European longitudinal study on the relationship between adolescents' alcohol marketing exposure and alcohol use

Zero alcohol products and adolescents: A tool for harm reduction or a trojan horse?

INTRODUCTION

Zero alcohol products (ZAPs) could reduce alcohol-related harms by acting as a substitute for alcoholic beverages. However, concerns have been raised regarding the potential for these products to expose young people to additional alcohol-related stimuli, further normalising alcohol use and acting as a gateway to underage alcohol consumption. Scarce research has examined whether these concerns are warranted.

METHOD

This project comprised two parts involving Australian adolescents aged 15-17 years. Part 1 was a series of 5 online focus groups (n = 44) that provided initial insights into perceptions of and experiences with ZAPs. Part 2 was a national online survey (n = 679) that assessed the generalisability of the focus group findings and identified factors associated with ZAP-related attitudinal and behavioural outcomes.

RESULTS

ZAPs were found to be salient and attractive to Australian adolescents. Over a third of surveyed adolescents (37%) had tried ZAPs. The focus group participants and survey respondents generally perceived ZAPs in a positive light, seeing them as a useful alternative to alcohol for both adolescents and adults who want to circumvent social expectations to use alcohol. Some of the study participants acknowledged the potential for ZAPs to serve as a gateway to alcohol use and recommended reducing their visibility and accessibility.

CONCLUSION

ZAPs are likely exposing minors to additional alcohol-related stimuli potentially increasing their risk of underage alcohol consumption. Regulatory responses to ZAPS need to protect young people from the potential adverse consequences of ZAPs exposure while enabling the products to be used by adults as an alcohol substitute.

The potential adverse effects of minors' exposure to alcohol-related stimuli via licenced venues: A narrative review

ISSUES

Young people are particularly impressionable when it comes to forming expectations and attitudes around alcohol consumption. Any stimuli that normalise and foster positive expectations around alcohol use may increase the risk of underage alcohol consumption. Alcohol venues that market themselves as being appropriate 'family friendly' establishments for children risk exposing minors to environments that are saturated with alcohol-related stimuli. However, research examining how exposure to licenced venues affects underage people is very limited. The aim of this narrative review was to identify and synthesise relevant evidence to better understand how attending these venues might affect minors.

APPROACH

A narrative review of research published between January 2016 and November 2022 was conducted to investigate the potential effects on underage people of exposure to licenced venues and stimuli encountered in/around these venues. Examined stimuli included alcohol advertising, people consuming alcohol and alcohol outlets.

KEY FINDINGS

The reviewed literature indicates that the risk of alcohol-related harm among minors is likely to increase with greater exposure to alcohol venues due to the associated exposure to alcohol advertising, exposure to others consuming alcohol and higher outlet density. In combination, these factors are likely to normalise alcohol consumption for minors and create positive alcohol expectancies.

IMPLICATIONS AND CONCLUSION

Venues serving alcohol should be discouraged from targeting families and parents should be warned about the risks associated with taking minors to venues where alcohol is sold and consumed.

Association between single-channel and cumulative exposure to alcohol advertising and drinking behaviours among Australian adolescents

INTRODUCTION

Widespread commercial promotion of alcohol products in Australia undermines the abstinence message for young people. This study aims to document the frequency of adolescents' exposure to alcohol advertising and examine associations with drinking behaviours.

METHODS

Students aged 12-17 years (n = 3618) participating in a cross-sectional survey self-reported their exposure to alcohol advertising via eight sources. Students also indicated whether they had never consumed alcohol, consumed at least a few sips of alcohol in their lifetime but none in the past month ('irregular drinkers') or consumed more than 10 drinks in their lifetime including at least one drink in the past month ('drinkers'). Multinomial logistic regression analyses examined associations between both single-channel and cumulative exposure to alcohol advertising and drinking status, controlling for sex, age and education sector.

RESULTS

Television (61%), the internet (56%) and at sporting events (50%) were the most common channels through which students reported seeing alcohol advertising. Weekly exposure via each of the eight assessed channels was associated with being a drinker (vs. a non-drinker or an irregular drinker, respectively), whereas only weekly exposure via television and sporting events was associated with being an irregular drinker (vs. a non-drinker). As students' level of cumulative exposure to alcohol advertising increased, so too did their likelihood of being a drinker.

