Evaluation outcomes of a Western Australian campaign designed to reduce alcohol use in pregnancy.

OBJECTIVE: To assess (i) the effectiveness of a mass media campaign communicating the potential harms associated with consuming even small amounts of alcohol in pregnancy and (ii) changes in females' intentions to abstain during pregnancy after campaign exposure. METHODS: Independent samples of ∼400 Western Australian adults (18-45 years) were recruited at two time points (before and after the 'One Drink' campaign) to complete online surveys. Attitudinal and behavioural intention outcomes were assessed at both time points. Descriptive analyses and generalised linear models were used to assess outcomes. RESULTS: Three-quarters (76%) of the post-campaign sample members reported awareness of the campaign. In the descriptive analyses there were significant improvements in three of the seven attitudinal items. The regression models yielded significant increases in agreement that pregnant women should not drink alcohol (assessed among females and males) and intentions to abstain during pregnancy (assessed among females only). CONCLUSIONS: The results indicate favourable understanding and behavioural intention effects from exposure to a campaign promoting alcohol abstinence during pregnancy. IMPLICATIONS FOR PUBLIC HEALTH: This study demonstrates that investment in campaigns warning about alcohol use in pregnancy is likely to be a worthwhile approach to reduce the burden of alcohol-related harms to individuals and society.

Evaluating an alcohol harm-reduction campaign advising drinkers of the alcohol-cancer link.

INTRODUCTION: Public awareness of the alcohol-cancer link is low. Provision of this information could reduce alcohol consumption and related harms. The Spread campaign is a multi-media education campaign implemented in Western Australia to inform people about the carcinogenic properties of alcohol and associated harms. The aims of the present study were to (i) examine attitudinal and behavioural outcomes of the Spread campaign and (ii) identify demographic and drinking status factors associated with enactment of harm-reduction behaviours resulting from exposure. METHOD: A cross sectional survey of Western Australian drinkers (consumed alcohol at least a few times in the previous 12 months, n = 760) examined campaign recognition, campaign perceptions, and behaviours resulting from campaign exposure. Chi-square analyses and a generalised linear model were used to identify demographic and alcohol-related factors associated with behavioural outcomes. RESULTS: Around two-thirds of respondents recognised the campaign (65%), and of these, 22% reported successfully reducing how often or how much they drank due to seeing the campaign. Three quarters (73%) of all respondents considered the campaign message about the alcohol-cancer link to be believable. Respondents drinking at levels above the Australian guideline were less likely to have positive perceptions of the campaign than those complying with the guideline, but were more likely to report enacting the assessed harm-reduction behaviours as a result of campaign exposure. DISCUSSION AND CONCLUSION: The results suggest that provision of information about the alcohol-cancer link has the potential to motivate reduced alcohol consumption. Implementing such campaigns could constitute an effective alcohol harm-reduction strategy.

Trends in and factors associated with parental provision of alcohol to minors in Western Australia, 2013-2019.

INTRODUCTION: Some parents provide alcohol to their underage children, despite a range of negative outcomes being associated with this practice. The present study aimed to assess factors associated with and changes in parental provision behaviours from 2013 to 2019 in Western Australia. METHODS: Annual cross-sectional online surveys were conducted (total n = 2635). Assessed variables included parents' demographic characteristics, alcohol use, awareness of the relevant Australian alcohol guideline, attitudes to parental provision of alcohol and provision behaviours. A binary logistic generalised linear model was used to identify factors associated with parental provision of alcohol. RESULTS: Parental provision of alcohol prevalence decreased from 40% in 2013 to 27% in 2019. The following variables were significantly associated with parental provision: permissive attitudes to provision (ß = 2.82); older parental age (ß = 1.28); a lack of knowledge of the relevant guideline (ß = 0.78); survey year (ß = 0.083); and greater alcohol use (ß = 1.12). Socioeconomic position was not associated with parental provision. Female parents were more likely to report that an adult in the household provided children with alcohol (ß = 1.3) DISCUSSION AND CONCLUSIONS: The findings suggest that (i) although still commonplace, parental provision of alcohol to minors in Western Australia has declined over time; and (ii) the effectiveness of campaigns aiming to reduce this behaviour may be enhanced by targeting households with parents who are older and heavier drinkers and by including content that challenges permissive views on alcohol provision to minors.

