Developing an alcohol policy assessment toolkit: application in the western Pacific

Bull World Health Organ 2014;92:726–733 | doi: http://dx.doi.org/10.2471/BLT.13.130708 Research 726 Developing an alcohol policy assessment toolkit: application in the western Pacific Natacha Carragher,a Joshua Byrnes,b Christopher M Doranc & Anthony Shakeshafta Introduction Globally, alcohol consumption contributes to an estimated 9.6% of all disability-adjusted life-years.1 Fortunately, effective evidence-based policies for alcohol control can protect popula- tion health and well-being, save lives, reduce health-care costs and increase productivity.2–4 Indeed, every European country has some form of national alcohol control policy framework.3 Policy development, however, is only one step. The World Health Organization (WHO) and other leading international agencies have repeatedly called for countries to assess, compare and refine their national alcohol control policy frameworks.3,5,6 There is limited guidance, however, on how these activities should be carried out. A reliable and valid tool for quantifying alcohol policy stringency and enforcement would yield a stan- dardized, succinct summary of a country’s policy framework and facilitate investigation of the relationship between alcohol policies and consumption per capita. It would also enable meaningful comparisons across countries and jurisdictions and comparisons within countries over time. Further, it could highlight weak policies and provide estimates of the impact of policy improvements on consumption. A small number of scales have been developed to assess national alcohol control policies.7 Although informative, these scales have several limitations. These include the failure to: (i) comprehensively assess enforcement,7–14 (even though enforcement varies considerably across policies and countries and is likely to impact effectiveness);15 (ii) demonstrate the scale’s feasibility through a practical application;10 (iii) dem- onstrate the scale’s robustness through sensitivity analyses;7–12 (iv) rank countries according to their degree of alcohol con- trol;12 (v) relate alcohol policy scores to corresponding per capita consumption estimates7–12 or adjust for income – which shows considerable between-country variation – in per capita consumption estimates;13,14 and (vi) provide complete assess- ment of policies and use up-to-date literature.13,15,16 We aimed to address these limitations and develop a comprehensive and practical tool to measure the stringency and enforcement of national alcohol control policies. To demonstrate our tool’s feasibility and practical value, we applied it to nine study areas in the western Pacific. De- spite recent increases in alcohol consumption in the region,17 previous alcohol policy scales have been largely applied to Europe. Only two previous studies have evaluated alcohol control policies in the western Pacific and both focused on high-income countries.12,13 In this paper, we compared the relative strength of national alcohol policy frameworks across a range of developed and developing study areas in the region. We used up-to-date policy data, conducted comprehensive sensitivity analyses to demonstrate the tool’s robustness and investigated the relationship between alcohol policy scores and income-adjusted levels of alcohol consumption per capita. Methods The assessment tool We developed the Toolkit for Evaluating Alcohol policy Stringency and Enforcement-16 (TEASE-16), which builds on previous policy evaluation scales.13 It is the first tool to assess levels of stringency and enforcement comprehensively. As summarized in Table 1, TEASE-16 has five main components: (i) five regulatory domains; (ii) 16 evidence-based alcohol control policies or policy topics; (iii) effectiveness star ratings Objective To demonstrate the development and feasibility of a tool to assess the adequacy of national policies aimed at reducing alcohol consumption and related problems. Methods We developed a quantitative tool – the Toolkit for Evaluating Alcohol policy Stringency and Enforcement (TEASE-16) – to assess the level of stringency and enforcement of 16 alcohol control policies. TEASE-16 was applied to policy data from nine study areas in the western Pacific: Australia, China excluding Hong Kong Special Administrative Region (SAR), Hong Kong SAR, Japan, Malaysia, New Zealand, the Philippines, Singapore and Viet Nam. Correlation and regression analyses were then used to examine the relationship between alcohol policy scores and income-adjusted levels of alcohol consumption per capita. Findings Vast differences exist in how alcohol control policies are implemented