DISCUSSION AND CONCLUSIONS

Alcohol advertising exposure is positively associated with drinking among Australian adolescents. Tighter restrictions on alcohol advertising across all media in Australia may reduce adolescent exposure and help de-normalise alcohol use.

Programmatic alcohol advertising, social media and public health: Algorithms, automated challenges to regulation, and the failure of public oversight

Ongoing partnerships between transnational alcohol corporations and global social media platforms have transformed alcohol advertising in ways that undermine existing marketing regulations and threaten all forms of public oversight. In this paper I analyse this historic shift, arguing that new forms of programmatic alcohol advertising have emerged out of increasingly intensive processes of datafication on social media. Programmatic advertising is distinguished by increasing automation, turning advertising into a process of continually experimenting on the public to optimise advertising's "outputs", which now include conversions (sales). This experimental process relies on the delegation of agency to profit maximising, algorithmic machines that make alcohol advertising decisions with public health consequences. I contend that public health must now grapple with "algorithmic sovereignty": how private, corporate machines make decisions that challenge regulation and public oversight. Drawing on a case study of Meta's programmatic systems, I argue programmatic alcohol advertising exacerbates existing problems for the regulatory control of alcohol advertising on social media, while introducing entirely novel concerns. Machines make decisions in ways that are efficacious yet obscure, even to those who design and own them and to those who use them for marketing purposes. They allow for the maximisation of profit while obfuscating public oversight of the health impacts of alcohol advertising, and they make decisions in ways that are both predictive and pre-emptive, continuously nudging social media users towards consumption through altering, in real-time, the personalised content they encounter. This leaves established means for public oversight of alcohol marketing operating retrospectively while commodification of social life through alcohol advertising acts in the present to reshape the future. The machinic vision of programmatic alcohol advertising assesses social media users for their commercial utility, not as citizens with health needs, and may be producing evolving negative health outcomes that will only ever be understood in retrospect once their deleterious impact has become evident. Steps towards more effective public health interventions must begin with clearer recognition of these fundamental changes in advertising.

Underage Adolescents' Reactions to Adverts for Beer and Spirit Brands and Associations with Higher Risk Drinking and Susceptibility to Drink: A Cross-Sectional Study in the UK

AIMS

In the UK, adolescents under the minimum legal purchasing age (<18 years) are aware of a variety of alcohol marketing activities. It is therefore important to examine how such marketing appeals and how it might shape consumption. This study assessed the relationships between positive reactions to alcohol adverts and susceptibility to drink among never drinkers and higher-risk drinking among current drinkers.

METHODS

Online cross-sectional survey of 11-17 year olds (n = 2582) in the UK. Adolescents were shown three video alcohol adverts (Fosters Radler/Haig Club Clubman/Smirnoff). Reactions to each were measured by eight scale-items (e.g. 1 = makes [Brand] seem unappealing to 5 = makes [Brand] seem appealing), which were combined into a composite score (coded: positive versus other). Logistic regressions assessed associations between overall positive advert reactions and drinking behaviours.

RESULTS

Half of adolescents had overall positive reactions to the Smirnoff (52%) and Fosters (53%) adverts, and a third (34%) had a positive reaction to the Haig Club advert. Across all three adverts, positive reactions were associated with ~1.5 times increased odds of being susceptible to drink among never drinkers. Among current drinkers, positive reactions to the Foster's Radler and Haig Club adverts were associated with around 1.4 times increased odds of being a higher-risk drinker.

CONCLUSIONS

These alcohol advertisements commonly appealed to underage adolescents, and these reactions were associated with susceptibility among never drinkers and higher-risk consumption among current drinkers. Regulatory consideration should be given to what messages are permitted in alcohol advertising, including international alternatives (e.g. only factual information).