Would you like fries with that? Investigating fast-food outlet availability near schools in Perth, Western Australia.

ISSUE ADDRESSED: Locating fast-food outlets near schools is a potential public health risk to schoolchildren, given the easy access and repeated exposure to energy-dense, nutrient-poor foods they provide. Fast-food outlet availability near schools has not been previously investigated in Perth, Western Australia. This study aimed to quantify fast-food outlet availability near Perth schools and determine whether differences in area-level disadvantage and school type exist. METHODS: Fast-food outlet locations were sourced from Perth Local Governments in 2018/2019. All Perth Primary (n = 454), Secondary (n = 107) and K-12 (n = 94) schools were assigned an area-level disadvantage decile ranking based on the Australian Bureau of Statistics Socio-Economic Index for Areas (SEIFA). Regression models assessed whether fast-food outlet availability within 400 m, 800 m and 1 km of schools differed by school type (ie, Primary/Secondary/K-12) or SEIFA. RESULTS: Secondary schools were significantly more likely than Primary and K-12 schools to have a higher presence and density of fast-food outlets and the "Top 4" fast-food outlet chains (McDonalds, Hungry Jacks, KFC and Red Rooster) nearby. Schools located in low socio-economic status (SES) areas had a significantly higher density of fast-food outlets within 400 m, and "Top 4" fast-food outlet chains within 400 m and 1 km, than schools located in high SES area. CONCLUSIONS: Perth schools are surrounded by fast-food outlets with densities significantly higher around secondary schools and schools located in lower SES areas. SO WHAT?: Policies and regulations aimed at reducing fast-food outlets near schools is an essential strategy to improve dietary intakes and reduce obesity in schoolchildren.

Evaluation outcomes of an alcohol and pregnancy campaign targeting multiple audiences.

INTRODUCTION: The aim of this study was to evaluate the effectiveness of a mass media campaign alerting the public to the potential harms of alcohol to unborn babies and to inform future intervention efforts. METHOD: An online survey was administered to 889 adult Western Australians. The survey assessed demographic characteristics, typical alcohol use, recognition and perceptions of the campaign, and behavioural changes resulting from campaign exposure. A multiple regression analysis was conducted to identify factors associated with perceived campaign effectiveness. RESULTS: Most respondents reported having seen/heard the campaign on at least one form of media (71%). Most considered the campaign to be believable (89%), clear (88%), trustworthy (87%), memorable (82%) and among the best they had seen (78%). As a result of campaign exposure, a large majority reported increased concern about drinking during pregnancy (85%) and most female respondents reported being much less likely to use alcohol during a pregnancy (83%). One-third of female respondents (33%) reported that as a result of being exposed to the campaign they had decided not to consume alcohol while pregnant. Confidence to abstain, awareness of strategies to abstain, lower socioeconomic position, residing in the metropolitan area and recognising the campaign were significantly associated with greater perceived campaign effectiveness. DISCUSSION AND CONCLUSIONS: Results indicate the campaign was well received by respondents, increased concern about drinking alcohol during pregnancy and positively influenced women's intentions to refrain from drinking while pregnant. Well-designed campaigns on alcohol avoidance during pregnancy can be considered acceptable and effective by target audiences.

Cost-effectiveness of LiveLighter® - a mass media public education campaign for obesity prevention.

