STAKEHOLDERS' INTERESTS IDENTIFIED THROUGH THEIR VIEWS ON THE ALCOHOL POLICY MEASURES IN SLOVENIA INTERESI AKTERJEV ALKOHOLNE POLITIKE SKOZI NJIHOVO MNENJE O UKREPIH ALKOHOLNE POLITIKE V SLOVENIJI Sandra Radoš Krnel1, Tanja Kamin2, Matej Košir3, Mirko Markič4 Prispele: 10. 9. 2009 - Sprejete: 9. 11. 2009 Original scientific article UDC 613.8(497.4) Abstract Aims: The purpose of the study was to determine how the stakeholders involved in alcohol policy in Slovenia view the importance and impact of alcohol policy measures in alcohol-related harm reduction, and to identify their interests. Methods: The questionnaire comprising 25 statements across nine alcohol policy domains was sent to 320 stakeholders involved in alcohol policy in Slovenia. They were divided in^o the following four main groups: governmental organisations, public health organisations, non-governmental organisations and alcohol industry. The data collected were analysed using the SPSS programme. Differences between the groups concerning their views on individual alcohol policy interventions were measured using the ANOVA and t-test. Results: Factor analysis of stakeholders' views identified three main alcohol policy platforms: education, regulation and pricing. All the participating stakeholder's emphasized education, communication, training and raising public awareness as the most important activities that had the greatest impact on the reduction of alcohol-related harm. Governmental and non-governmental organisations and public health institutions assigned significantly higher scores to the impact of regulatory alcohol policy measures and to the importance of regulatory policies on reducing alcohol-related harm than the alcohol industry. The alcohol industry perceived the pricing measures taken to reduce harm done by alcohol as having a significantly lower impact and lesser importance than did the group of other stakeholders. Conclusions: Like similar studies of attitudes towards alcohol policy in Europe, our research showed that different stakeholders are guided by different interests in relation to particular alcohol policy measures; howevei^, these differences were lesser than those identified at the EU level. In spite of stakeholders' different interests and views concerning particular alcohol strategies and alcohol policy in general, we have identified common grounds for them to work together to prepare better and more effective measures of alcohol-related harm prevention in Slovenia. Key words: interests, alcehel policy, stakeholders, alcehel policy measures Izvirni znanstveni članek UDK 613.8(497.4) Izvle~ek Namen dela: Z raziskavo smo želeli ugotoviti, kakšno mnenje o vplivu in pomembnosti posameznih ukrepov alkoholne politikee pri zmanjševanju škodljivih posledic zaradi alkohola imajo različni akterji alkoholne politikee v Sloveniji, in prepoznati njihove interese. Osnovne metode: Izvedli smo ^antitativno raziskavo, in sicer z vprašalnikom, ki je vseboval 25 tr^ditev v okviru 9 področij alkoholne politike. Vprašalnik smo poslali 320 akterjem alkoholne politike v Sloveniji, razdeljenim v 4 glasne skupine: hladne or^ganizacije, javnozdravstvene organizacije, nevladne or^ganizacije ^er alkoholna industrija. Zbrane podatke smo obdelali s programom SPSS. Razlije v pogledih na posamezno področje alkoholne politik^e ^Inštitut za varevanje zdravja Republike Slevenije, Trubarjeva 2, 1000 Ljubljana 2Univerza v Ljubljani, Fakulteta za družbene vede, Kardeljeva pleščad 5, 1000 Ljubljana 3Inštitut Utrip, Parmeva 36, 1000 Ljubljana 9Unlverza na Primerskem, Fakulteta za management, Cankarjeva 5, 6000 Keper Cerrespendence te: e-mail: sandra.rades@ivz-rs.si med različnimi akterji smo ugotavljali s testom ANOVA in t-testom. Glavni izsledki: Faktorska analiza mnenj posameznih akterjev alkoholne politike v Sloveniji je razkrila tri glavne dejavnike: izobraževanje in ozaveščanje, regulacijske ukrepe in cenovne ukrepe. Vsi akterji so kot najpomembnejše ukrepe in ukrepe z največjim učinkom izpostavili ukrepe, povezane z izobraževanjem, komuniciranjem in ozaveščanjem. Ukrepe s področja regulative alkoholna industrija zaznava kot občutno manj pomembne in z manjšim vplivom na zmanjševanje škodljivih posledic alkohola kot ostali akterji. Enako je z oceno ukrepov s področja cenovne politike. Poglavitni sklepi: Tako kot podobna raziskava o razumevanju alkoholne politike na evropski ravni tudi z našo ugotavljamo, da posamezne akterje alkoholne politike vodijo različni interesi v povezavi s posameznimi ukrepi alkoholne politike, vendar pa v Sloveniji te razlike niso tako izrazite kot na evropski ravni.Čeprav imajo akterji različne poglede in interese glede alkoholne politike in njenih posameznih ukrepov, smo z raziskavo prepoznali tista področja, na katerih lahko akterji sodelujejo pri pripravi boljših in učinkovitejših ukrepov alkoholne politike za preventivo škodljivih učinkov alkohola v Sloveniji. Ključne besede: interesi, alkoholna politika, akterji, ukrepi alkoholne politike 1 Introduction Alcohol, smoking and overweight are key lifestyle-related health determinants in the European Union (EU). Harmful consumption of alcohol causes serious health and social problems, which are affecting an increasingly large number of people. From a policy perspective, tobacco and alcohol have a lot in common. Both are related to excise taxes and limited age access. An important difference between the two is that smoking is discouraged outright, whereas for alcohol only excessive consumption is discouraged. (1) Drinking is affected by social norms governing alcohol use. Social norms are the established standards of conduct, i.e. of anticipated, culturally desirable and socially acceptable behaviour. (2) They state what is normal and thus create pressure to conform and behave in a particular way. In most cases, this pressure is internal and reflects what we think others will expect of us in particular situations. (3, 4) Drinking alcohol at all important social events, from birth celebration to