Exposure to Alcohol Marketing and Alcohol-Related Consequences in Young Adults

Exposure to alcohol marketing is positively associated with alcohol consumption. However, few research studies have tested alcohol marketing's effect on other alcohol-related outcomes. Consequently, the current study sought to identify associations between exposure to alcohol marketing and alcohol-related consequences in young adults. Methods: A secondary analysis of the 2020 Rhode Island Young Adult Survey was conducted. Participants were lifetime drinkers (n = 390) who were 18 to 25 years old and lived in Rhode Island for at least part of 2020. Past 30 day exposure to 6 forms of alcohol marketing was assessed. Alcohol consequences were measured using 8 items from the Brief Young Adult Alcohol Consequences Questionnaire. Logistic regression models were adjusted for AUDIT score, age, race/ethnicity, gender, sexual orientation, employment status, and enrollment in school. Results: 92.3% of participants reported past 30 days exposure to any form of alcohol marketing. 43.6% of participants reported experiencing any alcohol-related consequence. Exposure to any form of alcohol marketing was positively associated with experiencing alcohol-related consequences (OR[95% CI] = 3.35 [1.19, 9.44]). After disaggregation by marketing type, only television exposure remained significantly associated with alcohol-related consequences (OR[95% CI] = 1.85 [1.06, 3.24]). Conclusions: Exposure to alcohol advertising on television may be positively associated with experiencing negative alcohol consequences in young adults. If confirmed, the findings may renew interest in strengthening alcohol marketing guidelines and regulations.

Reducing the Global Burden of Alcohol-Associated Liver Disease: A Blueprint for Action

Alcohol-associated liver disease (ALD) is a major driver of global liver related morbidity and mortality. There are 2.4 billion drinkers (950 million heavy drinkers) and the lifetime prevalence of any alcohol use disorder (AUD) is 5.1%-8.6%. In 2017, global prevalence of alcohol-associated compensated and decompensated cirrhosis was 23.6 million and 2.5 million, respectively. Combined, alcohol-associated cirrhosis and liver cancer account for 1% of all deaths worldwide with this burden expected to increase. Solutions for this growing epidemic must be multi-faceted and focused on both population and patient-level interventions. Reductions in ALD-related morbidity and mortality require solutions that focus on early identification and intervention, reducing alcohol consumption at the population level (taxation, reduced availability and restricted promotion), and solutions tailored to local socioeconomic realities (unrecorded alcohol consumption, focused youth education). Simple screening tools and algorithms can be applied at the population level to identify alcohol misuse, diagnose ALD using non-invasive serum and imaging markers, and risk-stratify higher-risk ALD/AUD patients. Novel methods of healthcare delivery and platforms are needed (telehealth, outreach, use of non-healthcare providers, partnerships between primary and specialty care/tertiary hospitals) to proactively mitigate the global burden of ALD. An integrated approach that combines medical and AUD treatment is needed at the individual level to have the highest impact. Future needs include (1) improving quality of ALD data and standardizing care, (2) supporting innovative healthcare delivery platforms that can treat both ALD and AUD, (3) stronger and concerted advocacy by professional hepatology organizations, and (4) advancing implementation of digital interventions.

Residents perceptions of the alcohol environment: A participatory photovoice project in two districts with different socio-economic status in a large city

The purpose of this study was to present the alcohol environment as perceived by its residents in two districts of Madrid using the Photovoice participatory methodology. Secondly, we compared the results according to the socio-economic status of the districts. The study was conducted in the city of Madrid, Spain, in two districts with different socio-economic status. A total of 26 people participated, who took and discussed photographs about their alcohol environment. They grouped them into 33 final categories, such as the socialising role of alcohol or the alcohol advertising. Co-authors further grouped participants final categories into seven general areas. The participants in the Photovoice project have helped to deepen the understanding of the alcohol urban environment. These results may help to design more effective policies to prevent hazardous alcohol consumption.