BACKGROUND: The Western Australian LiveLighter® program has implemented a series of mass media advertising campaigns that aim to encourage adults to achieve and maintain a healthy weight through healthy behaviours. This study aimed to assess the cost-effectiveness of the LiveLighter® campaign in preventing obesity-related ill health in the Western Australian population from the health sector perspective. METHODS: Campaign effectiveness (delivered over 12 months) was estimated from a meta-analysis of two cohort studies that surveyed a representative sample of the Western Australian population aged 25-49 years on discretionary food consumption one month pre- and one month post-campaign. Campaign costs were derived from campaign invoices and interviews with campaign staff. Long-term health (measured in health-adjusted life years (HALYs)) and healthcare cost-savings resulting from reduced obesity-related diseases were modelled over the lifetime of the population using a validated multi-state lifetable Markov model (ACE-Obesity Policy model). All cost and health outcomes were discounted at 7% and presented in 2017 values. Uncertainty analyses were undertaken using Monte-Carlo simulations. RESULTS: The 12-month intervention was estimated to cost approximately A$2.46 million (M) (95% uncertainty interval (UI): 2.26M; 2.67M). The meta-analysis indicated post-campaign weekly reduction in sugary drinks consumption of 0.78 serves (95% UI: 0.57; 1.0) and sweet food of 0.28 serves (95% UI: 0.07; 0.48), which was modelled to result in average weight reduction of 0.58 kilograms (95%UI: 0.31; 0.92), 204 HALYs gained (95%UI: 103; 334), and healthcare cost-savings of A$3.17M (95%UI: A$1.66M; A$5.03M). The mean incremental cost-effectiveness ratio showed that LiveLighter® was dominant (cost-saving and health promoting; 95%UI: dominant; A$7 703 per HALY gained). The intervention remained cost-effective in all sensitivity analyses conducted. CONCLUSION: The LiveLighter® campaign is likely to represent very good value-for-money as an obesity prevention intervention in Western Australia and should be included as part of an evidence-based obesity prevention strategy.

Does fast-food outlet density differ by area-level disadvantage in metropolitan Perth, Western Australia?

ISSUE ADDRESSED: Socio-economic spatial patterning of fast-food outlets can result in disparities in the availability and access of food across geographic areas, contributing to health inequalities. This study investigated whether area-level socio-economic disparities exist in fast-food availability across the Perth metropolitan region of Western Australia. METHODS: Fast-food outlet locations were sourced from Perth Local Governments in 2018/2019. All Perth suburbs (n = 328) were allocated a decile ranking based on the Australian Bureau of Statistics Socio-Economic Index for Areas with decile 1 indicating relatively greater disadvantage and decile 10 indicating a relative lack of disadvantage. Zero-inflated negative binomial regression models, adjusted for suburb area and population density, were used to investigate the association between area-level disadvantage decile and availability of fast-food outlets. RESULTS: A socio-economic gradient was identified; for every unit increase in disadvantage decile (ie a reduction in relative disadvantage), the count of fast-food outlets decreased by 6% (P < .01), and the count of the "top ranking" fast-food chains (ie McDonalds, KFC, Hungry Jacks and Red Rooster) decreased by 10% (P < .001). CONCLUSIONS: Consistent with evidence internationally and from within Australia, socio-economic spatial patterning of fast-food outlet availability was shown to exist in Perth, with greater fast-food availability in areas with more relative socio-economic disadvantage. SO WHAT?: To address health inequities associated with fast-food consumption, policy and practice changes are needed that manage fast-food outlet proliferation in areas of greater socio-economic disadvantage.

Children's exposure to outdoor food advertising near primary and secondary schools in Australia.