mourning the death, (5) is a norm in Slovenia. Some subgroups accept and encourage even binge drinking. (6) Regarding the relation to alcohol consumption a range of different drinking cultures have been identified around the world: abstinent (Muslims), ceremonial (Jews), ambivalent (Great Britain, the USA), permissive (Spain, Italy) and hyper-permissive (France). In general, Slovenia has the characteristics of hyper-permissive cultures, with some characteristics of ambivalent cultures. (7) The total estimated tangible cost of alcohol consumed in the EU in 2003 was €125bn (€79bn-€220bn), equivalent to 1.3% GDP. (3) Some studies indicate even higher numbers, one of them stating that the economic burden due to harmful use of alcohol is estimated to be 2% to 3 % of GDP. (8) These figures call for the implementation of more effective measures and interventions in the area of alcohol consumption. Public policies that regard the relationship between alcohol, health, and social welfare are alcohol policies. (3, 9) The goal of alcohol policy is to protect public health from harmful influences of alcohol on the national or international levels. (10) It refers to a set of jurisdiction and social measures taken to minimize health and social harms of alcohol consumption. These measures may be conducted in any governmental or societal sector and may include strategies that are not directly related to alcohol consumption, but, for instance, promote healthier alternatives to drinking. National alcohol policy should be made up of a set of individual policies, strategies, and implementing actions. (11, 12) Alcohol policies can be grouped into five categories as follows: (i) policies that reduce drinking and driving; (ii) policies that support education, communication, training and raising of public awareness; (iii) policies that regulate the alcohol market; (iv) policies that support the reduction of harm in drinking and surrounding environments; and (v) policies that support interventions for individuals. (3) In the developed countries there is a common trend to deregulate the majority of fields, except those where products or activities are potentially harmful to health. In these areas, the governments are oriented towards increased regulation. The need for regulation is particularly explicit in the fields in which potential danger to one's health involves also harm to the others, like in drunk driving. (13) Any regulation, including those on alcohol use, is subject to negotiations among various interest groups. Even the governments have an ambivalent attitude towards the alcohol issue. The governments have a legal and moral obligation to protect citizens from harmful consequences of alcohol consumption, but also to provide for a sustainable income to the governmental budget through taxes on alcohol consumption. The alcohol industry is an important economic player as it contributes significantly to the national budget through taxes on alcohol. (14) The alcoholic beverages industry plays an important economic role in many European countries, yet the well-documented costs of inappropriate alcohol use are very high, both for for the individual and for the society. (3, 15) Policy perception of alcohol as an economic commodity can weaken health concerns related to alcohol production and consumption, and undermine the evidence of substantial health impact. (3) Taken together, the positive and the negative impacts of alcohol lead to ambivalent public opinion about the alcohol issue and to ambivalent attitudes towards alcohol in the governmental policy. (16) Because of the competing interests the process of developing the policy and procedures can be as important as the implementation of this policy itself. (15) Formulating alcohol policy must be a challenge for the whole population and a task performed by a society as a whole. (17) Kol{ek et al. stated that tobacco- and alcohol-related issues should be addressed by a comprehensive community-based approach with the participation of primary health centre teams and policymakers. (18) Governments, alcohol industry, health lobbies and others should take part in the development of alcohol policy. In Slovenia, the Ministry of Health preserved its role in defining public health priorities.(19) This process should involve other stakeholders, such as health consumers nongovernmental organizations (NGOs), self-help groups, small producers and vendors of alcoholic beverages, hospitality industry, schools, employers groups, syndicates and media. (20, 21, 22) Some scholars argue that attaining benefits is the primary motive of the individual's actions. (23) Pursuing own interests leads to interest-driven behaviour towards other participants that are important to achieving our goals. Interest-driven behaviour is characteristic of individuals as well as of associations, communities and societies, and may have a decisive influence within these. (24) Interest-group activities are interactions through which individuals and private groups not holding government authority seek to influence policy. (25) Some interest groups are more powerful than others in the sense that they are more successful in influencing the outcomes of policy debates. A rough calculation of the political power of an interest group - and thus of one's political influence as a group member - is derived from its size. (26) The bigger the group the more dominant its position in the society. In addition, interest groups may further be differentiated according to their primary interest, i.e. economic or private versus public interest. While the difference between the two is sometimes rhetorical - after all, almost every group believes it is acting, directly or indirectly, in the broader public interest - there is also a more technical way to distinguish between the two. Public interest groups are those groups that are supposed to act for public good rather than on behalf of the organization's and its members' direct interest. (26, 27) Nevertheless, all