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It is well reported that alcohol, especially consumed in large amounts, can have negative effects on the drinker and on others. It has the potential to cause harm to health via three broad mechanisms: toxicity, intoxication and dependence, and is strongly linked to over 60 negative health outcomes.1,2 Research has also identified a variety of social harms to drinkers and those around them including legal problems, harmful impacts on employment, finances, relationships with family and friends and problems with violence.3A recent cross-sectional survey of New Zealand adults found that exposure to heavy drinkers had a negative impact on an individual's self-reported wellbeing and health status.4Alcohol is the most commonly used recreational drug in New Zealand, as it is in many countries, but alcohol-related harms are not well characterised or widely appreciated. While particular consumption patterns are associated with more harm, demographic and social factors may also change the likelihood of individuals experiencing alcohol-related harm.2There is plenty of international research to demonstrate that individuals with higher average alcohol intake are at increased risk, and that pattern of consumption is also an important factor in the risk of experiencing alcohol-related harms, with regular heavy episodic drinkers being at significantly more risk of harm.3,5,6 Many studies have shown that men and young people have higher risk of both heavy episodic drinking and of alcohol-related harms.6,7The New Zealand Law Commission's review of alcohol use in New Zealand concluded that over 80% of New Zealand adults drank alcohol at least occasionally and that approximately a quarter of the adult population reported drinking large quantities when they drink. This suggests a significant proportion of the population is likely to be contributing to harm to themselves and others.2There is some recent literature that has reported the experience of alcohol-related harm in the New Zealand population. On a population level the 2007/08 New Zealand Alcohol and Drug Use Survey collected data on both consumption patterns and harm from drinking. Current drinkers were asked if there had been a time when they felt their alcohol use had had a harmful effect on their friendships or social life, home life, work, study or employment opportunities, financial position, legal problems, difficulty learning or physical health/injury.8 In this sample, 12.2% of current drinkers reported having experienced at least one of the problems listed, with men, people in the youngest age group, people of Māori ethnicity and those living in the most deprived areas at significantly increased risk.8 This reflected the findings of the earlier Health Behaviours Survey (2004) which also found males and people of Māori ethnicity to be at increased risk of harm.9A national survey of drinking in New Zealand in 2000 asked respondents about their experience of 15 alcohol-related problems (which varied in severity) in the previous year. The survey found that 61% of men and 49% of women reported having experienced at least one of the 15 problems, while 11% of men and 7% of women reported experiencing five or more.10 A 2005 study of New Zealand University students found that heavy episodic drinking and associated harms to health and social factors were common amongst students.11Alcohol-related harm is not confined to the individual doing the drinking. Many of the consequences drinkers experience as a result of their own drinking can also have negative effects on those around them. A 2009 New Zealand study on physical and sexual assault showed that alcohol use by someone other than the victim of the assault is involved in over half of reported events.12Also, a recent paper on the involvement of alcohol in aggression between intimate partners showed that the involvement of alcohol in partner aggression was associated with increased severity of aggression and that a pattern of heavy episodic drinking was associated with higher reporting of aggression within intimate relationships.13The aims of this study were to: Examine the prevalence and distribution of two groups of negative drinking-related experiences in a sample of New Zealand adults. These were: 1. subjectively assessed adverse effects of drinking, including effects on family, finances and physical health, and 2. the experience of alcohol-related troubles, more objective events such as trouble with the law, loss of job, and aggression due to alcohol. Examine factors associated with higher risk of experiencing these harms and troubles. Methods Setting—In 2007, New Zealand had a population of approximately 4 million people, with 77% of people listing their ethnicity as European, 15% as Māori, 7% as Pacific, 10% as Asian and 1% as Other (percentages add to more the 100% as individuals can identify as having more than one ethnicity).14 Participants and procedures—This was a cross-sectional survey of a nationally representative sample of New Zealand residents aged 18-80 years, randomly selected from the electoral roll, conducted using a postal questionnaire that was completed by the respondent and mailed back to the investigators in a reply-paid envelope. The data collection methods have been described in more detail in a study of alcohol involvement in partner aggression in New Zealand.13 Measures—The questionnaire was based on the expanded core GENACIS questionnaire from the International Research Group on Gender and Alcohol (IRGGA). A copy of this questionnaire is available at the following link: www.genacis.org/questionnaires/exp_core.pdf This questionnaire has been used in approximately 40 countries to provide data that are directly comparable for cross-national studies.15 The questionnaire contained 100 items and took 20-30 minutes to complete. It covered the following areas: demographic information (age, sex and ethnicity), social networks, respondent's alcohol consumption, drinking contexts, drinking consequences, intimate relations and sexuality, violence and victimization, and health and lifestyle. From the residential address listed on the electoral roll a New Zealand Deprivation Index 2006 (NZDep06) decile was obtained for each respondent and used as an indicator of socioeconomic position. NZDep06 is a small area deprivation measure, based on 9 items from the national census at the meshblock level. Meshblocks are the smallest unit of the census and include about 100 residents on average. NZDep06 deciles assign a score of 1-10 to participants on the basis of their residential address, with 1 representing the least, and 10 the most, deprived 10% of the population.16 Ethnicity was categorised as European, Asian, Māori and Other, due to small numbers of participants of other ethnicity. Alcohol consumption—Respondents were asked about drinking frequency and quantity of alcohol consumed per typical drinking occasion in the previous 12 months. Quantities of alcohol were reported in standard drinks (defined as 10g of pure ethanol). A pictorial guide was provided to assist participants to convert common beverages to standard drinks. Harms and troubles due to drinking—Current drinkers (having consumed any alcohol in the previous 12 months) were asked about drinking-related adverse experiences. These experiences were divided into two categories. Drinking-related harms were self-assessed personal problems resulting from an individual's drinking. Drinking-related troubles encompassed legal and social problems that the respondents could have experienced due to their heavy drinking. These related to specific, more objective events.17 Harms: In the last 12 months has your drinking had a harmful effect on: (1) work, studies or employment opportunities, (2) housework or chores around the house, (3) marriage/intimate relationships, (4) relationships with other family members, including children, (5) friendships and social life, (6) physical health, (7) finances. Responses for each item were no, yes once or twice, or yes more than twice. Troubles: In the last 12 months have you had any of the following experiences? (1) trouble with the law about your drinking and driving, (2) an illness connected with your drinking that kept you from working or your regular activities for a week or more, (3) lost a job, or nearly lost one, because of your drinking, (4) been annoyed by people criticising your drinking, (5) had a spouse or someone you lived with threaten to leave or actually leave due because of your drinking, (6) lost a friendship because of your drinking, (7) got into a fight while drinking. Responses for each item were no, yes once or twice, or yes more than twice. Analysis Drinking behaviours: Two drinking variables were used in these analyses. Heavy episodic drinking (HED) was defined as 5 or more drinks per occasion at least once a month in the past year, and high average daily consumption was defined as more than 20 grams of pure alcohol per day for women; and more than 30 grams per day for men. These correspond to the maximum consumption levels recommended by the Alcohol Advisory Council of New Zealand.18 Experience of alcohol-related harms and troubles: The prevalence of each harm and trouble as well as the prevalence of experiencing any alcohol-related harm or trouble in the last 12 months was calculated for the sample. Regression models—Logistic regression models were used to calculate the odds of respondents identified as current drinkers reporting any alcohol-related harm and trouble in the past year by sex, age, NZDep06 quintile, ethnicity, heavy episodic drinking in the past 12 months, and average daily consumption. Odds ratios for each variable were calculated controlling for all other variables. 95% confidence intervals were calculated for all odds ratios. Ethical approval—This study was conducted with the approval of the University of Otago Human Ethics Committee (06/171). Results Characteristics of the study population—There was a response rate of 49.5% for the survey with 1924 completed surveys returned and 110 people found to be ineligible. Of the sample 1723 (89.6%) were identified as current drinkers (having consumed alcohol in the previous 12 months). Table 1 shows the basic demographics and drinking behaviours for the current drinker population (n=1723). The sample over represented women and people aged 35 years and underrepresented people from the most deprived NZDep06 levels. The sample was predominately European, and under-represented those of Māori and Asian ethnicity. The proportion of male respondents identified as heavy episodic drinkers was almost twice that of female respondents (27.9% versus 14.7%), while men and women had similar proportions of people in each average daily consumption level. Experience of alcohol-related harms and troubles—Among respondents identified as current drinkers 36.2% reported experiencing any alcohol-related adverse event. Having experienced any alcohol-related harm in the past 12 months was reported by 33.8% of current drinkers (29.8% of women and 39.0% of men) and 12.7% reported having experienced any alcohol-related trouble (9.9% of women and 16.4% of men). The prevalence of current drinkers experiencing three or more alcohol-related harms in the previous year was 13.4% while the prevalence of experiencing three or more troubles was only 1.4%. Table 2 shows the prevalence of each of the 7 harms and 7 troubles in current drinkers. The most reported harm was that respondents drinking had a harmful effect on their physical health (18.0% once or twice in 12 months, 3.8% more than twice in the previous year. Harmful effects on housework, intimate relationships and finances were also common amongst this current drinker population. Table 1. Characteristics of current drinker population and distributions of alcohol-related variables Variable** n*(%) Heavy episodic drinking (%) High average consumption† (%) Any harm (%) Any trouble (%) Gender Male Female 760 (44.1) 963 (55.9) 27.9 14.7 14.2 15.9 39.0 29.8 16.4 9.9 Age 18-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-70 years 129 (7.5) 264 (15.3) 390 (22.6) 452 (26.2) 362 (21.0) 126 (7.3) 48.4 29.8 19.6 19.5 8.9 10.7 14.6 10.9 10.9 18.7 15.2 25.9 58.9 44.1 37.3 33.1 20.9 10.8 41.7 16.9 11.6 11.7 4.9 2.7 NZDep06 1-2 3-4 5-6 7-8 9-10 450 (26.6) 408 (24.1) 352 (20.8) 272 (16.1) 213 (12.6) 16.6 24.0 18.4 20.9 27.2 14.5 17.3 13.7 15.8 15.4 28.2 36.6 34.4 30.8 45.0 9.1 13.1 13.0 11.4 21.4 Ethnicity European Asian Māori Other 1468 (85.3) 66 (3.8) 147 (8.6) 37 (2.2) 19.6 10.3 35.3 25.0 15.8 1.8 15.6 6.9 32.0 26.6 57.0 29.0 10.9 3.1 34.1 20.6 *Due to rounding percentages do not always add to 100%; **Where there was missing data (<5% of sample in all cases) for a variable those individuals were excluded from that analysis. †More than 20 grams per day for women, more than 30grams per day for men. Table 2. Prevalence of alcohol-related harms and troubles in current drinkers In the last 12 months has YOUR drinking had a harmful effect on your: No (%) Yes, once or twice (%) Yes, more than twice (%) Work, studies or employment opportunities Housework or chores around the house Marriage/intimate relationship Relationships with other family members Friendships or social life Physical health Finances 94.4 83.4 87.2 93.3 93.9 78.2 87.9 4.1 13.2 10.9 5.7 5.4 18.0 8.3 1.5 3.4 2.0 1.0 0.7 3.8 3.8 In the last 12 months have you had one of the following experiences:

Summary

Abstract

Aim

To quantify the prevalence and distribution of negative effects of drinking among New Zealand adults.

Method

A postal survey was completed by 1924 people aged 18-70 randomly selected from the New Zealand electoral roll (49.5% response). Information on drinking patterns, demographics and specific alcohol-related harms and troubles in the previous 12 months was collected.

Results

33.8% of current drinkers reported that they had been adversely affected by their own drinking in one or more specified domains in the past 12 months (charmd) and 12.7% reported one or more specified alcohol-related ctroublesd. Men were more likely to report alcohol-related harm (OR=1.3; 95% confidence interval [CI] 1.0-1.7) and alcohol-related trouble (OR=1.5; 95%CI 1.1-2.1) compared to women. People of M ori ethnicity and those with an NZDep06 score of 9-10 were at increased risk of both harms and troubles. The odds of reporting a harm or trouble in the past year decreased substantially with age. Heavy episodic drinking and level of average daily consumption were both associated with increased risk of both alcohol-related harm and trouble, but this did not explain all of the variation.

Conclusion

Prevalence of harm and trouble resulting from drinking is high in the general population as judged by the drinkers themselves. These findings support the association of heavy alcohol consumption with increased risk of alcohol-related harm. They also suggest that being male, young, M ori or living in a very deprived area in NZ are associated with a higher risk of alcohol-related harm.