ISSUE ADDRESSED: Previous research has highlighted children's frequent exposure to advertisements of unhealthy food and beverages on television. However, the food industry is increasingly utilising non-broadcast channels such as outdoor advertising (eg billboards, bus shelters, shop fronts) for product marketing. Few studies have investigated children's exposure to outdoor food advertising around primary and secondary schools. This study aimed to quantify the presence and content of outdoor food advertisements within a 500 m radius of primary and secondary schools in Perth, Western Australia. METHODS: A cross-sectional design was used to capture outdoor advertisements within a 500 m radial buffer around the school boundary. The INFORMAS protocol for monitoring outdoor advertising around child-serving institutions was used. Sixty-four primary and secondary schools in Perth, Australia, were selected using random sampling within socio-economic and population density strata. RESULTS: In total, 5636 outdoor advertisements were identified within a 500 m radius of all 64 schools combined and 30% were for food. Of the 1708 food advertisements, 74% were for unhealthy (non-core) food. The most frequently advertised food products were alcohol, fast food and sugar-sweetened beverages. Only 8% of food advertisements featured a healthy product. The majority of schools (75%) had at least one food advertisement within 500 m (mean 36, range 3-190). Schools in lower socio-economic areas had more food advertisements and a significantly higher proportion of unhealthy food advertisements within 250 m. CONCLUSION: Outdoor advertising around schools constitutes a potential frequent source of children's exposure to unhealthy food and alcohol advertising. SO WHAT?: Policy interventions restricting the content of outdoor food advertising near schools are needed.

A content analysis of the tweets of e-cigarette proponents in Australia.

ISSUE ADDRESSED: Social media sites have become platforms for public discourse on e-cigarettes, providing proponents with an opportunity to disseminate favourable information about the devices. Research examining the information being presented by Australian proponents of e-cigarettes is limited. Accordingly, this study explored the Twitter feeds of Australian proponents of e-cigarettes to determine the nature of the e-cigarette-related content being disseminated. METHODS: All publicly available e-cigarette-related tweets and retweets (n = 1397) disseminated over a 15-week period by five Australian e-cigarette proponents were captured and analysed. RESULTS: The main topics covered in the 1397 tweets analysed related to (a) criticism of the arguments made by public health agencies/advocates who oppose e-cigarettes (29%), (b) Australian e-cigarette policy (19%), (c) the health risks of e-cigarettes (16%) and (d) the efficacy of e-cigarettes as smoking cessation aids (13%). Proponents argued that the precautionary principle adopted by public health agencies/advocates lacks an appropriate evidence base and that legalising e-cigarettes would reduce smoking rates and smoking-related harm. Proponents minimised the risks associated with e-cigarette use and only presented evidence indicating that use facilitates smoking cessation. CONCLUSIONS: The assessed tweets have the potential to reduce the public's trust in the information being presented by authoritative public health agencies/advocates. The dissemination of information downplaying the health risks associated with e-cigarettes may distort perceptions of the devices. SO WHAT?: To assist tobacco control efforts, results highlight the need for (a) ongoing surveillance of the tweets of e-cigarette proponents and (b) provision of evidence-based counterarguments on social media.

Policies to restrict unhealthy food and beverage advertising in outdoor spaces and on publicly owned assets: A scoping review of the literature.

Unhealthy food marketing influences attitudes, preferences, and consumption of unhealthy foods, leading to excess weight gain. Outdoor advertising is highly visible (often displayed on publicly owned assets), but the evidence supporting regulation is unclear. This systematic scoping review of academic and grey literature aimed to (1) describe potential health and economic impacts of implementing government-led policies that restrict unhealthy food advertising in outdoor spaces or on public assets (including studies examining prevalence of advertising, associations with health outcomes and interventional studies); (2) identify and describe existing policies; and (3) identify factors perceived to have influenced policy implementation. Thirty-six academic studies were eligible for inclusion. Most reported on prevalence of unhealthy food advertising, demonstrating high prevalence around schools and in areas of lower socioeconomic position. None examined health and economic impacts of implemented policies. Four jurisdictions were identified with existing regulations; five had broader marketing or consumer protection policies that captured outdoor food marketing. Facilitators of policy implementation included collaboration, effective partnerships, and strong political leadership. Barriers included lobbying by food, media, and advertising industries. Implementation of food marketing policies in outdoor spaces and on public assets is feasible and warranted. Strong coalitions and leadership will be important to drive the policy agenda forward.

Association between food-outlet availability near secondary schools and junk-food purchasing among Australian adolescents.