entities, either economic or public, are driven by particular positions and interests. In the realm of alcohol policies, the alcohol industry is considered a private interest group with profit as its main interest; public health organisations and non-governmental organisations are regarded as public interest groups.The government, as a specific stakeholder, pursues larger public benefits - health of the citizens on one side, and employment and government revenues, on the other - but also has the power to enforce its interests. A conflict of interests in the areas of protection of economic profits, free market (non)regulation, freedom of choice, health protection, to name just a few, constantly arises between different government levels, as well as between departments, the market and the individual. (1) Because of the involvement of different stakeholders in the process of alcohol policy development, opposing interests are anticipated: one group wants to decrease and another to increase the consumption of alcohol. (28) It is also suggested that the alcohol industry influences the design of alcohol policy, particularly as concerns price increases, reduced access to alcohol and control of marketing communications, particularly advertising. (29, 30, 31) The alcohol industry, however, is not the only culprit supporting less effective polices; strong support for weak or ineffective interventions, and opposition to effective alcohol policies can be detected in the governmental body and among members of the general public. (32) Many policy makers therefore seem to be reluctant to risk political unpopularity through aggressive alcohol control measures. (21) The aim of our study was to determine the attitudes that different stakeholders in alcohol policy in Slovenia hold towards the impact and importance of policy in reducing alcohol-related harm. The stakeholders' opinions on the current alcohol policy differ because they address the alcohol issue in different ways. Through their opinions stakeholders express their perspectives en the prcblem, its causes, evidence and scluticns, and thus articulate their interests. ""Interests are the underlying cencerns, needs, desires, er fears behind a negetiaters' pesitien, which metivate the negetiater te take that pesitien." (33) In the precess ef designing and implementing alcehel pelicies it is crucial te identify different pesitiens ef the main stakehelders en the issue in erder te assure a censtructive dialegue ameng them. We believe that the identified epiniens will expese different stakehelders' pesitiens and articulate interests ef the gevernment and particular interest greup in relatien te the alcehel issue. Differences ameng the key stakehelders and the anticipated difficulties in their cellaberatien, but alse seme cemmen greunds fer develeping and implementing alcehel pelicy will thus be identified. The study was designed with regard te the research en understanding alcehel pelicy in Eurepe cenducted by Andersen and Baumberg. (3, 34) The same research framewerk was chesen fer twe reasens: - the research medel and the questiennaire have already been tested - the data ef eur study can be cempared with the results reperted fer Eurepe. 2 Method 2.1 Participants and procedure This study makes part ef the research preject entitled "Stakehelders' understanding ef alcehel pelicy in Slevenia", which is part ef the wider preject MOSA ("Mebilisatien ef the seciety fer mere respensible use ef alcehel"), ceerdinated by the Faculty ef Secial Sciences, University ef Ljubljana, and supperted by the Ministry ef Health ef the Republic ef Slevenia. A database ef all stakehelders in alcehel pelicy in Slevenia, prepared within the preject MOSA, was used fer the study. This database includes 320 entities. The stakehelders were divided inte the fellewing feur main greups: - gevernmental erganisatiens (GOs) (33 entities), - public health erganisatiens (PHOs) (103 entities), - nen-gevernmental erganisatiens (NGOs) (132 entities) and - alcehel and related industry (AI) (52 entities). Because ef a relatively small number ef stakehelders in the database, all ef them were included in the research. Fieldwerk was carried eut in Nevember and December 2008, and a standardised questiennaire was used as the field methed. The questiennaire was sent by mail tegether with a return envelepe and an accempanying nete stating that the respenses weuld be treated cenfidentially and that the repert ef the results weuld net reveal identity ef the respendents. The cempletien rate was 54.1 %; 173 questiennaires received were used in this analysis. The highest respense rate was recerded fer nen-gevernmental erganisatiens - 61.4 %, fellewed by public health erganisatiens (prefessienals) - 54.4 %, and gevernmental erganisatiens - 48.5 %. The respense rate was lewest in the greup ef alcehel and related industries- 38.5 %. 2.2 Measures The questiennaire design was similar te that ef the questiennaire prepared by Andersen and Baumberg in the study "Stakehelders' views ef alcehel pelicy". (34). The respendents ef their survey were Eurepean stakehelders in alcehel pelicy. Our questiennaire was adapted te lecal circumstances and teek inte censideratien the Slevene Act Restricting the Use ef Alcehel. (35) The final questiennaire cemprised the fellewing 25 items acress nine alcehel pelicy demains: drinking and driving; educatien, cemmunicatien, training and raising public awareness; packaging and labelling ef alcehel preducts; price and tax measures te reduce harm dene by alcehel; illicit trade in alcehelic preducts; sales te miners; alcehel advertising, premetien and spensership; reducing harm in drinking and surreunding envirenments; and interventiens and assistance fer family members ef peeple with alcehel dependence. The respendents were asked te indicate their epinien ef the impact ef each item in Table 2 en reducing alcehel-related harm, using a 10 peint scale frem 1, ""ne impact", te 10, ""very high impact". Next, they were asked