in the western Pacific. Out of a possible 100 points, the nine study areas achieved TEASE-16 scores that ranged from 24.1 points for the Philippines to 67.5 points for Australia. Study areas with high policy scores – indicating relatively strong alcohol policy frameworks – had lower alcohol consumption per capita. Sensitivity analyses indicated scores and rankings for each study area remained relatively stable across different weighting schemes, indicating that TEASE-16 was robust. Conclusion TEASE-16 could be used by international and national regulatory bodies and policy-makers to guide the design, implementation, evaluation and refinement of effective policies to reduce alcohol consumption and related problems. a National Drug and Alcohol Research Centre, University of New South Wales, 22-32 King Street, Sydney, New South Wales, 2031, Australia. b Centre for Applied Health Economics, Griffith University, Meadowbrook, Australia. c Hunter Medical Research Institute, New Lambton, Australia. Correspondence to Natacha Carragher (email: n.carragher@unsw.edu.au). (Submitted: 20 November 2013 – Revised version received: 14 May 2014 – Accepted: 14 May 2014 – Published online: 23 June 2014 ) Bull World Health Organ 2014;92:726–733| doi: http://dx.doi.org/10.2471/BLT.13.130708 727 Research Alcohol control policies in the western PacificNatacha Carragher et al. Table 1. Components of the Toolkit for Evaluating Alcohol policy Stringency and Enforcement-16 (TEASE-16) Domain, policy topic Effectiveness star ratinga Level of stringency Level of enforcementb Physical availability Legal minimum age for alcohol purchase (years) 3 16 Poor, moderate, or strong17 18 19 ≥ 20 Alcohol server liability for damages caused by actions of patrons 2 No Poor, moderate or strongYes Government monopoly of alcohol retail sales 2 None Poor, moderate or strongPartial government monopoly Full government monopoly Restrictions on density of outlets 2 None Poor, moderate or strongOn wine only On wine and spirits On wine, spirits and beer Restrictions on the hours and days of sale 2 None Poor, moderate or strongOn hours or days On both hours and days Drinking context Community mobilization programmes to increase public awareness or prevent alcohol problems 2 No Poor, moderate or strongYes Mandatory training of bar staff and management to better manage aggression 2 No Poor, moderate or strongYes Alcohol pricesc Beer price index 3 0–0.29 Poor, moderate or strong0.30–0.59 0.60–0.89 ≥ 0.90 Wine price index 3 0–0.9 Poor, moderate or strong1.0–1.9 2.0–2.9 ≥ 3.0 Spirit price index 3 0–2.9 Poor, moderate or strong3.0–5.9 6.0–8.9 ≥ 9.0 Alcohol advertising Restrictions imposed on the majority of alcohol advertising media 1 No restrictions Poor, moderate or strongIndustry self-regulation Partial statutory restrictions Ban Drivers of motor vehicles Frequency of random breath testing 3 Never Poor, moderate or strongRarely Occasionally Often Very often Legal blood alcohol concentration limit in adult drivers (mg/dL) 3 ≥ 0.08 Poor, moderate or strong0.03–0.07 0–0.02 Legal blood alcohol concentration limit in youth drivers (mg/dL) 3 ≥ 0.04 Poor, moderate or strong0.02–0.03 0–0.01 (continues. . .) Natacha Carragher et al.Alcohol control policies in the western Pacific Research 728 Bull World Health Organ 2014;92:726–733| doi: http://dx.doi.org/10.2471/BLT.13.130708 (i.e. ratings of the effectiveness of the policies in reducing the adverse effects of alcohol, which were based on expert reviews of the literature);2 (iv) level of stringency; and (v) level of enforce- ment. Further details on the conceptual framework of TEASE-16 are provided in Appendix A (available at: https://ndarc. med.unsw.edu.au/resource/appendix- tease-16-supplementary-details). Following Brand et al.,13 we exam- ined five broad regulatory domains that were identified in a WHO-sponsored comprehensive analysis of alcohol policies.2 Within these domains, we focused on 16 policies that have been implemented around the world and evaluated by experts as being effective in reducing the adverse effects of alco- hol.2 Like Brand et al.,13 we excluded policies that: have limited effectiveness (e.g. warning labels on containers for alcoholic drinks and/or that relate to the treatment of problem drinkers) be- cause we wished to focus on preventive public health strategies; and we were not implemented in any of the nine study areas under investigation (e.g. minimum pricing). Each policy was rated according to level of stringency and enforcement (Appendix A). Briefly, stringency refers to the relative strictness of a given policy. For example, limiting the age of those who can purchase alcohol to 16, 17, 18, 19 