Author Information

Jessica Meiklejohn, Jennie Connor; Department of Preventive and Social Medicine, University of Otago, Dunedin. Kypros Kypri; Injury Prevention Research Unit, Department of Preventive and Social Medicine, University of Otago, Dunedin & Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, University of Newcastle, NSW, Australia.

Acknowledgements

This survey was funded by an Otago University Research Grant and Jessica Meiklejohn was supported by a scholarship from the Alcohol Advisory Council of New Zealand. We also thank Kimberly Cousins for coordinating data collection and Dr Ari Samaranayaka for providing statistical advice.

Correspondence

Jessica Meiklejohn, Department of Preventive and Social Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand. Fax: +64 (0)3 4797298

Correspondence Email

jessica.meiklejohn@otago.ac.nz

Competing Interests

Rehm J, Room R, Graham K, et al. Alcohol as a Risk Factor for Global Burden of Disease. European Addiction Research. 2003;9:157-164.Law Commission. Alcohol in our lives: An issues paper on the reform of New Zealand's liquor laws. Wellington: Law Commission; 2009.Rehm J, Gmel G. Patterns of alcohol consumption and social consequences. Results from an 8-year follow-up study in Switzerland. Addiction. 1999;94:899-912.Casswell S, Quan You R, Huckle T. Alcohol's harm to others: reduced wellbeing and health status for those with heavy drinkers in their lives. Addiction. 2011;106:1087-1094.Room R, Bondy S, Ferris J. The risk of harm to oneself from drinking, Canada 1989. Addiction. 1995;90:499-513.Makela K, Mustonen H. Positive and negative experiences related to drinking as a function of annual alcohol intake. British Journal of Addiction. 1988;83:403-408.Makela K, Mustonen H. Relationships of drinking behaviour, gender and age with reported positive and negative experiences related to drinking. Addiction. 2000;95:727-736.Ministry of Health. Alcohol use in New Zealand - Key results of the 2007/08 New Zealand Alcohol and Drug Use Survey. Wellington: Ministry of Health; 2009.Stefanogiannis N, Mason K, Yeh LC. Alcohol use in New Zealand: Analysis of the 2004 New Zealand Health Behaviours Survey - Alcohol Use. Public Health Intelligence. Wellington: Ministry of Health; 2007.Habgood R, Caswell S, Pledger M, Bhatta K. Drinking in New Zealand: National surveys comparison 1995 & 2000. Auckland: Alcohol and Public Health Research Unit; 2001.Kypri K, Paschall M, Langley J, et al. Drinking and alcohol-related harm among New Zealand university students: findings from a national web-based survey. Alcoholism: Clinical and experimental research. 2009;33:307-314.Connor J, You R, Casswell S. Alcohol-related harm to others: a survey of physical and sexual assault in New Zealand. N Z Med J. 2009;122:10-20. http://journal.nzma.org.nz/journal/122-1303/3793/content.pdfConnor J, Kypri K, Bell M, Cousins K. Alcohol involvement in aggression between intimate partners in New Zealand: a national cross-sectional study. BMJ Open. 2011; 1(1): e000065Ministry of Social Development. Ethnic composition of the population. 2010 16/11/2010].http://www.webcitation.org/5uHD62Y0RWilsnack RW, Wilsnack SC, Kristjanson AF, et al. Gender and alcohol consumption: patterns from the multinational GENACIS project. Addiction. 2009;104:1487-1500.Salmond C, Crampton P, Atkinson J. NZDep 2006 Index of Deprivation. Wellington: Department of Public Health, University of Otago; 2007.Connor J, Kypri K, Bell M, Cousins K. Alcohol outlet density, levels of drinking and alcohol-related harm in New Zealand:a national study. Journal of Epidemiology and Community Health. 2010;65:841-846.ALAC. Upper limits for responsible drinking: Policy Statement 6. Wellington: Alcohol Advisory Council of New Zealand; 2002.Meiklejohn J, Connor J, Kypri K. The Effect of Low Survey Response Rates on Estimates of Alcohol Consumption in a General Population Survey. PLoS ONE. 2012;7:e35527.Kypri K, Samaranayaka A, Connor J, et al. Non-response bias in a web-based health survey of New Zealand tertiary students. Preventive Medicine. 2011;53:274-277.Babor T, Caetano R, Casswell S, et al. Alcohol: No ordinary commodity - Research and Public Policy. Oxford: Oxford University Press; 2003.