OBJECTIVES: We sought to investigate the association between food-outlet availability near Australian secondary schools and frequency of Australian students' discretionary food purchases. METHODS: Secondary-school students in Perth (Western Australia) reported the frequency of their discretionary food purchases from food outlets near their school (17 schools, n = 2389 students grades 7-12, ages 12-17 y). Food-outlet availability was sourced from local governments, then geocoded. A mixed-effects model was used in analyses. RESULTS: Almost half of students (45%) purchased discretionary foods from food outlets near their secondary school at least weekly. Only the density of top-ranking fast-food chain outlets near secondary schools was associated with a significant increase in the frequency of discretionary food purchases. CONCLUSIONS: Availability of major fast-food chains near Australian secondary schools appears to be a key driver of Australian students' discretionary food purchasing. Restricting these outlets near schools may help reduce adolescents' discretionary food intake.

Exposure to unhealthy food and beverage advertising during the school commute in Australia.

BACKGROUND: Food marketing exposure has the potential to influence children's dietary behaviours and health status, however, few studies have identified how 'obesogenic' the outdoor food marketing environment is along public transport (bus and/or train) or walking routes that children take to school. METHODS: Audits of all outdoor advertisements present along likely train, bus and walking routes to 24 secondary schools (ie, 3 routes per school, 72 routes total) were conducted in Perth, Western Australia (WA). The size, content, type and setting of each advertisement were recorded in accordance with the International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support protocol for monitoring outdoor advertising. RESULTS: Of the 4016 total advertisements observed, almost half were for food (n=1754, 44%) and of these, 80% (n=1397) advertised discretionary (non-core) foods, and 8% (n=138) advertised healthy (core) foods. On average, commuting to school by train, bus and walking exposed Perth schoolchildren to 37.1, 22 and 4.5 discretionary (non-core) food ads per one-way trip to school, respectively. CONCLUSIONS: Children living in Perth, WA experience a high level of exposure to unhealthy outdoor food advertisements during the school commute. Policies which restrict the placement and content of outdoor advertising, could be a useful strategy in the fight against childhood obesity.

Who sells tobacco, who stops? A comparison across different tobacco retailing schemes.

BACKGROUND: Licensing of tobacco retailers has been proposed as a mechanism to encourage retailers to stop selling tobacco. However, previous studies of tobacco licensing and/or of retailers who have stopped selling have been restricted to one legislative environment. This study examines patterns of tobacco retailing across three legislative environments with three different licensing schemes (an annual fee-based licence, a zero-cost, one-off notification scheme and no notification/licensing scheme). METHOD: A telephone survey was conducted of 2928 potential tobacco retailers who could personally choose whether or not to sell tobacco (rather than the decision being made at a head office). RESULTS: Unexpectedly, the annual licence fee to sell tobacco was not significantly associated with a lower rate of selling tobacco or a higher rate of stopping. After allowing for other factors, probability of selling, stopping selling and reported importance of tobacco sales varied across outlet types (p<0.001 for all three outcomes), and according to the remoteness of the retailer (p<0.001, p trend=0.041 and p=0.025 respectively). CONCLUSION: A fee of $A286 was not associated with a lower rate of selling, or a higher rate of stopping. The effect of licensing on retailer numbers will presumably be greater for higher licence fees, but will also depend on the perceived importance of tobacco sales to the retailer. In turn, importance of tobacco sales appears to depend on market factors, including proximity to major urban centres and low-cost competitors. A higher licence fee is likely to have a larger effect on discouraging retailers from selling.

'Friends with benefits': how tobacco companies influence sales through the provision of incentives and benefits to retailers.