or ≥ 20 year-olds, reflects increasingly stringent policy positions on controlling the availability of alcohol. Enforcement refers to the strength at which a given policy is implemented in practice. We divided levels of enforcement into three categories: (i) poor – reflecting policies that were rarely or poorly enforced, or instances where no legislation or enforceable powers were in place; (ii) moderate – referring to policies that had limited or occasional enforcement or were enforced only when violations were reported or blatant; and (iii) strong – reflecting widely enforced policies. Although TEASE-16 builds on Brand et al.’s Alcohol Policy Index,13 the scales differ in terms of policy conceptualizations, effectiveness rat- ings, inclusion of enforcement ratings, the development of three alternative weighting schemes combining strin- gency and enforcement ratings, and the use of income-adjusted estimates of alcohol consumption per capita (Appendix A). Scoring and sensitivity analyses Each of the 16 policy topics was al- located a maximum potential number of points based on peer-reviewed as- sessments of effectiveness in reducing the adverse effects of alcohol (Table 1). Proportionate points were then allo- cated according to the particular level of stringency and enforcement. For each study area, scores across all 16 policy topics were collated to yield an overall score ranging between 0 and 100. Then study areas were rank ordered. To examine the robustness of TEASE-16, we applied different weight- ing methods to each policy topic ac- cording to its effectiveness rating and subsequently calculated the correspond- ing proportionate point scores. We tested alternative weighting methods to avoid the risk of study areas rejecting TEASE-16 on the grounds that a par- ticular weighting scheme was unfairly punitive. In total, four different weighting methods were used to assign strin- gency and enforcement points: base- line, heavy, equal and area-specific. In baseline weighting, weights of 1, 2 and 3 were applied to policy topics with one-, two- and three-star effectiveness ratings, respectively. Heavy weighting used corresponding weights of 1, 3 and 5 whereas equal weighting assigned the same weight to all policies regardless of effectiveness ratings. Area-specific weights were also derived – using data envelopment analysis18 and implement- ed with the Solver add-in for Excel 2010 (Microsoft, Redmond, United States of America) – in a manner that optimized a study area’s relative performance. Area-specific weights were constrained to reflect effectiveness ratings (i.e. a three-star policy topic received a greater weight than a two-star policy and a two-star topic received a greater weight than a one-star policy). Additional constraints were specified to ensure that the area-specific weights were plausible and to avoid instances where a study area might be awarded a perfect rating because zero weights had been allocated to policy topics that had minimal strin- gency. For example, the area-specific weights were constrained so that the maximum weight was less than 12-fold higher than the minimum weight. For each of the four weighting schemes, three methods were used to yield combined ratings for stringency and enforcement (see Appendix A). In one method – 50:50 combination – equivalent points were allocated to stringency and enforcement. In another method – 25:75 combination – a quarter of the points were assigned to stringency Domain, policy topic Effectiveness star ratinga Level of stringency Level of enforcementb Mandatory penalties for exceeding the legal maximum blood alcohol concentration 2 No penalty Poor, moderate or strongFine Penalty points Disqualification or licence suspension Imprisonment Other Graduated licensing for young drivers 2 No Poor, moderate, or strongYes a Policies that were considered to be effective in reducing the adverse effects of alcohol were given one-, two- and three-star ratings, respectively.2 b Poor reflects policies that were rarely or poorly enforced, or instances where no legislation or no enforceable powers were in place; moderate refers to policies that had limited or occasional enforcement, or were enforced only when violations were reported or blatant; and strong reflects widely enforced policies. c Price indexes were calculated using guidelines by Brand et al.13 The price index refers to the retail price (including alcohol taxes) for a standard size beverage container (0.5 L beer, 0.75 L wine or 0.75 L spirits), taking into account a country’s standard of living. This adjustment involves dividing the retail price by the per capita share of a country’s gross domestic product and