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It is well reported that alcohol, especially consumed in large amounts, can have negative effects on the drinker and on others. It has the potential to cause harm to health via three broad mechanisms: toxicity, intoxication and dependence, and is strongly linked to over 60 negative health outcomes.1,2 Research has also identified a variety of social harms to drinkers and those around them including legal problems, harmful impacts on employment, finances, relationships with family and friends and problems with violence.3A recent cross-sectional survey of New Zealand adults found that exposure to heavy drinkers had a negative impact on an individual's self-reported wellbeing and health status.4Alcohol is the most commonly used recreational drug in New Zealand, as it is in many countries, but alcohol-related harms are not well characterised or widely appreciated. While particular consumption patterns are associated with more harm, demographic and social factors may also change the likelihood of individuals experiencing alcohol-related harm.2There is plenty of international research to demonstrate that individuals with higher average alcohol intake are at increased risk, and that pattern of consumption is also an important factor in the risk of experiencing alcohol-related harms, with regular heavy episodic drinkers being at significantly more risk of harm.3,5,6 Many studies have shown that men and young people have higher risk of both heavy episodic drinking and of alcohol-related harms.6,7The New Zealand Law Commission's review of alcohol use in New Zealand concluded that over 80% of New Zealand adults drank alcohol at least occasionally and that approximately a quarter of the adult population reported drinking large quantities when they drink. This suggests a significant proportion of the population is likely to be contributing to harm to themselves and others.2There is some recent literature that has reported the experience of alcohol-related harm in the New Zealand population. On a population level the 2007/08 New Zealand Alcohol and Drug Use Survey collected data on both consumption patterns and harm from drinking. Current drinkers were asked if there had been a time when they felt their alcohol use had had a harmful effect on their friendships or social life, home life, work, study or employment opportunities, financial position, legal problems, difficulty learning or physical health/injury.8 In this sample, 12.2% of current drinkers reported having experienced at least one of the problems listed, with men, people in the youngest age group, people of Māori ethnicity and those living in the most deprived areas at significantly increased risk.8 This reflected the findings of the earlier Health Behaviours Survey (2004) which also found males and people of Māori ethnicity to be at increased risk of harm.9A national survey of drinking in New Zealand in 2000 asked respondents about their experience of 15 alcohol-related problems (which varied in severity) in the previous year. The survey found that 61% of men and 49% of women reported having experienced at least one of the 15 problems, while 11% of men and 7% of women reported experiencing five or more.10 A 2005 study of New Zealand University students found that heavy episodic drinking and associated harms to health and social factors were common amongst students.11Alcohol-related harm is not confined to the individual doing the drinking. Many of the consequences drinkers experience as a result of their own drinking can also have negative effects on those around them. A 2009 New Zealand study on physical and sexual assault showed that alcohol use by someone other than the victim of the assault is involved in over half of reported events.12Also, a recent paper on the involvement of alcohol in aggression between intimate partners showed that the involvement of alcohol in partner aggression was associated with increased severity of aggression and that a pattern of heavy episodic drinking was associated with higher reporting of aggression within intimate relationships.13The aims of this study were to: Examine the prevalence and distribution of two groups of negative drinking-related experiences in a sample of New Zealand adults. These were: 1. subjectively assessed adverse effects of drinking, including effects on family, finances and physical health, and 2. the experience of alcohol-related troubles, more objective events such as trouble with the law, loss of job, and aggression due to alcohol. Examine factors associated with higher risk of experiencing these harms and troubles. Methods Setting—In 2007, New Zealand had a population of approximately 4 million people, with 77% of people listing their ethnicity as European, 15% as Māori, 7% as Pacific, 10% as Asian and 1% as Other (percentages add to more the 100% as individuals can identify as having more than one ethnicity).14 Participants and procedures—This was a cross-sectional survey of a nationally representative sample of New Zealand residents aged 18-80 years, randomly selected from the electoral roll, conducted using a postal questionnaire that was completed by the respondent and mailed back to the investigators in a reply-paid envelope. The data collection methods have been described in more detail in a study of alcohol involvement in partner aggression in New Zealand.13 Measures—The questionnaire was based on the expanded core GENACIS questionnaire from the International Research Group on Gender and Alcohol (IRGGA). A copy of this questionnaire is available at the following link: www.genacis.org/questionnaires/exp_core.pdf This questionnaire has been used in approximately 40 countries to provide data that are directly comparable for cross-national studies.15 The questionnaire contained 100 items and took 20-30 minutes to complete. It covered the following areas: demographic information (age, sex and ethnicity), social networks, respondent's alcohol consumption, drinking contexts, drinking consequences, intimate relations and sexuality, violence and victimization, and health and lifestyle. From the residential address listed on the electoral roll a New Zealand Deprivation Index 2006 (NZDep06) decile was obtained for each respondent and used as an indicator of socioeconomic position. NZDep06 is a small area deprivation measure, based on 9 items from the national census at the meshblock level. Meshblocks are the smallest unit of the census and include about 100 residents on average. NZDep06 deciles assign a score of 1-10 to participants on the basis of their residential address, with 1 representing the least, and 10 the most, deprived 10% of the population.16 Ethnicity was categorised as European, Asian, Māori and Other, due to small numbers of participants of other ethnicity. Alcohol consumption—Respondents were asked about drinking frequency and quantity of alcohol consumed per typical drinking occasion in the previous 12 months. Quantities of alcohol were reported in standard drinks (defined as 10g of pure ethanol). A pictorial guide was provided to assist participants to convert common beverages to standard drinks. Harms and troubles due to drinking—Current drinkers (having consumed any alcohol in the previous 12 months) were asked about drinking-related adverse experiences. These experiences were divided into two categories. Drinking-related harms were self-assessed personal problems resulting from an individual's drinking. Drinking-related troubles encompassed legal and social problems that the respondents could have experienced due to their heavy drinking. These related to specific, more objective events.17 Harms: In the last 12 months has your drinking had a harmful effect on: (1) work, studies or employment opportunities, (2) housework or chores around the house, (3) marriage/intimate relationships, (4) relationships with other family members, including children, (5) friendships and social life, (6) physical health, (7) finances. Responses for each item were no, yes once or twice, or yes more than twice. Troubles: In the last 12 months have you had any of the following experiences? (1) trouble with the law about your drinking and driving, (2) an illness connected with your drinking that kept you from working or your regular activities for a week or more, (3) lost a job, or nearly lost one, because of your drinking, (4) been annoyed by people criticising your drinking, (5) had a spouse or someone you lived with threaten to leave or actually leave due because of your drinking, (6) lost a friendship because of your drinking, (7) got into a fight while drinking. Responses for each item were no, yes once or twice, or yes more than twice. Analysis Drinking behaviours: Two drinking variables were used in these analyses. Heavy episodic drinking (HED) was defined as 5 or more drinks per occasion at least once a month in the past year, and high average daily consumption was defined as more than 20 grams of pure alcohol per day for women; and more than 30 grams per day for men. These correspond to the maximum consumption levels recommended by the Alcohol Advisory Council of New Zealand.18 Experience of alcohol-related harms and troubles: The prevalence of each harm and trouble as well as the prevalence of experiencing any alcohol-related harm or trouble in the last 12 months was calculated for the sample. Regression models—Logistic regression models were used to calculate the odds of respondents identified as current drinkers reporting any alcohol-related harm and trouble in the past year by sex, age, NZDep06 quintile, ethnicity, heavy episodic drinking in the past 12 months, and average daily consumption. Odds ratios for each variable were calculated controlling for all other variables. 95% confidence intervals were calculated for all odds ratios. Ethical approval—This study was conducted with the approval of the University of Otago Human Ethics Committee (06/171). Results Characteristics of the study population—There was a response rate of 49.5% for the survey with 1924 completed surveys returned and 110 people found to be ineligible. Of the sample 1723 (89.6%) were identified as current drinkers (having consumed alcohol in the previous 12 months). Table 1 shows the basic demographics and drinking behaviours for the current drinker population (n=1723). The sample over represented women and people aged 35 years and underrepresented people from the most deprived NZDep06 levels. The sample was predominately European, and under-represented those of Māori and Asian ethnicity. The proportion of male respondents identified as heavy episodic drinkers was almost twice that of female respondents (27.9% versus 14.7%), while men and women had similar proportions of people in each average daily consumption level. Experience of alcohol-related harms and troubles—Among respondents identified as current drinkers 36.2% reported experiencing any alcohol-related adverse event. Having experienced any alcohol-related harm in the past 12 months was reported by 33.8% of current drinkers (29.8% of women and 39.0% of men) and 12.7% reported having experienced any alcohol-related trouble (9.9% of women and 16.4% of men). The prevalence of current drinkers experiencing three or more alcohol-related harms in the previous year was 13.4% while the prevalence of experiencing three or more troubles was only 1.4%. Table 2 shows the prevalence of each of the 7 harms and 7 troubles in current drinkers. The most reported harm was that respondents drinking had a harmful effect on their physical health (18.0% once or twice in 12 months, 3.8% more than twice in the previous year. Harmful effects on housework, intimate relationships and finances were also common amongst this current drinker population. Table 1. Characteristics of current drinker population and distributions of alcohol-related variables Variable** n*(%) Heavy episodic drinking (%) High average consumption† (%) Any harm (%) Any trouble (%) Gender Male Female 760 (44.1) 963 (55.9) 27.9 14.7 14.2 15.9 39.0 29.8 16.4 9.9 Age 18-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-70 years 129 (7.5) 264 (15.3) 390 (22.6) 452 (26.2) 362 (21.0) 126 (7.3) 48.4 29.8 19.6 19.5 8.9 10.7 14.6 10.9 10.9 18.7 15.2 25.9 58.9 44.1 37.3 33.1 20.9 10.8 41.7 16.9 11.6 11.7 4.9 2.7 NZDep06 1-2 3-4 5-6 7-8 9-10 450 (26.6) 408 (24.1) 352 (20.8) 272 (16.1) 213 (12.6) 16.6 24.0 18.4 20.9 27.2 14.5 17.3 13.7 15.8 15.4 28.2 36.6 34.4 30.8 45.0 9.1 13.1 13.0 11.4 21.4 Ethnicity European Asian Māori Other 1468 (85.3) 66 (3.8) 147 (8.6) 37 (2.2) 19.6 10.3 35.3 25.0 15.8 1.8 15.6 6.9 32.0 26.6 57.0 29.0 10.9 3.1 34.1 20.6 *Due to rounding percentages do not always add to 100%; **Where there was missing data (<5% of sample in all cases) for a variable those individuals were excluded from that analysis. †More than 20 grams per day for women, more than 30grams per day for men. Table 2. Prevalence of alcohol-related harms and troubles in current drinkers In the last 12 months has YOUR drinking had a harmful effect on your: No (%) Yes, once or twice (%) Yes, more than twice (%) Work, studies or employment opportunities Housework or chores around the house Marriage/intimate relationship Relationships with other family members Friendships or social life Physical health Finances 94.4 83.4 87.2 93.3 93.9 78.2 87.9 4.1 13.2 10.9 5.7 5.4 18.0 8.3 1.5 3.4 2.0 1.0 0.7 3.8 3.8 In the last 12 months have you had one of the following experiences:

Summary

Abstract

Aim

To quantify the prevalence and distribution of negative effects of drinking among New Zealand adults.

Method

A postal survey was completed by 1924 people aged 18-70 randomly selected from the New Zealand electoral roll (49.5% response). Information on drinking patterns, demographics and specific alcohol-related harms and troubles in the previous 12 months was collected.

Results

33.8% of current drinkers reported that they had been adversely affected by their own drinking in one or more specified domains in the past 12 months (charmd) and 12.7% reported one or more specified alcohol-related ctroublesd. Men were more likely to report alcohol-related harm (OR=1.3; 95% confidence interval [CI] 1.0-1.7) and alcohol-related trouble (OR=1.5; 95%CI 1.1-2.1) compared to women. People of M ori ethnicity and those with an NZDep06 score of 9-10 were at increased risk of both harms and troubles. The odds of reporting a harm or trouble in the past year decreased substantially with age. Heavy episodic drinking and level of average daily consumption were both associated with increased risk of both alcohol-related harm and trouble, but this did not explain all of the variation.

Conclusion

Prevalence of harm and trouble resulting from drinking is high in the general population as judged by the drinkers themselves. These findings support the association of heavy alcohol consumption with increased risk of alcohol-related harm. They also suggest that being male, young, M ori or living in a very deprived area in NZ are associated with a higher risk of alcohol-related harm.

Author Information

Jessica Meiklejohn, Jennie Connor; Department of Preventive and Social Medicine, University of Otago, Dunedin. Kypros Kypri; Injury Prevention Research Unit, Department of Preventive and Social Medicine, University of Otago, Dunedin & Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, University of Newcastle, NSW, Australia.

Acknowledgements

This survey was funded by an Otago University Research Grant and Jessica Meiklejohn was supported by a scholarship from the Alcohol Advisory Council of New Zealand. We also thank Kimberly Cousins for coordinating data collection and Dr Ari Samaranayaka for providing statistical advice.

Correspondence

Jessica Meiklejohn, Department of Preventive and Social Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand. Fax: +64 (0)3 4797298