te express their epinien ef the impertance ef implementing the particular pelicy measure en a scale ef 1, ""net at all impertant" te 10, ""very impertant". They were asked te express their views ef the pelicy impact and its impertance separately, because differences in their epiniens regarding the same pelicy measure were anticipated. Se, the educatien pelicy measure can be censidered as having a lew pelicy impact, but is nevertheless regarded as very impertant fer the implementatien. The questiennaire included seme basic demegraphic variables and twe self-evaluatien questiens abeut the participants' knewledge ef alcehel pelicy and the Act Restricting the Use ef Alcehel in Slevenia. The respendents rated their knewledge en a scale ef 0, "net at all familiar" te 10, "excellent knewledge". The following hypotheses were tested: - alcohol industry will view the measures taken in the area of education as having a higher impact on reducing the harm done by alcohol than will governmental and non-governmental organisations and public health institutions (H1) - alcohol industry will score the importance of imposing measures in the field of education to reduce alcohol-related harm higher than governmental and non-governmental organisations and public health institutions (H2) - governmental and non-governmental organisations and public health institutions will score the impact of regulatory measures of alcohol policy on alcohol harm reduction higher than alcohol industry (H3). - governmental and non-governmental organisations and public health institutions will rate the importance of regulatory measures of alcohol policy to lower alcohol harm higher than alcohol industry (H4). These hypotheses were based on the present knowledge of stakeholders' views of alcohol policies, especially on the results of the above mentioned study by Anderson and Baumberg conducted at the European scale. (34) 2.3 Data analysis The data were analysed using SPSS. Means and standard errors of the mean were calculated for the items (impact and importance) for each of the four stakeholder groups (i.e. governmental organisations, public health organisations, non-governmental organisations and alcohol and related industries). Analysis of variance (SPSS version 13) was used to test for significant differences between the means of the four groups. The level of significance was at <0.05. Factor analysis was done with the SPSS version 13 (varimax rotation, and eigenvalue >1.0). The 25 items were reduced by factor analysis to three groups of similar items for the alcohol policy impact and for the alcohol policy importance in reducing the harm done by alcohol. Examination of question contents, rotated component matrix and eigenvalues suggested that the analysis should be restricted to three factors. Factor 1 has largely to do with the educational approaches; factor 2 with regulations, and factor 3 with the pricing of alcohol. Responses to the items within each factor were summed and then divided by the number of items within the factor. Differences in the opinions on particular alcohol measures between the groups were measured using ANOVA and t-test. 3 Results The average age of the respondents was 44.7 years; 63 % of them were women and 37 % were men; 79.9 % had university degree or higher. The stakeholders self-evaluated their knowledge of alcohol policy and of the Act Restricting the Use of Alcohol in Slovenia. The participants rated their knowledge on a scale of 0 - ""not familiar" to 10 - "excellent knowledge". The average score for the knowledge of alcohol policy and for the Act Restricting the Use of Alcohol in Slovenia was 6.1 and 6.0, respectively. The self-evaluated knowledge of alcohol policy was rated highly by the alcohol and related industry and lowest by the non-governmental organisations. All stakeholders share very similar perceptions of their knowledge of the Act Restricting the Use of Alcohol in Slovenia. Table 1 presents the respondents' opinions of the policy impact on and importance in reducing alcohol harm on a scale ranging from 1 ("no impact or not important at all") to 10 ("very high impact and very important") for each of the nine alcohol policy domains. For better clarity, the results were grouped into nine domains and are not presented separately for each of the 25 measures. Differences were found between the views expressed by alcohol and related industries and those of the other three groups (governmental organisations, public health organisations, non-governmental organisations), which were likely to share similar opinions. In the domains "education, communication, training and public awareness" and ""interventions and assistance for family members of people with alcohol dependence" all four groups held similar opinions. The perceived impact of the policy measure in the domain "Interventions and assistance for family members of people with alcohol dependence" was on average rated highest by all participants. All participants rated highest the importance of policy measures in the domains "sales to minors", "interventions and assistance for family members of people with alcohol dependence" and ""education, communication, training and public awareness". Table 1. Opinions of the policy impact and importance in reducing the harm done by alcohol. Group means of the results on a scale of 1 (no impact or not important at all) to 10 (very high impact and very important) for each of nine alcohol policy domains. Tabela 1. Mnenja o učinkih in pomembnosti ukrepov za zmanjševanje škode, ki jo povzroča alkohol. Srednje vrednosti skupin na lestvici od 1 (nima vpliva ali sploh ni pomemben)do 10 (zelo velik učinek in zelo pomemben) za v^sako of devetih področij alkoholne politike. PHOsb GOsa NGOsc Javno- AId Average Alcohol policy domains Vladne zdravstvene Nevladne Alkoholna Področja alkoholne politike organizacije organizacije organizacije industrija Poprečje DRINKING AND DRIVING PITJE IN VOŽNJA Impact učinek 7.33 7.81 7.83 5.76 7.54 Importance pomembnost 