subsequently multiplying the result by 10 000 to yield a price index with an approximate range of 0–20. (. . .continued) Bull World Health Organ 2014;92:726–733| doi: http://dx.doi.org/10.2471/BLT.13.130708 729 Research Alcohol control policies in the western PacificNatacha Carragher et al. and the remainder to enforcement. In the third method – multiplicative com- bination – stringency ratings were mul- tiplied by a third of the raw enforcement rating. All calculations were conducted in Excel 2010. Data retrieval Since low-income nations generally have a greater disease burden per unit of alco- hol consumption than high-income na- tions,19 we retrieved alcohol policy and consumption data from both developed areas of the western Pacific (Australia, China excluding Hong Kong Special Administrative Region (SAR), Hong Kong SAR, Japan, New Zealand and Singapore) and developing areas (Ma- laysia, the Philippines and Viet Nam).20 These nine study areas are economically diverse and geographically widespread; they have different epidemiological profiles and reflect a range of cultural, religious and social practices relating to alcohol use. Policies We obtained data on stringency and enforcement from peer-reviewed papers and WHO reports published between 2008 and 2012, as well as government and related public health websites. A full list of the data sources is available from the corresponding author. Where information was unclear or outdated, we verified policies with the relevant public health and government officials in August–October 2012. This ensured that we included the most up-to-date legislation and that policy topics were correctly weighted. Extensive efforts were undertaken to cross-reference data to ensure accuracy. Complete informa- tion on stringency and enforcement was retrieved for all 16 policy topics in each of the nine study areas. Alcohol consumption For each study area, an estimate of the average percentage of alcohol by volume was used to convert total volume of alcoholic drinks sold in 201121–29 into total volume of alcohol consumed in pure alcohol. The result was then mul- tiplied by 1 000 000 and divided by the population estimate, in millions, for the study area– obtained via the websites of the relevant national statistics agency and verified by officials – to yield an estimate of the mean volume of alcohol consumed per capita in 2011. Since al- cohol consumption is positively related to income,2 we divided each estimate by the relevant gross domestic product per capita – reported in international dollars using purchasing power parity exchange rates30 – to yield an income- adjusted estimate of alcohol consump- tion per capita for the year 2011 in each study area. Analysis For each study area, we calculated alcohol policy scores using 12 sets of assumptions – reflecting the four weighting methods and three methods for combining ratings of stringency and enforcement. To facilitate comparisons, we calibrated the scores generated under each set of assumptions to yield equiva- lent ranges. Subsequently, we identified the median rank and overall score for all 12 assumptions for each study area. We then calculated Pearson’s or Spearman’s correlation coefficients – as appropri- ate – to compare these medians with the corresponding baseline ranks (i.e. those produced using baseline weighting). Additionally, we calculated correlations using the extreme values – rather than medians – to provide a measure of the robustness of TEASE-16. To evaluate the relationship between policy scores and income-adjusted alcohol consump- tion per capita, we performed a simple linear regression in SPSS (SPSS Inc., Chicago, USA). Results Strength of policy frameworks We compared the comprehensiveness of alcohol control policies in nine study areas in the western Pacific by calculat- ing a rating for each regulatory domain (Table 2). Overall, the median rating was 56.4 points – out of a possible 100 points – with ratings ranging from 24.1/100 in the Philippines to 67.5/100 in Australia. The nine study areas received median domain ratings of 5.9/28.9 points for physical availability policies, 3.9/10.5 points for drinking context policies, 18.4/23.7 points for alcohol pricing policies, 0.4/2.6 points for alcohol ad- vertising policies and 23/34.2 points for motor vehicle regulations. Policy scores and alcohol consumption A strong inverse relationship was ob- served between income-adjusted levels of alcohol consumption per capita and alcohol policy scores (r = −0.88; P = 0.001; Fig. 1). To exclude price de- mand influences, we recalculated alco- hol policy scores after removing alcohol prices from the model. This resulted in a minor