Correspondence Email

jessica.meiklejohn@otago.ac.nz

Competing Interests

Rehm J, Room R, Graham K, et al. Alcohol as a Risk Factor for Global Burden of Disease. European Addiction Research. 2003;9:157-164.Law Commission. Alcohol in our lives: An issues paper on the reform of New Zealand's liquor laws. Wellington: Law Commission; 2009.Rehm J, Gmel G. Patterns of alcohol consumption and social consequences. Results from an 8-year follow-up study in Switzerland. Addiction. 1999;94:899-912.Casswell S, Quan You R, Huckle T. Alcohol's harm to others: reduced wellbeing and health status for those with heavy drinkers in their lives. Addiction. 2011;106:1087-1094.Room R, Bondy S, Ferris J. The risk of harm to oneself from drinking, Canada 1989. Addiction. 1995;90:499-513.Makela K, Mustonen H. Positive and negative experiences related to drinking as a function of annual alcohol intake. British Journal of Addiction. 1988;83:403-408.Makela K, Mustonen H. Relationships of drinking behaviour, gender and age with reported positive and negative experiences related to drinking. Addiction. 2000;95:727-736.Ministry of Health. Alcohol use in New Zealand - Key results of the 2007/08 New Zealand Alcohol and Drug Use Survey. Wellington: Ministry of Health; 2009.Stefanogiannis N, Mason K, Yeh LC. Alcohol use in New Zealand: Analysis of the 2004 New Zealand Health Behaviours Survey - Alcohol Use. Public Health Intelligence. Wellington: Ministry of Health; 2007.Habgood R, Caswell S, Pledger M, Bhatta K. Drinking in New Zealand: National surveys comparison 1995 & 2000. Auckland: Alcohol and Public Health Research Unit; 2001.Kypri K, Paschall M, Langley J, et al. Drinking and alcohol-related harm among New Zealand university students: findings from a national web-based survey. Alcoholism: Clinical and experimental research. 2009;33:307-314.Connor J, You R, Casswell S. Alcohol-related harm to others: a survey of physical and sexual assault in New Zealand. N Z Med J. 2009;122:10-20. http://journal.nzma.org.nz/journal/122-1303/3793/content.pdfConnor J, Kypri K, Bell M, Cousins K. Alcohol involvement in aggression between intimate partners in New Zealand: a national cross-sectional study. BMJ Open. 2011; 1(1): e000065Ministry of Social Development. Ethnic composition of the population. 2010 16/11/2010].http://www.webcitation.org/5uHD62Y0RWilsnack RW, Wilsnack SC, Kristjanson AF, et al. Gender and alcohol consumption: patterns from the multinational GENACIS project. Addiction. 2009;104:1487-1500.Salmond C, Crampton P, Atkinson J. NZDep 2006 Index of Deprivation. Wellington: Department of Public Health, University of Otago; 2007.Connor J, Kypri K, Bell M, Cousins K. Alcohol outlet density, levels of drinking and alcohol-related harm in New Zealand:a national study. Journal of Epidemiology and Community Health. 2010;65:841-846.ALAC. Upper limits for responsible drinking: Policy Statement 6. Wellington: Alcohol Advisory Council of New Zealand; 2002.Meiklejohn J, Connor J, Kypri K. The Effect of Low Survey Response Rates on Estimates of Alcohol Consumption in a General Population Survey. PLoS ONE. 2012;7:e35527.Kypri K, Samaranayaka A, Connor J, et al. Non-response bias in a web-based health survey of New Zealand tertiary students. Preventive Medicine. 2011;53:274-277.Babor T, Caetano R, Casswell S, et al. Alcohol: No ordinary commodity - Research and Public Policy. Oxford: Oxford University Press; 2003.