Adolescents' Perceived Drinking Norms Toward Alcohol Misuse: An Integrative Review

The purpose of this integrative review is to synthesize prior research on the relationship between adolescents' perceived subjective and descriptive drinking norms and their drinking intention and behaviors. Four databases (CINAHL, PubMed, Cochrane, and Sociological Abstracts) were searched to identify relevant articles. Thirty-one peer-reviewed articles published from 2010 to 2020 were reviewed. The results highlight that adolescents' perceived drinking norms derived from their parents and peers, such as approving or disapproving attitudes, significantly influence adolescents' drinking intention and behaviors. Moreover, pro-drinking messages, advertisements, and postings from electronic media (i.e., TV, movies, and the Internet) and online social networks (e.g., Facebook, Instagram, and Twitter) shape adolescents' drinking intention and encourage adolescents to initiate alcohol consumption early and/or escalate their drinking. Thus, future interventions should focus on subjective drinking norms that stem from interpersonal relationships in combination with perceived descriptive drinking norms derived from various media exposure.

How Internet Contracts Impact Research: Content Analysis of Terms of Service on Consumer Product Websites

BACKGROUND

Companies use brand websites as a promotional tool to engage consumers on the web, which can increase product use. Given that some products are harmful to the health of consumers, it is important for marketing associated with these products to be subject to public health surveillance. However, terms of service (TOS) governing the use of brand website content may impede such important research.

OBJECTIVE

The aim of this study is to explore the TOS for brand websites with public health significance to assess possible legal and ethical challenges for conducting research on consumer product websites.

METHODS

Using Statista, we purposefully constructed a sample of 15 leading American tobacco, alcohol, psychiatric pharmaceutical, fast-food, and gun brands that have associated websites. We developed and implemented a structured coding system for the TOS on these websites and coded for the presence versus absence of different types of restriction that might impact the ability to conduct research.

RESULTS

All TOS stated that by accessing the website, users agreed to abide by the TOS (15/15, 100%). A total of 11 out of 15 (73%) websites had age restrictions in their TOS. All alcohol brand websites (5/15, 33%) required users to enter their age or date of birth before viewing website content. Both websites for tobacco brands (2/15, 13%) further required that users register and verify their age and identity to access any website content and agree that they use tobacco products. Only one website (1/15, 7%) allowed users to display, download, copy, distribute, and translate the website content as long as it was for personal and not commercial use. A total of 33% (5/15) of TOS unconditionally prohibited or put substantial restrictions on all of these activities and/or failed to specify if they were allowed or prohibited. Moreover, 87% (13/15) of TOS indicated that website access could be restricted at any time. A total of 73% (11/15) of websites specified that violating TOS could result in deleting user content from the website, revoking access by having the user's Internet Protocol address blocked, terminating log-in credentials, or enforcing legal action resulting in civil or criminal penalties.

CONCLUSIONS

TOS create complications for public health surveillance related to e-marketing on brand websites. Recent court opinions have reduced the risk of federal criminal charges for violating TOS on public websites, but this risk remains unclear for private websites. The public health community needs to establish standards to guide and protect researchers from the possibility of legal repercussions related to such efforts.

Exposure to Digital Alcohol Marketing and Alcohol Use: A Systematic Review

OBJECTIVE

Alcohol marketing has proliferated on digital media, such as websites, social media, and apps. A systematic review was conducted to examine studies of associations between exposure to digital alcohol marketing and alcohol consumption.

METHOD

Eight electronic databases were searched for "alcohol" and "marketing" through 14 February 2017. Studies were included if exposure to digital alcohol marketing and alcohol consumption, or related attitudes and intentions, were assessed. Studies were excluded if they only measured exposure to alcohol depictions posted online by family and friends. Study quality was also assessed.

RESULTS

In all, 25 studies were included, including 2 randomized controlled trials, 15 cross-sectional studies, and 8 prospective cohort studies. There was a consistent finding across studies that participation and engagement with digital alcohol marketing--such as clicking on an alcohol ad, visiting an alcohol-branded website, liking or sharing an ad on social media, or downloading alcohol-branded content--was positively associated with alcohol use. The effects of simple exposure to digital alcohol advertising were inconclusive. Proper blinding of subjects, measuring exposures before the outcomes, and measuring the exposures multiple times would improve study quality.