change to the observed relation- ship (r = −0.83; P = 0.003). Based on the slope of the regression line, a one-point increase in alcohol policy score equated to a 1.8% decrease in income-adjusted Table 2. TEASE-16 alcohol policy scores for nine study areas in the western Pacific, 2011 Study area Rank Points scored Physical availability Drinking context Alcohol prices Alcohol advertising Motor vehicle regula- tions Total Australia 1 11.2 5.3 18.4 0.4 32.2 67.5 Singapore 2 14.5 5.3 23.7 0.4 20.5 64.4 New Zealand 3 3.9 3.9 23.7 0.4 30.3 62.3 Hong Kong SAR 4 10.5 5.3 17.8 1.5 23.0 58.1 Japan 5 5.9 3.9 21.1 0.4 25.0 56.4 Malaysia 6 9.6 3.9 23.7 2.0 16.6 55.8 Chinaa 7 5.9 0.0 17.8 0.0 26.4 50.1 Viet Nam 8 5.9 7.9 11.8 2.6 13.6 41.8 Philippines 9 5.9 0.0 17.8 0.4 0.0 24.1 Median 5.9 3.9 18.4 0.4 23.0 56.4 Maximum points available 28.9 10.5 23.7 2.6 34.2 100 SAR: Special Administrative Region; TEASE-16: Toolkit for Evaluating Alcohol policy Stringency and Enforcement-16. a Excluding Hong Kong SAR. Note: Low scores indicate scope for strengthening policies. Bull World Health Organ 2014;92:726–733| doi: http://dx.doi.org/10.2471/BLT.13.130708730 Research Alcohol control policies in the western Pacific Natacha Carragher et al. consumption of alcohol consumption per capita. Sensitivity analyses Rankings remained relatively stable across the 12 assumptions tested, with those of only three study areas – Hong Kong SAR, Japan and Malaysia – differ- ing by three positions (Table 3). Corre- lation analyses confirmed that median ranks (r = 0.98; P < 0.0001) and ratings (r = 1.0; P < 0.0001) differed minimally from the baseline ranks and ratings. Indeed, even when baseline ranks and ratings were compared with the ex- treme corresponding ranks (r = 0.97; P < 0.0001) and ratings (r = 0.97; P < 0.0001) from the 12 assumptions, correlation coefficients remained high. The negative relationship between me- dian ratings and consumption remained robust (r = −0.86, P = 0.003). Discussion Studies comparing alcohol policy frame- works and consumption across coun- tries are scarce.15 To address this gap, we developed and applied a tool to evaluate policies across nine study areas in the western Pacific. We found striking varia- tions in how policies were implemented. Among the nine study areas evaluated, the Philippines had the weakest alcohol policy framework whereas Australia had the strongest. Australia was particularly strong in relation to policies limiting driving while under the influence of alcohol and alcohol pricing policies. In Australia – as in most of the other study areas – alcohol advertising policies were relatively weak. In the Philippines, all regulatory domains were gener- ally weak, particularly those relating to drinking context and driving policies. Although we used TEASE-16 to evaluate alcohol control policies and consumption at a particular point in time, the tool could be used to evaluate policy changes and consumption within a study area over time. Under a log re- gression function, an increase in alcohol policy score would have a greater impact on consumption for study areas with weak policy frameworks than for study areas with strong policy frameworks. For example, targeted policy improvements resulting in a seven-point increase in the TEASE-16 score would reduce per capita consumption in the Philippines – per 1000 international dollars of gross domestic product – by 0.19 litres but the corresponding reduction in Japan would only be 0.09 litres. Like Brand et al.,13 we found that study areas with more stringent – and strongly enforced – alcohol policies had significantly lower levels of con- sumption. Although we recognize that there are many structural and contex- tual factors influencing the extent and patterns of alcohol consumption, the results indicate that alcohol consump- tion rates – whatever their causes and even after controlling for differences in income – are at least partially related to the strength of national alcohol control policies. In addition to the need for ongoing social and treatment programmes for in- dividuals and communities at high risk of alcohol-related harm, WHO encour- ages its Member States to regularly assess and refine their alcohol control policy frameworks.4,6 This paper highlights considerable scope for strengthening policies in the western Pacific, particu- larly in relation to the advertising and physical availability of alcohol. Our study has several limitations. First, considerable heterogeneity exists in alcohol policies and cultural differ- ences may affect the level of alcohol consumption per capita. These differ- ences are not captured in TEASE-16, which focuses on