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It is well reported that alcohol, especially consumed in large amounts, can have negative effects on the drinker and on others. It has the potential to cause harm to health via three broad mechanisms: toxicity, intoxication and dependence, and is strongly linked to over 60 negative health outcomes.1,2 Research has also identified a variety of social harms to drinkers and those around them including legal problems, harmful impacts on employment, finances, relationships with family and friends and problems with violence.3A recent cross-sectional survey of New Zealand adults found that exposure to heavy drinkers had a negative impact on an individual's self-reported wellbeing and health status.4Alcohol is the most commonly used recreational drug in New Zealand, as it is in many countries, but alcohol-related harms are not well characterised or widely appreciated. While particular consumption patterns are associated with more harm, demographic and social factors may also change the likelihood of individuals experiencing alcohol-related harm.2There is plenty of international research to demonstrate that individuals with higher average alcohol intake are at increased risk, and that pattern of consumption is also an important factor in the risk of experiencing alcohol-related harms, with regular heavy episodic drinkers being at significantly more risk of harm.3,5,6 Many studies have shown that men and young people have higher risk of both heavy episodic drinking and of alcohol-related harms.6,7The New Zealand Law Commission's review of alcohol use in New Zealand concluded that over 80% of New Zealand adults drank alcohol at least occasionally and that approximately a quarter of the adult population reported drinking large quantities when they drink. This suggests a significant proportion of the population is likely to be contributing to harm to themselves and others.2There is some recent literature that has reported the experience of alcohol-related harm in the New Zealand population. On a population level the 2007/08 New Zealand Alcohol and Drug Use Survey collected data on both consumption patterns and harm from drinking. Current drinkers were asked if there had been a time when they felt their alcohol use had had a harmful effect on their friendships or social life, home life, work, study or employment opportunities, financial position, legal problems, difficulty learning or physical health/injury.8 In this sample, 12.2% of current drinkers reported having experienced at least one of the problems listed, with men, people in the youngest age group, people of Māori ethnicity and those living in the most deprived areas at significantly increased risk.8 This reflected the findings of the earlier Health Behaviours Survey (2004) which also found males and people of Māori ethnicity to be at increased risk of harm.9A national survey of drinking in New Zealand in 2000 asked respondents about their experience of 15 alcohol-related problems (which varied in severity) in the previous year. The survey found that 61% of men and 49% of women reported having experienced at least one of the 15 problems, while 11% of men and 7% of women reported experiencing five or more.10 A 2005 study of New Zealand University students found that heavy episodic drinking and associated harms to health and social factors were common amongst students.11Alcohol-related harm is not confined to the individual doing the drinking. Many of the consequences drinkers experience as a result of their own drinking can also have negative effects on those around them. A 2009 New Zealand study on physical and sexual assault showed that alcohol use by someone other than the victim of the assault is involved in over half of reported events.12Also, a recent paper on the involvement of alcohol in aggression between intimate partners showed that the involvement of alcohol in partner aggression was associated with increased severity of aggression and that a pattern of heavy episodic drinking was associated with higher reporting of aggression within intimate relationships.13The aims of this study were to: Examine the prevalence and distribution of two groups of negative drinking-related experiences in a sample of New Zealand adults. These were: 1. subjectively assessed adverse effects of drinking, including effects on family, finances and physical health, and 2. the experience of alcohol-related troubles, more objective events such as trouble with the law, loss of job, and aggression due to alcohol. Examine factors associated with higher risk of experiencing these harms and troubles. Methods Setting—In 2007, New Zealand had a population of approximately 4 million people, with 77% of people listing their ethnicity as European, 15% as Māori, 7% as Pacific, 10% as Asian and 1% as Other (percentages add to more the 100% as individuals can identify as having more than one ethnicity).14 Participants and procedures—This was a cross-sectional survey of a nationally representative sample of New Zealand residents aged 18-80 years, randomly selected from the electoral roll, conducted using a postal questionnaire that was completed by the respondent and mailed back to the investigators in a reply-paid envelope. The data collection methods have been described in more detail in a study of alcohol involvement in partner aggression in New Zealand.13 Measures—The questionnaire was based on the expanded core GENACIS questionnaire from the International Research Group on Gender and Alcohol (IRGGA). A copy of this questionnaire is available at the following link: www.genacis.org/questionnaires/exp_core.pdf This questionnaire has been used in approximately 40 countries to provide data that are directly comparable for cross-national studies.15 The questionnaire contained 100 items and took 20-30 minutes to complete. It covered the following areas: demographic information (age, sex and ethnicity), social networks, respondent's alcohol consumption, drinking contexts, drinking consequences, intimate relations and sexuality, violence and victimization, and health and lifestyle. From the residential address listed on the electoral roll a New Zealand Deprivation Index 2006 (NZDep06) decile was obtained for each respondent and used as an indicator of socioeconomic position. NZDep06 is a small area deprivation measure, based on 9 items from the national census at the meshblock level. Meshblocks are the smallest unit of the census and include about 100 residents on average. NZDep06 deciles assign a score of 1-10 to participants on the basis of their residential address, with 1 representing the least, and 10 the most, deprived 10% of the population.16 Ethnicity was categorised as European, Asian, Māori and Other, due to small numbers of participants of other ethnicity. Alcohol consumption—Respondents were asked about drinking frequency and quantity of alcohol consumed per typical drinking occasion in the previous 12 months. Quantities of alcohol were reported in standard drinks (defined as 10g of pure ethanol). A pictorial guide was provided to assist participants to convert common beverages to standard drinks. Harms and troubles due to drinking—Current drinkers (having consumed any alcohol in the previous 12 months) were asked about drinking-related adverse experiences. These experiences were divided into two categories. Drinking-related harms were self-assessed personal problems resulting from an individual's drinking. Drinking-related troubles encompassed legal and social problems that the respondents could have experienced due to their heavy drinking. These related to specific, more objective events.17 Harms: In the last 12 months has your drinking had a harmful effect on: (1) work, studies or employment opportunities, (2) housework or chores around the house, (3) marriage/intimate relationships, (4) relationships with other family members, including children, (5) friendships and social life, (6) physical health, (7) finances. Responses for each item were no, yes once or twice, or yes more than twice. Troubles: In the last 12 months have you had any of the following experiences? (1) trouble with the law about your drinking and driving, (2) an illness connected with your drinking that kept you from working or your regular activities for a week or more, (3) lost a job, or nearly lost one, because of your drinking, (4) been annoyed by people criticising your drinking, (5) had a spouse or someone you lived with threaten to leave or actually leave due because of your drinking, (6) lost a friendship because of your drinking, (7) got into a fight while drinking. Responses for each item were no, yes once or twice, or yes more than twice. Analysis Drinking behaviours: Two drinking variables were used in these analyses. Heavy episodic drinking (HED) was defined as 5 or more drinks per occasion at least once a month in the past year, and high average daily consumption was defined as more than 20 grams of pure alcohol per day for women; and more than 30 grams per day for men. These correspond to the maximum consumption levels recommended by the Alcohol Advisory Council of New Zealand.18 Experience of alcohol-related harms and troubles: The prevalence of each harm and trouble as well as the prevalence of experiencing any alcohol-related harm or trouble in the last 12 months was calculated for the sample. Regression models—Logistic regression models were used to calculate the odds of respondents identified as current drinkers reporting any alcohol-related harm and trouble in the past year by sex, age, NZDep06 quintile, ethnicity, heavy episodic drinking in the past 12 months, and average daily consumption. Odds ratios for each variable were calculated controlling for all other variables. 95% confidence intervals were calculated for all odds ratios. Ethical approval—This study was conducted with the approval of the University of Otago Human Ethics Committee (06/171). Results Characteristics of the study population—There was a response rate of 49.5% for the survey with 1924 completed surveys returned and 110 people found to be ineligible. Of the sample 1723 (89.6%) were identified as current drinkers (having consumed alcohol in the previous 12 months). Table 1 shows the basic demographics and drinking behaviours for the current drinker population (n=1723). The sample over represented women and people aged 35 years and underrepresented people from the most deprived NZDep06 levels. The sample was predominately European, and under-represented those of Māori and Asian ethnicity. The proportion of male respondents identified as heavy episodic drinkers was almost twice that of female respondents (27.9% versus 14.7%), while men and women had similar proportions of people in each average daily consumption level. Experience of alcohol-related harms and troubles—Among respondents identified as current drinkers 36.2% reported experiencing any alcohol-related adverse event. Having experienced any alcohol-related harm in the past 12 months was reported by 33.8% of current drinkers (29.8% of women and 39.0% of men) and 12.7% reported having experienced any alcohol-related trouble (9.9% of women and 16.4% of men). The prevalence of current drinkers experiencing three or more alcohol-related harms in the previous year was 13.4% while the prevalence of experiencing three or more troubles was only 1.4%. Table 2 shows the prevalence of each of the 7 harms and 7 troubles in current drinkers. The most reported harm was that respondents drinking had a harmful effect on their physical health (18.0% once or twice in 12 months, 3.8% more than twice in the previous year. Harmful effects on housework, intimate relationships and finances were also common amongst this current drinker population. Table 1. Characteristics of current drinker population and distributions of alcohol-related variables Variable** n*(%) Heavy episodic drinking (%) High average consumption† (%) Any harm (%) Any trouble (%) Gender Male Female 760 (44.1) 963 (55.9) 27.9 14.7 14.2 15.9 39.0 29.8 16.4 9.9 Age 18-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-70 years 129 (7.5) 264 (15.3) 390 (22.6) 452 (26.2) 362 (21.0) 126 (7.3) 48.4 29.8 19.6 19.5 8.9 10.7 14.6 10.9 10.9 18.7 15.2 25.9 58.9 44.1 37.3 33.1 20.9 10.8 41.7 16.9 11.6 11.7 4.9 2.7 NZDep06 1-2 3-4 5-6 7-8 9-10 450 (26.6) 408 (24.1) 352 (20.8) 272 (16.1) 213 (12.6) 16.6 24.0 18.4 20.9 27.2 14.5 17.3 13.7 15.8 15.4 28.2 36.6 34.4 30.8 45.0 9.1 13.1 13.0 11.4 21.4 Ethnicity European Asian Māori Other 1468 (85.3) 66 (3.8) 147 (8.6) 37 (2.2) 19.6 10.3 35.3 25.0 15.8 1.8 15.6 6.9 32.0 26.6 57.0 29.0 10.9 3.1 34.1 20.6 *Due to rounding percentages do not always add to 100%; **Where there was missing data (<5% of sample in all cases) for a variable those individuals were excluded from that analysis. †More than 20 grams per day for women, more than 30grams per day for men. Table 2. Prevalence of alcohol-related harms and troubles in current drinkers In the last 12 months has YOUR drinking had a harmful effect on your: No (%) Yes, once or twice (%) Yes, more than twice (%) Work, studies or employment opportunities Housework or chores around the house Marriage/intimate relationship Relationships with other family members Friendships or social life Physical health Finances 94.4 83.4 87.2 93.3 93.9 78.2 87.9 4.1 13.2 10.9 5.7 5.4 18.0 8.3 1.5 3.4 2.0 1.0 0.7 3.8 3.8 In the last 12 months have you had one of the following experiences:

Summary

Abstract

Aim

To quantify the prevalence and distribution of negative effects of drinking among New Zealand adults.