7.93 8.44 8.34 6.1 8.07 EDUCATION, COMMUNICATION, TRAINING AND PUBLIC AWARENESS IZOBRAŽEVANJE, KOMUNICIRANJE, USPOSABLJANJE IN OZAVEŠČANJE JAVNOSTI impact 7.79 7.76 7.79 7.65 7.76 importance 8.38 8.63 8.81 7.65 8.58 PACKAGING AND LABELLING OF ALCOHOL PRODUCTS EMBALAŽA IN OZNAČEVANJE ALKOHOLNIH PIJAČ impact 6.11 6.2 6.03 4.82 5.95 importance 6.81 7.33 6.95 5.08 6.84 PRICE AND TAX MEASURES TO REDUCE THE HARM DONE BY ALCOHOL CENOVNI IN DAVČNI UKREPI ZA ZMANJŠEVANJE ŠKODE ZARADI UŽ IVANJA ALKOHOLA impact 6.4 6.58 5.98 4.95 6.09 importance 6.54 7.17 6.53 5.38 6.6 ILLICIT TRADE IN ALCOHOLIC PRODUCTS NELEGALNO TRGOVANJE Z ALKOHOLNIMI PIJAČAMI impact 5.06 5.41 5.63 6.6 5.62 importance 5.56 6.09 6.42 6.9 6.29 SALES TO MINORS PRODAJA MLADOLETNIKOM impact 8.75 8.18 8.04 7.65 8.11 importance 9.13 9.29 9.27 8.28 9.15 ALCOHOL ADVERTISING, PROMOTION AND SPONSORSHIP OGLAŠEVANJE, PROMOCIJA IN SPONZORIRANJE impact 6.84 7.25 6.9 4.19 6.69 importance 7.16 8.3 8.23 4.69 7.74 REDUCING HARM IN DRINKING AND SURROUNDING ENVIRONMENTS ZMANJŠEVANJE ŠKODE V PIVSKIH OKOLJIH UIN OKOLICI impact 7.38 7.52 7.42 6.9 7.39 importance 8.13 8.47 8.48 7.7 8.35 INTERVENTIONS AND ASSISTANCE FOR FAMILY MEMBERS OF PEOPLE WITH ALCOHOL DEPENDENCE UKREPI IN POMOČ DRUŽINSKIM ČLANOM ODVISNIKOV OD ALKOHOLA impact 8.38 8.3 8.51 7.98 8.37 importance 8.28 9.14 9.28 8.2 9.02 a GOs - governmental organisations b PHOs - public health organisations (professionals) c NGOs - non-governmental organisations d AI - alcohol industry Since the number of variables for each measure was relatively high (50 variables, represented by the score of impact and importance for 25 items), factor analysis was used to explain the connections between them using a lower number of factors representing common extensions. Based on the theory and factor analysis three factors were obtained; factor 1, has largely to do with the educational approaches; factor 2 with regulations, and factor 3 with the pricing of alcohol. The results of factor analysis are presented in Table 2, with numbers in the corresponding factor's column indicating the factor loadings for each item. The 25 items were grouped into nine alcohol policy domains. Table 2. The results of the factor analysis for each of the 25 items concerning impact and importance of the measui-e of alcohol policy.a Tabela 2. Rezultati faktorske analize glede učinkov in pomembnosti vsakega od 25 ukrepov alkoholne politike. Factor 1 Education Faktor 1 Izobraževanje Factor 2 Regulation Faktor 2 Zakonska določila Factor 3 Pricing Faktor 3 Cena 1 im nce t: im 1 im nce tar por im im ce n ta im DRINKING AND DRIVING PITJE IN VOŽNJA 1. A maximum blood alcohol concentration limit of 0.5 g/L (0.24 mg/L in exhaled air) Najvišja dovoljena raven koncentracije alkohola v krvi - 0.5 g/L (0.24 mg/L v izdihanem zraku) 0.29 0.30 2. A maximum blood alcohol concentration limit of 0.0 g/L (0.0 mg/L in exhaled air) for all drivers Najvišja dovoljena raven koncentracije alkohola v krvi - 0.0 g/L (0.0 mg/L v izdihanem zraku) za voznike 0.60 0.53 3. Random breath testing and punishment for drink driving Naključni preizkusi z alkotesti in kaznovanje zaradi vožnje pod vplivom alkohola 0.24 0.26 4. Designated driver campaigns Akcije za treznega dežurnega voznika 0.37 0.40 EDUCATION, COMMUNICATION, TRAINING AND PUBLIC AWARENESS IZOBRAŽEVANJE, KOMUNICIRANJE, USPOSABLJANJE IN 0ZAVE[ČANJE JAVNOSTI 5. Education programmes in schools, colleges and universities Izobraževalni programi v šolah, višješolskih ustanovah in na univerzah 0.49 0.60 6. Education campaigns on health risks of alcohol consumption Izobraževalne akcije o nevarnosti pitja alkohola za zdravje 0.50 0.54 7. Education campaigns on hazardous and harmful alcohol consumption Izobraževalne akcije o tveganem in škodljivem uživanju alkohola 0.49 0.65 PACKAGING AND LABELLING OF ALCOHOL PRODUCTS EMBALAŽA IN OZNAČEVANJE ALKOHOLNIH PIJAČ 8. Alcohol products should not promote erroneous impressions about their characteristics or health effects Oznake na alkoholnih pijačah ne smejo vsebovati zavajajočih podatkov o njihovih značilnostih ali vplivih na zdravje 0.46 0.42 9. Alcohol products should carry safety and health warnings Na alkoholnih pijačah morajo biti opozorila o varnosti in vplivih na zdravje 0.44 0.43 10. Alcohol products should contain information on alcohol concentration, alcohol content, calorific value and ingredients that might lead to allergies Na alkoholnih pijačah mora biti označena koncentracija alkohola, vsebnost alkohola, kalorična vrednost in sestavine, ki lahko povzročijo alergije 0.39 0.48 PRICE AND TAX MEASURES TO REDUCE HARM DONE BY ALCOHOL CENOVNI IN DAVČNI UKREPI ZA ZMANJŠEVANJE [KODE ZARADI UŽIVANJA ALKOHOLA 11. The price of alcohol should be increased in line with inflation Cene alkoholnih pijač se morajo zviševati sorazmerno z Inflacijo. 0.72 0.53 12. Taxes should be proportional to the alcoholic content of alcoholic beverages with no threshold Davki morajo biti sorazmerni z vsebnostjo alkohola v alkoholnih pijačah, brez praga 0.81 0.70 13. Higher alcohol concentration beverages, such as spirits, should be taxed at a disproportional higher level Pijače z visoko koncentracijo alkohola, npr. žganje, morajo iti obdavčene po ustrezno višji stopnji 0.81 0.70 ILLICIT TRADE IN ALCOHOLIC PRODUCTS NELEGALNO TRGOVANJE Z ALKOHOLNIMI PIJAČAMI 14. Alcohol products should be marked to enable monitoring of their trade and legal status Oznacbe na alkoholnih pijačah morajo omogočiti nadzor trgovanja z njimi in njihov trgovski status 0.38 0.41 SALES TO MINORS PRODAJA MLADOLETNIKOM 15. The sales of alcohol products to persons under the age set by law, should be prohibited Prodajo alkoholnih pijač osebam mlajšim , kot to določa zakon, je treba prepovedati 0.36 0.45 16. Penalties against sellers and distributors to ensure compliance with relevant measures should be implemented Uvesti je treba kazenske ukrepe proti prodajalcem in distributerjem , da bi tako zagotovili ravnanje v skladu z ukrepi 0.23 0.31 ALCOHOL ADVERTISING, PROMOTION