formal, national Fig. 1. Relationship between alcohol policy scores and income-adjusted alcohol consumption per capita, western Pacific, 2011 Singapore Malaysia Australia New Zealand Japan China (excluding Hong Kong SAR) Viet Nam Philippines Hong Kong SAR Alcohol consumption per capita adjusted for incomea 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 TE AS E- 16 p ol icy sc or e 100 90 80 70 60 50 40 30 20 10 0 GDP: gross domestic product; SAR: Special Administrative Region; TEASE-16: Toolkit for Evaluating Alcohol policy Stringency and Enforcement. a Litres per 1000 international dollars of GDP per capita. Note: Policy scores were determined for nine study areas using the TEASE-16. Table 3. TEASE-16 sensitivity analyses for nine study areas in the western Pacific, 2011 Study area Ranka Scorea Baseline Median Range Baseline Median Range Australia 1 1 1–2 67.5 62.2 36–83 Singapore 2 3 2–4 64.4 56.7 30–80 New Zealand 3 3 1–3 62.3 56.3 32–74 Hong Kong SAR 4 5 4–7 58.1 51.8 24–73 Japan 5 4 3–6 56.4 50.7 26–65 Malaysia 6 6 4–7 55.8 49.9 25–71 Chinab 7 7 5–7 50.1 46.7 22–58 Viet Nam 8 8 8–9 41.8 39.1 11–56 Philippines 9 9 8–9 24.1 20.9 8–26 SAR: Special Administrative Region; TEASE-16: Toolkit for Evaluating Alcohol policy Stringency and Enforcement-16. a In total, 12 alternative weighting methods were tested. The baseline model generated ranks and scores, whereas the remaining models generated medians and ranges. b Excluding Hong Kong SAR. Bull World Health Organ 2014;92:726–733| doi: http://dx.doi.org/10.2471/BLT.13.130708 731 Research Alcohol control policies in the western PacificNatacha Carragher et al. alcohol policies. Nevertheless, where possible, we attempted to minimize the effects of differences within study areas. For Australia, for example, we collected data from all eight states and territories for each policy topic and then used the general consensus to reflect the national position. Second, although TEASE-16 assesses a panoply of alcohol control policies, it does not cover the full spec- trum of policies. However, as Karlsson and Österberg point out,11 it would be laborious – if not impossible – to do this, as there are over 100 relevant policies. Third, it is well recognized in the literature that there is a close relation- ship between national affluence and alcohol consumption.31 For this reason, we adjusted consumption estimates to take account of each study area’s per capita gross domestic product. However, the extent and patterns of alcohol con- sumption in any nation are not entirely determined by regulatory framework and affluence.31,32 Many other factors (e.g. socioeconomic factors, physical environment, biological and genetic fac- tors, access to health-care services and facilities, and individual characteristics) are involved. Any observed disparities in consumption patterns may therefore result from the complex interplay of a variety of structural and contextual factors. In designing and implementing effective alcohol control policies, it is important to account for this panoply of mitigating factors and to adopt a coordinated response. Fourth, the cross-sectional nature of this study means that a causal rela- tionship between alcohol policy scores and income-adjusted estimates of per capita alcohol consumption cannot be inferred. Fifth, cross-national compari- sons will necessarily restrict sample size because the collection of policy data and the cross-referencing of sources are so time-consuming. The use of small sample sizes reduces statistical power and increases the likelihood of potential bias from outliers. Accordingly, caution should be exercised in extrapolating this study’s findings beyond the study areas examined. However, since our finding of an inverse relationship between alcohol policy scores and alcohol consumption remained robust across 12 alternative weighting schemes – and matches the conclusions drawn by Brand et al.,13 who analysed alcohol policies in 30 countries – we can conclude there was little bias in our study. Sixth, although enforcement is a critical component of policy evalua- tion, its measurement presents a chal- lenge due to the difficulty in securing objective data. To minimize bias, we attempted to verify enforcement data by cross-referencing information with numerous officials and against relevant statistics. Finally, while TEASE-16 ap- pears to be reliable and have content, face and criterion validity; construct validity and test–retest reliability have yet to be established. Despite its shortcomings, TEASE-16 has numerous benefits. First, TEASE-16 provides an updated, empirical synopsis of national policies across several study areas. Second, by reducing