CONCLUSIONS

Although more research is needed, existing studies suggest that engagement with digital alcohol marketing is positively associated with increased alcohol consumption and increased binge or hazardous drinking behavior. Governments should consider implementing digital alcohol marketing regulations under the precautionary principle as the alcohol industry's self-regulated marketing codes are likely ineffective at protecting populations vulnerable to alcohol-related harm.

Internet Alcohol Marketing Recall and Drinking in Underage Adolescents

OBJECTIVE

Evidence suggests that adolescents are exposed to alcohol marketing in digital media. We aimed to assess recall of Internet alcohol marketing and its association with underage drinking.

METHODS

New England adolescents age 12 to 17 years (N = 202) were recruited from a pediatric clinic. Subjects completed an online survey assessing: 1) general simple recall of Internet alcohol marketing and 2) image-prompted recall of specific Internet alcohol marketing channels (display ads, commercials, brand websites, and brand social media pages). Cross-sectional associations between recall (simple and image-prompted) and ever-drinking were each assessed in regression analysis adjusting for age, gender, race, parent education, ever-smoking, media use, sensation-seeking, peer/parent drinking, parent monitoring/responsiveness, and parent Internet monitoring.

RESULTS

In this sample (Mage = 14.5 years; 55% female; 89% white; high parent education), 20% reported ever-drinking and 87% recalled Internet alcohol marketing. Of the latter, 67% recalled display ads, 67% Internet commercials, 5% websites, and 5% social media pages. In logistic regression, higher simple Internet alcohol advertising recall was independently associated with higher odds of ever-drinking for simple (adjusted odds ratio: 2.66 [1.04,6.83]) but not for image-prompted recall.

CONCLUSIONS

Despite controlling for potential confounders, simple recall of Internet alcohol marketing was significantly associated with underage drinking whereas image-prompted recall was significant only in bivariate analysis, likely due to small sample and a more limited range of specific channels assessed than those accessed by adolescents. Further longitudinal studies using image-prompted recall and capturing a broader range of internet platforms could be used to better understand adolescent engagement with alcohol marketing and guide policy and prevention efforts.

The influence of alcohol outlet density and advertising on youth drinking in urban Tanzania

Despite the detrimental effects of alcohol on adolescent health, high rates of alcohol use are reported among Tanzanian youth. We conducted systematic community mapping and participatory group activities with 177 adolescents in Dar es Salaam to explore how alcohol outlet density and advertising may contribute to adolescent drinking in urban Tanzania. Findings revealed a high density of alcohol-selling outlets and outdoor advertisements. The abundance of alcohol-related cues, including their close proximity to places where youth congregate, may facilitate and increase adolescent alcohol use in Tanzania. Participants recommended several changes to the alcohol environment to reduce adolescent drinking. Structural interventions that reduce adolescents' access and exposure to alcohol are needed in Tanzania.

Designing drunkenness: How pubs, bars and nightclubs increase alcohol sales

Using ethnographic data, this paper investigates the techniques used inside pubs, bars and nightclubs to solicit and sustain alcohol consumption among patrons. Focus is on venues with the majority of patrons belonging to the age group of approximately 15-35 years. The paper identifies a number of techniques, both overt and covert, including: alcohol advertising; special offers (e.g. 'Happy Hours' and 'all you can drink' specials); bartenders' use of strategic intimacy, flirtation, and encouragements to buy more; speed drinking devices (e.g. shot glasses, 'beer bongs' and large pitchers); and architectural features that hamper moderate drinking while accelerating the purchase and intake of alcohol. These techniques were used most extensively in low-priced venues with the youngest patrons (e.g. themed chain pubs) and less so in more expensive venues with more adult patrons (e.g. craft beer bars). The paper argues that youth-oriented drinking venues may be conceived as staged atmospheres of consumption where individuals are seduced and compelled into purchasing alcohol. A team of 12 researchers collected the data through interviews and observations in pubs, bars and nightclubs in four cities across Denmark.

Awareness of alcohol marketing, ownership of alcohol branded merchandise, and the association with alcohol consumption, higher-risk drinking, and drinking susceptibility in adolescents and young adults: a cross-sectional survey in the UK

OBJECTIVES

To explore awareness of alcohol marketing and ownership of alcohol branded merchandise in adolescents and young adults in the UK, what factors are associated with awareness and ownership, and what association awareness and ownership have with alcohol consumption, higher-risk drinking and susceptibility.