AND SPONSORSHIP OGLAŠEVANJE, PROMOCIJA IN SPONZORIRANJE ALKOHOLNIH PIJAČ 17. All forms of alcohol advertising, promotion and sponsorship that promote an alcohol product to minors should be prohibited Prepovedati je treba vse vrste oglaševanja, promocije in sponzoriranja ponudbe alkoholnih pijač mladoletnim osebam 0.63 0.70 18. Appropriate health warnings or safety messages should accompany all alcohol advertising, promotion and sponsorship Oglaševanje, promocija in sponzoriranje alkoholnih pijač morajo vedno vključevati tudi opozorila glede varnosti in vplivov alkohola na zdravje 0.48 0.49 19. The use of direct or indirect sale promotions that encourage the purchase of alcohol products should be prohibited Prepovedati je treba neposredne ali posredne oglaševalske akcije, ki spodbujajo prodajo alkoholnih pijač 0.77 0.81 20. All alcohol advertising, promotion and sponsorship should be restricted to information about the product only Oglaševanje, promocijo in sponzoriranje alkoholnih pijač je treba omejiti le na informacijo o izdelku 0.56 0.52 21. All forms of alcohol advertising should be prohibited Prepovedati je treba vse oblike oglaševanja alkoholnih pijač. 0.83 0.84 REDUCING HARM IN DRINKING AND SURROUNDING ENVIRONMENTS ZMANJŠEVANJE ŠKODE V PIVSKIH OKOLJIH IN OKOLICI 22. Alcohol sales should be prohibited to intoxicated persons Prepovedati je treba prodajo alkoholnih pijač vinjenim osebam 0.37 0.44 23. The hospitality industry and servers of alcohol should be trained to reduce the harm done by alcohol intoxication Zaposlene v gostinstvu ie treba poučiti, kako zmanjšati škodo zaradi opijanja. 0.59 0.67 INTERVENTIONS AND ASSISTANCE FOR FAMILY MEMBERS OF PEOPLE WITH ALCOHOL DEPENDENCE UKREPI IN POMOČ DRUŽINSKIM ČLANOM OSEB ODVISNIH OD ALKOHOLA 24. Programmes for counselling family members of people with harmful alcohol consumption should be widely implemented Pospešiti je treba izvajanje programov svetovanja družinskim članom tveganih pivcev 0.55 0.66 25. Education of health and social workers for the identification of family violence connected to alcohol Izobraževanje zdravstvenih in socialnih delavcev za prepoznavanje nasilja v družini, povezanega z alkoholom 0.65 0.75 a The numbers in the table are the factor loadings for each item (the numbers are located in the corresponding factor's column). The 25 items are grouped into nine alcohol policy domains. Table 3 presents the results for three factors (mean and standard error of estimation) for stakeholdres' views on the impact and importance of policies concerning reduction of alcohol-related harm using a scale of 1 (no impact or not important at all) to 10 (very high impact and very important). The results of factor analysis for Factor 1 (education) showed that there was no significant difference between different stakeholders in Slovenia as concerns their opinions on the impact of alcohol policy measures in the field of education (p=0.525). Governmental and non-governmental organisations and public health institutions were found to score the importance of educational measures higher than alcohol and related industries (p =0.005). Governmental and non-governmental organisations and public health institutions (professionals) perceived the regulatory measures (Factor 2 - regulation) as of higher impact (p<0.001) and importance (p<0.001) than alcohol and related industries. As for the Factor 3 (pricing), the results revealed no significant difference in scores of the impact of pricing measures of alcohol policy on the reduction of alcohol-related harm between the four groups of stakeholders. (p = 0.079). However, alcohol and related industries perceive the importance of pricing as significantly lower than the other three groups of stakeholders (p = 0.029). The results show that alcohol and related industries gave the lowest score to all three factors and that all the stakeholders' groups perceived the impact and the importance of pricing measures in alcohol policy as the lowest. There follow the regulatory and the educational measures of alcohol policy, which were perceived as of the highest impact and importance. Table 3. Results for three factors (mean and standard error of estimation) for opinions of the policy impact and of the policy importance in reducing the harm done by alcohol on a scale of 1 (no impact or not important at all) to 10 (very high impact and very important). Tabela 3. Rezultati za tri faktorje (srednja vrednost in standardna napaka ocene) za mnenja o učinku in pomembnosti alkoholne politike pri zmanjševanju škode zaradi uživanja alkohola na lestvici od 1 (brez učinka ali povsem nepomembno) do 10 (zelo velik učinek in zelo pomembno). Impact učinek Importance pomembnost GOsa PHOsb NGOsc AId ANOVAe GOsa PHOsb NGOsc AId ANOVAe Factor 1 Education Faktor 1 Izobraževanje 7.50 (0.35) 7.46 (0.18) 7.43 (0.16) 6.95 (0.33) 0.525 7.96 (0.36) 8.35 (0.14) 8.31 (0.15) 7.25 (0.31) 0.005 Factor 2 Regulation Faktor 2 Zakonska določila 6.74 (0.59) 7.26 (0.22) 7.06 (0.20) 4.13 (0.42) 0.000 7.19 (0.50) 8.24 (0.18) 8.22 (0.17) 4.67 (0.39) 0.000 Factor 3 Pricing Faktor 3 Cena 6.40 (0.69) 6.58 (0.28) 5.98 (0.29) 4.95 (0.54) 0.079 6.54 (0.58) 7.17 (0.24) 6.53 (0.29) 5.38 (0.46) 0.029 a GOs - governmental organisations (GOs) b PHOs - public health organisations (professionals) (PHOs) c NGOs - non-governmental organisations (NGOs) d AI - alcohol industry (AI) e ANOVA - p value. In order to confirm the four hypotheses tested, t-tests were used for the comparison of alcohol and related industries and all other stakeholders (governmental and non-governmental organisations and public health institutions). The hypothesis 1 (H1), stating that the alcohol industry will score the impact of measures in the field of education on reducing alcohol-related harm higher than governmental and non-governmental organisations and public health institutions was not confirmed; the difference between the two groups was not significant (sig. 2-tailed 0.165). The hypothesis 2 (H2) stating that