a vast amount of data into a single score, the tool is useful for facilitating communication with the general public, public health advocates and policy-makers. Third, TEASE-16 overcomes limitations of previous alcohol policy scales. In the future, TEASE-16 could be used to conduct a more nuanced examination of the relationship between targeted poli- cies (e.g. measures taken against driving while under the influence of alcohol) and specific outcomes (e.g. numbers of alcohol-related road traffic accidents and fatalities). In summary, this paper presents an empirical tool for the comprehen- sive assessment of the stringency and enforcement of alcohol control poli- cies. TEASE-16 could be employed by national policy-makers and regulatory bodies to identify opportunities for developing or refining national policy frameworks and measuring the impact of policy changes on consumption. If risky alcohol consumption and related harms are to be reduced in the west- ern Pacific, efforts could be targeted towards strengthening weak policies, such as those relating to alcohol ad- vertising. ■ Acknowledgements We thank Louisa Degenhardt for her expert comments on an earlier version of this manuscript, Donald Brand for providing additional information on the Alcohol Policy Index and numerous officials for their help in retrieving and verifying the data that we analysed. Competing interests: None declared. صخلم ئدالها طيحلما برغ في قيبطتلا ؛لوحكلاب ةصالخا تاسايسلا مييقتل تاودأ ةعوممج ريوطت ةمئلام مييقت ةيغب اهاودجو تاودلأا ىدحإ ريوطت حشر ضرغلا تلاكشلماو لوحكلا كلاهتسا نم دحلل ةيمارلا ةينطولا تاسايسلا .هب ةلصلا تاذ ذافنلإاو ةماصرلا مييقتل تاودأ ةعوممج - ةيمك ةادأ انروط ةقيرطلا ىوتسم مييقتل - )TEASE-16( لوحكلاب ةصالخا تاسايسلا في قيبطت متو .ةشرع ةتسلا لوحكلا ةحفاكم تاسايس ذافنإو ةماصر قطانم عست نم ةدمتسلما ةسايسلا تانايب لىع TEASE-16 ءانثتساب ينصلاو ايلاترسأ :يه ،ئدالها طيحلما برغ في ةيسارد غنوك غنوه ميلقإو )SAR( صالخا يرادلإا غنوك غنوه ميلقإ ةروفاغنسو ينبلفلاو ادنليزوينو ايزيلامو نابايلاو صالخا يرادلإا دادترلااو طابترلاا تلايلتح مادختسا مت كلذ دعبو .مان تييفو لوحكلاب ةصالخا تاسايسلا تا�جرد ينب ةقلاعلا ةساردل .لخدلا باستحاب ةححصلما درفلل لوحكلا كلاهتسا تايوتسمو ةحفاكم تاسايس ذيفنت ةقيرط في ةيربك تافلاتخا دجوت جئاتنلا ،ةنكمم ةطقن 100 لصأ نمو .ئدالها طيحلما برغ في لوحكلا تحوارت TEASE-16 تاجرد عستلا ةيساردلا قطانلما تققح ضفخناو .ايلاترسلأ ةطقن 67.5 لىإ ينبلفلل ةطقن 24.1 نم لىع تلصح يتلا ةساردلا قطانم في درفلل لوحكلا كلاهتسا تاسايس رطأ لىإ يرشي امم - تاسايسلاب قلعتي مايف ةيلاع تاجرد تاجردلا ءاقب لىإ ةيساسلحا تلايلتح تراشأو .ًايبسن ةيوق لوحك تاططمخ برع ًايبسن ةتباث ةساردلا قطانم نم ةقطنم لك في بتارلماو .ةيوق تناك TEASE-16 نأ لىإ يرشي امم ،ةفلتخلما حيجترلا وعناصو ةينطولاو ةيلودلا ةيميظنتلا تائيلها عيطتست جاتنتسلاا تاسايس ميمصت هيجوتل TEASE-16 مادختسا تاسايسلا لوحكلا كلاهتسا نم دلحا ةيغب اهنيستحو اهريدقتو اهذيفنتو ةلاعف .هب ةلصلا تاذ تلاكشلماو Bull World Health Organ 2014;92:726–733| doi: http://dx.doi.org/10.2471/BLT.13.130708732 Research Alcohol control policies in the western Pacific Natacha Carragher et al. 摘要 开发酒精政策评估工具包 : 在西太平洋地区的应用 目的 证明工具的开发和可行性 , 以评估旨在减少酒精 消费和相关问题的国家政策是否充分。 方法 我们开发了一个定量工具 ( 评估酒精政策严格性 和实施的工具包 ,TEASE-16) 来评估 16 项酒精控制政策 的严格性和实施水平。对西太平洋九个研究区域的政 策数据使用 TEASE-16: 澳大利亚、中国 ( 不包括香港 特别行政区 (SAR))、香港特别行政区、日本、马来西亚、 新西兰、菲律宾、新加坡和越南。然后使用相关性和 回归分析来检查酒精政策分数和人均酒精消费收入调 节水平之间的关系。 结果 在西太平洋地区如何实施酒精控制政策存在巨 大差异。在可能的 100 分中 , 九个研究区域的得分范 围从菲律宾的 24.1 分到澳大利亚的 67.5 分不等。研究 政策得分高的地区 ( 表示相对严厉的酒精政策框架 ) 人均饮酒量较低。敏感性分析显示每一个研究区域在 不同加权方案中的分数和排名保持相对稳定 , 这表明 TEASE-16 是可靠的。 结论 国际和国家监管机构和政策制定者可以使用 TEASE-16 来指导设计、实施、评价和优化有效的政策 以减少酒精消费和相关问题。 Résumé Développement d’un outil d’évaluation de la politique en matière d’alcool: application dans le Pacifique occidental Objectif Démontrer le développement et la faisabilité d’un outil pour évaluer l’adéquation des politiques nationales visant la réduction de la consommation d’alcool et des problèmes associés. Méthodes Nous avons développé un outil quantitatif permettant d’évaluer le niveau de sévérité et d’application de 16 politiques de lutte contre l’alcoolisme (TEASE-16 pour «Toolkit for Evaluating Alcohol policy Stringency and Enforcement»). TEASE-16 a été appliqué aux données des politiques issues de 9 zones d’étude dans le Pacifique occidental: l’Australie, la Chine en excluant la Région administrative spéciale (RAS) de Hong Kong, la RAS de Hong Kong, le Japon, la Malaisie, la Nouvelle- Zélande, les Philippines, Singapour et le Viet Nam. Des analyses de corrélation et de régression ont ensuite été utilisées pour examiner la relation entre les résultats des politiques en matière d’alcool et les niveaux de consommation par habitant, ajustés en fonction du revenu. Résultats D’énormes différences existent dans la