DESIGN

Online cross-sectional survey conducted during April-May 2017.

SETTING

The UK.

PARTICIPANTS

Adolescents and young adults aged 11-19 years in the UK (n=3399).

MAIN OUTCOME MEASURES

Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) (0-12) and indication of higher-risk consumption (>5 AUDIT-C) in current drinkers. Susceptibility to drink (yes/no) in never drinkers.

RESULTS

Eighty-two per cent of respondents were aware of at least one form of alcohol marketing in the past month and 17% owned branded merchandise. χ2 tests found that awareness of marketing and ownership of branded merchandise varied within drinking variables. For example, higher awareness of alcohol marketing was associated with being a current drinker (χ2=114.04, p<0.001), higher-risk drinking (χ2=85.84, p<0.001), and perceived parental (χ2=63.06, p<0.001) and peer approval of consumption (χ2=73.08, p<0.001). Among current drinkers, multivariate regressions (controlling for demographics and covariates) found that marketing awareness and owning branded merchandise was positively associated with AUDIT-C score and higher-risk consumption. For example, current drinkers reporting medium marketing awareness were twice as likely to be higher-risk drinkers as those reporting low awareness (adjusted OR (AOR)=2.18, 95% CI 1.39 to 3.42, p<0.001). Among never drinkers, respondents who owned branded merchandise were twice as likely to be susceptible to drinking as those who did not (AOR=1.98, 95% CI 1.20 to 3.24, p<0.01).

CONCLUSIONS

Young people, above and below the legal purchasing age, are aware of a range of alcohol marketing and almost one in five own alcohol branded merchandise. In current drinkers, alcohol marketing awareness was associated with increased consumption and greater likelihood of higher-risk consumption. In never drinkers, ownership of branded merchandise was associated with susceptibility.

Alcohol policies and programmes which reduced alcohol-related harm

PURPOSE OF REVIEW

This review is a critical reflection on the effectiveness of evidence-based alcohol policies and their implementation, based on studies and observations that have arisen in recent years.

RECENT FINDINGS

This article covers themes in recent literature of: the relationship between alcohol consumption and harm, the variability of country contextual factors and the interactions of both country contexts and alcohol policies on changes in alcohol consumption and harm.

SUMMARY

These recent observations imply that alcoholic beverage policies and programmes should focus on contextual determinants in each country and community, and address targeted problems (like problem drinking) and harm (such as liver cirrhosis, cancer and road accidents), rather than consumption per se.

Effectiveness of Mass Media Campaigns to Reduce Alcohol Consumption and Harm: A Systematic Review

AIMS

To assess the effectiveness of mass media messages to reduce alcohol consumption and related harms using a systematic literature review.

METHODS

Eight databases were searched along with reference lists of eligible studies. Studies of any design in any country were included, provided that they evaluated a mass media intervention targeting alcohol consumption or related behavioural, social cognitive or clinical outcomes. Drink driving interventions and college campus campaigns were ineligible. Studies quality were assessed, data were extracted and a narrative synthesis conducted.

RESULTS

Searches produced 10,212 results and 24 studies were included in the review. Most campaigns used TV or radio in combination with other media channels were conducted in developed countries and were of weak quality. There was little evidence of reductions in alcohol consumption associated with exposure to campaigns based on 13 studies which measured consumption, although most did not state this as a specific aim of the campaign. There were some increases in treatment seeking and information seeking and mixed evidence of changes in intentions, motivation, beliefs and attitudes about alcohol. Campaigns were associated with increases in knowledge about alcohol consumption, especially where levels had initially been low. Recall of campaigns was high.

CONCLUSION

Mass media health campaigns about alcohol are often recalled by individuals, have achieved changes in knowledge, attitudes and beliefs about alcohol but there is little evidence of reductions in alcohol consumption.

SHORT SUMMARY

There is little evidence that mass media campaigns have reduced alcohol consumption although most did not state that they aimed to do so. Studies show recall of campaigns is high and that they can have an impact on knowledge, attitudes and beliefs about alcohol consumption.

