol used over time, the higher the risk of cancer.¹⁵⁰ Young people who drink at high-risk levels are more likely to become long-term high-risk drinkers and to experience alcohol-related problems and alcohol dependency and therefore are at significantly higher risk of alcohol-related cancer. ^151,152 In addition, in a 15-year Australian prospective cohort study, most adolescent binge drinkers, those who drank five or more standard drinks on a day, continued to binge drink into young adulthood (90% of males and 70% of females).¹⁵³

Australia’s alcohol guidelines recommend that to reduce the risk of injury and other harms to health, individuals under 18 years of age should refrain from drinking alcohol.¹⁵⁴ National surveys have shown that almost a third (31%) of young people aged 14-17 years were recent drinkers (i.e., consumed at least a full serve of alcohol in the last 12 months). In addition, 5.5% of young people aged 14-17 years and 42% of young people aged 18-24 years drink at levels considered to be risky for adults for immediate harms from alcohol.¹³⁷ Of all age groups, Australians aged 18-24 years reported the highest prevalence of high-risk drinking.¹⁵⁵

Individuals engaging in risky drinking patterns are likely to be underrepresented in national surveys and therefore surveys of young risky drinkers can help supplement findings from population surveys. While in the general population the average age at which 14–24-year-olds first tried alcohol has increased from 14.4 years in 1998 to 16.2 years in 2019¹⁵⁵, surveys of the heaviest drinking 14-19 year olds show that they start to drink around two years earlier (14 years) than the national average.¹⁵⁶ Among the heaviest drinking 14-19 year olds, females drank at average of 13.6 standard drinks and males drank an average of 16.8 standard drinks at their last risky drinking session.¹⁵⁷

While single occasion risky drinking among people under 30 years is lower than previous generations, over the long-term, for people over 40 years, drinking five or more standard drinks at least once a month has been trending upwards since 2001.¹⁵⁸ For people in their 50s, this rose from 22% in 2001 to 25% in 2022-2023.¹³⁷

A recent study in Australia examining alcohol use patterns among Australian women aged between 40 and 65 years and associated sociodemographic factors showed that 21 per cent are now drinking at "risky levels”.¹⁵⁹

When it comes to long-terms harms, such as risk of alcohol-related cancer, recent data shows that 33% of people aged between 60-69 years consumed alcohol at risky levels in 2023, which is similar to the proportions observed among people on their late 20s to people in their 50s.¹⁵⁹

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