Method

A postal survey was completed by 1924 people aged 18-70 randomly selected from the New Zealand electoral roll (49.5% response). Information on drinking patterns, demographics and specific alcohol-related harms and troubles in the previous 12 months was collected.

Results

33.8% of current drinkers reported that they had been adversely affected by their own drinking in one or more specified domains in the past 12 months (charmd) and 12.7% reported one or more specified alcohol-related ctroublesd. Men were more likely to report alcohol-related harm (OR=1.3; 95% confidence interval [CI] 1.0-1.7) and alcohol-related trouble (OR=1.5; 95%CI 1.1-2.1) compared to women. People of M ori ethnicity and those with an NZDep06 score of 9-10 were at increased risk of both harms and troubles. The odds of reporting a harm or trouble in the past year decreased substantially with age. Heavy episodic drinking and level of average daily consumption were both associated with increased risk of both alcohol-related harm and trouble, but this did not explain all of the variation.

Conclusion

Prevalence of harm and trouble resulting from drinking is high in the general population as judged by the drinkers themselves. These findings support the association of heavy alcohol consumption with increased risk of alcohol-related harm. They also suggest that being male, young, M ori or living in a very deprived area in NZ are associated with a higher risk of alcohol-related harm.

Author Information

Jessica Meiklejohn, Jennie Connor; Department of Preventive and Social Medicine, University of Otago, Dunedin. Kypros Kypri; Injury Prevention Research Unit, Department of Preventive and Social Medicine, University of Otago, Dunedin & Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, University of Newcastle, NSW, Australia.

Acknowledgements

This survey was funded by an Otago University Research Grant and Jessica Meiklejohn was supported by a scholarship from the Alcohol Advisory Council of New Zealand. We also thank Kimberly Cousins for coordinating data collection and Dr Ari Samaranayaka for providing statistical advice.

Correspondence

Jessica Meiklejohn, Department of Preventive and Social Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand. Fax: +64 (0)3 4797298

Correspondence Email

jessica.meiklejohn@otago.ac.nz

Competing Interests

Rehm J, Room R, Graham K, et al. Alcohol as a Risk Factor for Global Burden of Disease. European Addiction Research. 2003;9:157-164.Law Commission. Alcohol in our lives: An issues paper on the reform of New Zealand's liquor laws. Wellington: Law Commission; 2009.Rehm J, Gmel G. Patterns of alcohol consumption and social consequences. Results from an 8-year follow-up study in Switzerland. Addiction. 1999;94:899-912.Casswell S, Quan You R, Huckle T. Alcohol's harm to others: reduced wellbeing and health status for those with heavy drinkers in their lives. Addiction. 2011;106:1087-1094.Room R, Bondy S, Ferris J. The risk of harm to oneself from drinking, Canada 1989. Addiction. 1995;90:499-513.Makela K, Mustonen H. Positive and negative experiences related to drinking as a function of annual alcohol intake. British Journal of Addiction. 1988;83:403-408.Makela K, Mustonen H. Relationships of drinking behaviour, gender and age with reported positive and negative experiences related to drinking. Addiction. 2000;95:727-736.Ministry of Health. Alcohol use in New Zealand - Key results of the 2007/08 New Zealand Alcohol and Drug Use Survey. Wellington: Ministry of Health; 2009.Stefanogiannis N, Mason K, Yeh LC. Alcohol use in New Zealand: Analysis of the 2004 New Zealand Health Behaviours Survey - Alcohol Use. Public Health Intelligence. Wellington: Ministry of Health; 2007.Habgood R, Caswell S, Pledger M, Bhatta K. Drinking in New Zealand: National surveys comparison 1995 & 2000. Auckland: Alcohol and Public Health Research Unit; 2001.Kypri K, Paschall M, Langley J, et al. Drinking and alcohol-related harm among New Zealand university students: findings from a national web-based survey. Alcoholism: Clinical and experimental research. 2009;33:307-314.Connor J, You R, Casswell S. Alcohol-related harm to others: a survey of physical and sexual assault in New Zealand. N Z Med J. 2009;122:10-20. http://journal.nzma.org.nz/journal/122-1303/3793/content.pdfConnor J, Kypri K, Bell M, Cousins K. Alcohol involvement in aggression between intimate partners in New Zealand: a national cross-sectional study. BMJ Open. 2011; 1(1): e000065Ministry of Social Development. Ethnic composition of the population. 2010 16/11/2010].http://www.webcitation.org/5uHD62Y0RWilsnack RW, Wilsnack SC, Kristjanson AF, et al. Gender and alcohol consumption: patterns from the multinational GENACIS project. Addiction. 2009;104:1487-1500.Salmond C, Crampton P, Atkinson J. NZDep 2006 Index of Deprivation. Wellington: Department of Public Health, University of Otago; 2007.Connor J, Kypri K, Bell M, Cousins K. Alcohol outlet density, levels of drinking and alcohol-related harm in New Zealand:a national study. Journal of Epidemiology and Community Health. 2010;65:841-846.ALAC. Upper limits for responsible drinking: Policy Statement 6. Wellington: Alcohol Advisory Council of New Zealand; 2002.Meiklejohn J, Connor J, Kypri K. The Effect of Low Survey Response Rates on Estimates of Alcohol Consumption in a General Population Survey. PLoS ONE. 2012;7:e35527.Kypri K, Samaranayaka A, Connor J, et al. Non-response bias in a web-based health survey of New Zealand tertiary students. Preventive Medicine. 2011;53:274-277.Babor T, Caetano R, Casswell S, et al. Alcohol: No ordinary commodity - Research and Public Policy. Oxford: Oxford University Press; 2003.

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