Development and evaluation of the OHCITIES instrument: assessing alcohol urban environments in the Heart Healthy Hoods project

OBJECTIVES

To describe the development and test-retest reliability of OHCITIES, an instrument characterising alcohol urban environment in terms of availability, promotion and signs of consumption.

DESIGN

This study involved: (1) developing the conceptual framework for alcohol urban environment by means of literature reviewing and previous alcohol environment research experience; (2) pilot testing and redesigning the instrument; (3) instrument digitalisation; (4) instrument evaluation using test-retest reliability.

SETTING

Data for testing the reliability of the instrument were collected in seven census sections in Madrid in 2016 by two observers.

PRIMARY AND SECONDARY OUTCOME MEASURES

We computed per cent agreement and Cohen's kappa coefficients to estimate inter-rater and test-retest reliability for alcohol outlet environment measures. We calculated interclass coefficients and their 95% CIs to provide a measure of inter-rater reliability for signs of alcohol consumption measures.

RESULTS

We collected information on 92 on-premise and 24 off-premise alcohol outlets identified in the studied areas about availability, accessibility and promotion of alcohol. Most per cent-agreement values for alcohol measures in on-premise and off-premise alcohol outlets were greater than 80%, and inter-rater and test-retest reliability values were generally above 0.80. Observers identified 26 streets and 3 public squares with signs of alcohol consumption. Intraclass correlation coefficient between observers for any type of signs of alcohol consumption was 0.50 (95% CI -0.09 to 0.77). Few items promoting alcohol unrelated to alcohol outlets were found on public spaces.

CONCLUSIONS

The OHCITIES instrument is a reliable instrument to characterise alcohol urban environment. This instrument might be used to understand how alcohol environment associates with alcohol behaviours and its related health outcomes, and can help in the design and evaluation of policies to reduce the harm caused by alcohol.

Alcohol Advertising in Magazines and Underage Readership: Are Underage Youth Disproportionately Exposed?

BACKGROUND

The question of whether underage youth are disproportionately exposed to alcohol advertising lies at the heart of the public health debate about whether restrictions on alcohol advertising are warranted. The aim of this study was to determine whether alcohol brands popular among underage (ages 12 to 20 years) drinkers ("underage brands") are more likely than others ("other brands") to advertise in magazines with high underage readerships.

METHODS

We analyze the advertising of 680 alcohol brands in 49 magazines between 2006 and 2011. Using a random effects probit model, we examine the relationship between a magazine's underage readership and the probability of an underage or other brand advertising in a magazine, controlling for young adult (ages 21 to 29 years) and total readerships, advertising costs and expenditures, and readership demographics.

RESULTS

We find that underage brands are more likely than other brands to advertise in magazines with a higher percentage of underage readers. Holding all other variables constant at their sample means, the probability of an "other" brand advertising in a magazine remains essentially constant over the range of underage readership from 0.010 (95% confidence interval [CI], 0.007 to 0.013) at 5% to 0.012 (95% CI, 0.008 to 0.016) at 35%. In contrast, the probability of an underage brand advertising nearly quadruples, ranging from 0.025 (95% CI, 0.015 to 0.035) to 0.096 (95% CI, 0.057 to 0.135), where underage brands are 7.90 (95% CI, 3.89 to 11.90) times more likely than other brands to advertise.

CONCLUSIONS

Alcohol brands popular among underage drinkers are more likely than other brands to advertise in magazines with high underage readerships, resulting in the disproportionate exposure of underage youth. Current voluntary advertising industry guidelines are not adequate to protect underage youth from high and disproportionate exposure to alcohol advertising in magazines. To limit advertising exposure among underage youth, policy makers may want to consider regulation of alcohol advertising in magazines.

The Myriad Influences of Alcohol Advertising on Adolescent Drinking

Purpose of Review

This review investigates effects of alcohol advertising on adolescent drinking. Prior reviews focused on behavioral outcomes and long-term effects. In contrast, the present review focuses on subgroups with greater exposure to alcohol advertising, research methods to study alcohol advertising, potential mechanisms underlying relationships between adolescent exposure to alcohol advertising and increased drinking and points to prevention/intervention strategies that may reduce effects of alcohol advertising.