manière de mettre en œuvre les politiques de lutte contre l’alcoolisme dans le Pacifique occidental. Sur un total de 100 points possibles, les 9 zones d’étude ont obtenu des résultats de TEASE-16 compris entre 24,1 points pour les Philippines et 67,5 points pour l’Australie. Les zones d’étude avec des résultats de politique élevés – indiquant des cadres juridiques en matière d’alcool relativement sévères – présentaient une consommation d’alcool par habitant plus faible. Les analyses de sensibilité indiquaient que les résultats et les classements pour chaque zone d’étude restaient relativement stables avec toutes les différentes méthodes de pondération, indiquant que TEASE-16 était fiable. Conclusion TEASE-16 pourrait être utilisé par les organismes de réglementation et les responsables politiques internationaux et nationaux pour guider la conception, la mise en œuvre, l’évaluation et l’amélioration des politiques en vigueur pour réduire la consommation d’alcool et les problèmes associés. Резюме Набор средств для оценки алкогольной политики; результаты применения в западной части Тихого океана Цель Продемонстрировать разработку и реализуемость инструмента для оценки пригодности национальных политик, направленных на сокращение потребления алкоголя и связанных с этим проблем. Методы Был разработан количественный инструмент – Набор средств для оценки строгости и реализации алкогольной политики (TEASE-16) – для оценки уровня строгости и реализации 16 различных политик по противодействию потреблению алкоголя. Набор инструментов TEASE-16 был применен к данным по реализации политики в девяти исследуемых регионах западной части Тихого океана: Австралии, Китае, за исключением Специального административного района Гонконг (САР Гонконг), Японии, Малайзии, Новой Зеландии, Филиппин, Сингапура и Вьетнама. Затем, с помощью корреляционного и регрессионного анализов было изучено отношение между оценками политики и уровнями потребления алкоголя на душу населения с поправкой на уровень доходов. Результаты Существуют значительные различия в реализации политик по противодействию потреблению алкоголя в западной части Тихого океана. Из возможных 100 баллов набранные девятью регионами оценки TEASE-16 варьировались в диапазоне от 24,1 баллов (Филиппины) до 67,5 баллов (Австралия). Исследуемые регионы, получившие высокие оценки политики — указывающие на относительно жесткие рамки политики по противодействию потреблению алкоголя, — имели более низкое потребление алкоголя на душу населения. Анализы чувствительности показали, что оценки и рейтинги для каждого исследуемого региона оставались относительно стабильными при использовании различных средневзвешенных схем подсчета, что указывает на функциональность TEASE-16. Вывод TEASE-16 мог бы использоваться международными и национальными регулирующими и директивными органами для разработки, реализации, оценки и уточнения эффективных политик по снижению потребления алкоголя и связанных с этим проблем. Bull World Health Organ 2014;92:726–733| doi: http://dx.doi.org/10.2471/BLT.13.130708 733 Research Alcohol control policies in the western PacificNatacha Carragher et al. Resumen Desarrollo de un conjunto de herramientas de evaluación de las políticas relativas al alcohol en el Pacífico Occidental Objetivo Demostrar el desarrollo y la viabilidad de un instrumento para evaluar la adecuación de las políticas nacionales destinadas a reducir el consumo de alcohol y los problemas relacionados con este. Métodos Hemos desarrollado una herramienta cuantitativa - Toolkit for Evaluating Alcohol policy Stringency and Enforcement (TEASE-16) - para evaluar el nivel de rigor y de cumplimiento de 16 políticas de control del alcohol. Se aplicó el TEASE-16 a datos de políticas de nueve áreas de estudio en el Pacífico Occidental: Australia, China, excepto la Región Administrativa Especial (RAE) de Hong Kong, RAE Hong Kong, Japón, Malasia, Nueva Zelandia, Filipinas, Singapur y Viet Nam. Se emplearon análisis de correlación y regresión para examinar la relación entre las puntuaciones de las políticas relativas al alcohol y los niveles ajustados por ingresos de consumo de alcohol per cápita. Resultados El modo de implementar las políticas de control del alcohol en el Pacífico Occidental presenta grandes diferencias. De los 100 puntos posibles, las nueve áreas de estudio lograron puntuaciones TEASE-16 que variaron de 24,1 puntos para Filipinas a 67,5 puntos para Australia. Las áreas de estudio cuyas políticas obtuvieron los resultados más altos, que indican marcos normativos relativos para el alcohol relativamente sólidos, presentaron un consumo de alcohol per cápita menor. 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