BACKGROUND: In countries banning advertising and display of tobacco at point-of-sale, little is known about tobacco companies' continuing promotion of products through incentives and benefits to retailers. METHOD: A telephone survey of 4527 randomly selected Australian retailers was conducted in August 2018, and identified 800 current tobacco retailers (response rate: 72.4%) who were asked a series of questions about benefits offered to them by tobacco companies and what retailers agreed to in return. RESULTS: 41.1% of retailers reported being provided with a tobacco cabinet and 38.3% reported having a price list supplied by a tobacco company. One-third (33.3%) reported being offered at least one benefit from a tobacco company for doing something in return. Price discounts were the most frequently reported benefit (19.0%), followed by rebates (8.4%) and gifts (3.0%). Retailers also reported offers of prizes and incentives for increasing sales or demonstrating product knowledge. In return, retailers reported giving companies benefits such as prominence on the price list and/or in the tobacco cabinet and/or influence over the product range and stock levels. CONCLUSION: Tobacco companies are continuing to market tobacco and influence sales through provision of incentives and benefits to retailers. Laws that ban the supply of benefits to consumers should be extended to also prohibit the provision of benefits to tobacco retailers.

Unplanned purchasing of tobacco products: Beyond point of sale display.

ISSUE ADDRESSED: Tobacco products remain widely available and unplanned purchasing of tobacco has been implicated in cessation relapse. Little is known however about the frequency of consumers' unplanned tobacco purchases or the type of retail outlets where this is more likely to occur. METHODS: Questions on cigarette purchasing were added to a post-campaign telephone survey for the Make Smoking History Campaign in Western Australia. Respondents (n=200) were aged 25 to 54 years and were either current smokers or had quit in the last 4-5 weeks. Two-thirds of respondents had tried to quit in the past 2 years. Survey responses were analysed to look at place of purchase (the usual and after cessation relapse) and frequency and reasons for unplanned purchases. RESULTS: Supermarkets were the "usual" purchase location for the majority of respondents overall (78%), but the proportion who reported buying cigarettes from a supermarket after taking up smoking again declined substantially (52%), while purchases from convenience stores and service stations increased. Nearly a third (30%) of respondents indicated that they sometimes bought cigarettes unplanned or on impulse, and for 16%, this was at least once a week. CONCLUSIONS: Among smokers who have tried to quit but not succeeded, unplanned cigarette purchases are common. There is evidence to suggest that when people resume smoking after a cessation attempt, the cigarette purchase is not necessarily made at their "usual" type of retail outlet. SO WHAT?: The banning of point of sale tobacco display has not eliminated the pervasive availability and retail presence of tobacco, and unplanned purchasing of cigarettes is an impediment to successful smoking cessation. This study adds weight to growing momentum internationally and in Australia to reduce the widespread availability of tobacco products and decrease the barriers to quitting use of a product that kills over half of its consumers.

Understanding why some Australian retailers have stopped selling tobacco, some might and some are unlikely.

BACKGROUND: Widespread availability of tobacco has been shown to contribute to ongoing smoking and make quitting harder. This study investigates why some retailers in three Australian states decided to stop selling tobacco, others might stop selling and why others continue to sell in a declining market. METHODS: A telephone survey of 4527 randomly selected retailers was conducted in August 2018 (response rate=72.4%). This study examines responses to open-ended questions in the survey probing retailers' attitudes and beliefs regarding selling (or not selling) tobacco. RESULTS: 27.3% of the sample sold tobacco, and 13.3% had formerly sold. Outlets that had stopped selling most frequently mentioned minimal profit and/or sales as the reason for stopping selling (27.7% across all states). This was also the most frequent reason why retailers said they might stop selling. Uniquely in Western Australia (the only state in the study with a fee-based licensing scheme), 12.5% of former tobacco retailers named tobacco licensing as the reason for stopping sales-the second most frequent reason in Western Australia. Of current sellers who were unlikely to stop, the potential to lose sales was the most frequently named reason (31.0% across all states). CONCLUSION: Retailers report being driven by the profitability of tobacco when deciding whether or not to stop selling, although only a small percentage discussed losing incremental sales if they stopped selling. An annual licence fee contributed to some retailers stopping selling, showing that a fee-based tobacco license can contribute to a decline in retail availability of tobacco.