Recent Findings

Alcohol advertising influences current and future drinking. Further, evidence suggests adolescents may be targeted specifically. Alcohol advertisements may influence behavior by shifting alcohol expectancies, norms regarding alcohol use, and positive attitudes. Media literacy programs may be an effective intervention strategy.

Summary

Adolescents are exposed to large quantities of alcohol advertisements, which violates guidelines set by the alcohol industry. However, media literacy programs may be a promising strategy for adolescents to increase critical thinking and create more realistic expectations regarding alcohol.

Qualitative process evaluation of an Australian alcohol media literacy study: recommendations for designing culturally responsive school-based programs

Background

Alcohol media literacy programs seek to mitigate the potentially harmful effects of alcohol advertising on children’s drinking intentions and behaviours through equipping them with skills to challenge media messages. In order for such programs to be effective, the teaching and learning experiences must be tailored to their specific cultural context. Media in the Spotlight is an alcohol media literacy program aimed at 9 to 12 year old Australian children. This study evaluates the process and implementation of the program, outlining the factors that facilitated and inhibited implementation. From this evaluation, a pedagogical framework has been developed for health professionals implementing culturally responsive programs in school settings.

Methods

Process measures included: semi-structured interviews with teachers before and after the program was implemented (n = 11 interviews), program evaluation questionnaires completed by children (n = 166), lesson observations completed by teachers (n = 35 observations), and reflective journal entries completed by the researcher (n = 44 entries). A thematic analysis approach was used to analyse all of the data sets using NVivo. Inductive coding was used, whereby the findings were derived from the research objectives and multiple readings and interpretations of the data.

Results

Five key pedagogical considerations were identified that facilitated implementation. These were: connecting to the students’ life worlds to achieve cultural significance; empowering students with real-world skills to ensure relevance; ensuring programs are well structured with strong connections to the school curriculum; creating developmentally appropriate activities while providing a range of assessment opportunities; and including hands-on and interactive activities to promote student engagement. Three potential inhibitors to implementing the alcohol media literacy program in upper-elementary school classrooms were identified. These included topic sensitivities, classroom management challenges, and fitting new programs into already busy school schedules.

Conclusion

Overall, the program content and individual lessons were well received by the teachers and students. The lessons learned from the development, implementation and evaluation of this program can provide health professionals with key pedagogical strategies for designing culturally responsive educational programs. Culturally responsive programs are critical for ensuring interventions are effective for their specific context.

Does Industry-Driven Alcohol Marketing Influence Adolescent Drinking Behaviour? A Systematic Review

Aim

To systematically review evidence on the influence of specific marketing components (Price, Promotion, Product attributes and Place of sale/availability) on key drinking outcomes (initiation, continuation, frequency and intensity) in young people aged 9–17.

Methods

MEDLINE, EMBASE, SCOPUS, PsychINFO, CINAHL and ProQuest were searched from inception to July 2015, supplemented with searches of Google Scholar, hand searches of key journals and backward and forward citation searches of reference lists of identified papers.

Results

Forty-eight papers covering 35 unique studies met inclusion criteria. Authors tended to report that greater exposure to alcohol marketing impacted on drinking initiation, continuation, frequency and intensity during adolescence. Nevertheless, 23 (66%) studies reported null results or negative associations, often in combination with positive associations, resulting in mixed findings within and across studies. Heterogeneity in study design, content and outcomes prevented estimation of effect sizes or exploration of variation between countries or age subgroups. The strength of the evidence base differed according to type of marketing exposure and drinking outcome studied, with support for an association between alcohol promotion (mainly advertising) and drinking outcomes in adolescence, whilst only two studies examined the relationship between alcohol price and the drinking behaviour of those under the age of 18.

Conclusion

Despite the volume of work, evidence is inconclusive in all four areas of marketing but strongest for promotional activity. Future research with standardized measures is needed to build on this work and better inform interventions and policy responses.