the importance of alcohol policy measures in the area of education taken to reduce alcohol-related harm will be rated higher by the alcohol industry than by governmental and non-governmental organisations and public health institutions, was refused: alcohol and related industries scored the importance of education significantly lower than did other stakeholders (sig. 2-tailed 0.004). The results supported the hypothesis 3 (H3) that governmental and non-governmental organisations and public health institutions will score the impact of regulatory measures of alcohol policy on reducing the harm dene by alcehel higher than alcehel industry, and the hypethesis 4 (H4) stating that gevernmental and nen-gevernmental erganisatiens and public health institutiens will rate the impertance ef regulatery alcehel pelicy measures in lewering alcehel-related harm higher than the alcehel industry (sig. 2-tailed 0.000 fer beth hypetheses). As regards the Facter 3, the t-test demenstrates that the sceres ef the impact (sig. 2-tailed 0.035) and impertance (sig. 2-tailed 0.009) ef pricing measures in reducing alcehel harm perceived by alcehel and related industries were significantly lewer than these perceived by ether stakehelders. 4 Discussion The everall respense rate is relatively high (54.1 %) cempared te the respense rate ef 20%-40% fer investigatiens by mail reperted in the literature (36) The enly petential shertceming ef the methedelegy used is the respense rate ef alcehel and related industries (38.5 %) that is semewhat lewer in cemparisen te the ether greups. All stakehelders assign the greatest impertance te the measures related te educatien, cemmunicatien, training and raising public awareness. Interestingly, in centrast te the results ef ether EU studies, the gevernmental erganizatiens, nen-gevernmental erganizatiens and public health institutiens placed the impact and impertance ef alcehel pelicy measures in educatien significantly higher that did their ceunterpart erganizatiens at the EU level. Furthermere, the research at the EU level shewed that the alcehel industry rated the impertance and impact ef alcehel pelicy measures in educatien higher than did ether stakehelder greups. In Slevenia, the situatien is different: the alcehel industry rates the impertance and impact ef alcehel pelicy measures taken in educatien slightly lewer than ether greups ef stakehelders. It is interesting that all the participating stakehelders placed greatest emphasis en alcehel pelicy measures related te educatien, cemmunicatien, training and raising public awareness, since the evidence shews a rather limited impact ef educatien activities per se in limiting harmful censequences ef alcehel usage. It is true that the previsien ef infermatien and educatien is the key facter in raising public awareness and imparting knewledge. The infermatien clutter and cempeting messages distributed by varieus cemmunicaters whe eften have cempletely different metives fer cemmunicating abeut alcehel-related issues are characteristic ef eur envirenment. The messages abeut alcehel are eften centradictive. Furthermere, secial nerms in eur seciety still suppert drinking and easy access te alcehel. Such a climate dees net suppert sustained changes in drinking behavieur. (12) Why de all stakehelders in Slevenia assign such a great impertance te the educatien measures? It may be that the participating gevernmental erganizatiens are net familiar with the measures and activities that have preved effective. Furthermere, gevernments have a traditien ef develeping and implementing preventien pregrammes. In Slevenia, natienal and especially cemmunity-based preventive measures are fecused en scheel-based educatienal pregrammes. We have ne exact evidence ef the impact ef such pregrammes en drinking behavieur. Internatienal research shewed that despite seme examples ef beneficial impact ef scheel-based educatien, systematic reviews and meta-analyses demenstrated that the majerity ef well-evaluated studies shewed ne impact en behavieur even in the shert-term. (3) The questien arises whether educatien in general has net been successful er just inapprepriate educatienal appreaches have been used. Neither is it clear what the situatien weuld be if there was ne educatien en the alcehel issue at all. We think that educatien pregrammes have a place in alcehel pelicy previded that they are carefully cembined with ether measures. Such cemprehensive pelicy have repertedly preduced seme effect en drinking behavieur (30). Alse, the established high gevernmental perceptien ef the impertance ef taking educatien measures might be related te the annual secial advertising campaigns dedicated te the drinking and driving issue. These campaigns tend te be well accepted by the public in Slevenia, and may therefere be perceived as successful by the gevernment. Public health erganizatiens are anether impertant stakehelder greup stressing the impertance ef educatien measures in the alcehel pelicy. Their interest is te keep their significant rele in the transfer ef knewledge in scheels. Alcehel and related industries prebably perceive the impertance ef measures related te educatien higher than the impertance ef ether alcehel pelicy measures, because these measures affect them the least. Educatien is prebably perceived in the light ef free cheice ef a censumer and lesser market regulatien. Furthermere, alcehel and related industries suppert such campaigns as "respensible drinking" er "ne drinking and driving". Such campaigns seften the rele that the alcehel industry plays in alcehel abuse in the seciety by transferring the respensibility fer alcehel abuse en an individual. As expected, the alcohol and related industry gave much less weight to the regulatory measures, which, according to some research, constitute an effective way of reducing harm done by alcohol. (12) In Slovenia, the main regulatory measure is a partial ban on alcohol advertising, taxation and decreased accessibility to alcohol. These measures have a direct impact on alcohol sales and alcohol-related profits of the alcohol and related industry. It is expected, therefore that the alcohol and related industry would be very interested in influencing regulatory measures and that perceptions revealed in our research show their interest in loosening the regulations or at least maintaining their status quo. Governmental and non-governmental organisations and public health institutions give little weight to the pricing of alcohol beverages, despite the evidence that when the income and the price of other goods are held constant, a rise in alcohol prices leads to less alcohol consumption and less alcohol-related harm (and vice versa). (12) This may also be due to insufficient knowledge of the evidence base on effective alcohol policies. Another possible reason is that tax increase is a very unpopular issue for the government, especially in Slovenia where prices and excise duties for alcohol beverages are rather low in comparison to other European countries. In the past decase, Slovenia has woven a dense network of links between the alcohol industry and the media and other influential institutions that act as a strong lobbying platform for sustaining a rather untouchable status of the alcohol industry in Slovenia. This happens despite the fact that increasing alcohol taxes not only reduces alcohol consumption and the related harm, but also increases government revenue. The views on pricing policy expressed by alcohol and related industries did not differ markedly from the opinion of other stakeholders, which is a challenging result of this study. However, if we look at the measures covered by the Factor 3, only the first intervention ("the price of alcohol should be increased in line with inflation") is connected with general alcohol pricing policy. The other two measures, i.e. "taxes should be proportional to the alcoholic content of alcoholic beverages with no threshold" and "beverages with higher alcohol concentration, such as spirits, should be taxed at a disproportionally higher level" are aimed at increasing the taxes for alcoholic drinks with higher alcohol content. Since the majority of stakeholders in the alcohol arena in Slovenia are involved in the wine industry, they are affected by these measures to a much lesser degree than the producers of spirits. On the whole, the four groups of stakeholders score higher the measures that are less effective according to the evidence base for effective alcohol policies. Moreover, they score lower the measures that have proved more effective. These results suggest that stakeholders of alcohol policy in Slovenia share a rather poor knowledge of alcohol policy, especially of the evidence-based alcohol policy. We would suggest that greater emphasis be placed on informing and educating stakeholders on alcohol harm reduction evidence. There are some differences between our findings and those at the European level reported by Anderson and Baumberg. (3, 34) The main difference is that factor analysis gave different factors. In the European investigation the pricing measures fell under regulations. One possible explanation is that Slovenian stakeholders give less emphasis to the price. In Slovenia pricing is regulated only through excise duties regulation, which is a lower level of legislation (not adopted by the parliament), which means that pricing is not a very high priority of our alcohol policy at the moment. In many other European countries the pricing is an important alcohol policy measure. European stakeholders gave less emphasis to education measures compared to the stakeholders in Slovenia. The reason for this difference may be that governmental organisations and public health and non-governmental organisations are less informed and not sufficiently connected. Overall, the European study revealed much greater differences between the opinions on alcohol policy measures held by alcohol and related industries and those expressed by other stakeholders. The alcohol policy stakeholders in Europe seem to be more direct in expressing and exercising their interests, even when expressing their opinions on the impact and importance of particular alcohol policy measures. Another explanation could be that in Slovenia drinking alcohol makes an integral part of the national culture, and that many families are directly or indirectly involved in wine, beer or spirits production (themselves or as relatives of the producers or employees in the alcohol industry). Despite the fact that stakeholders have clearly different interests and that they mostly hold different views on the impact and importance of particular alcohol policy measures, there are some areas of alcohol policy, such as education and training, in which different stakeholders could join forces and work together. However, we should bear in mind different motives behind the high ranking of education and perceiving it as an important and effective measure. Furthermore, evidence from the foreign research warns us that these measures are not very effective if not combined with other approaches, and that investing in these measures should be proportional to investments in other policies. Alcohol and related industries have recently expressed willingness to take responsibility for training staff in bars, restaurants, pubs, night clubs and discos to adopt more responsible service practice. As stated by Anderson and Baumberg in the report "Alcohol in Europe", alcohol is not an ordinary commodity. It causes external costs and involves harm to others, and therefore requires more strict regulation. (3, 12) Policies that regulate the environment in which alcohol is marketed (economic and physical availability and commercial communications) are very effective in reducing alcohol-related harm. (12) In the light of this evidence stakeholders in alcohol and related industries will have to accept the fact that regulation is necessary. They will need to take part in the implementation of these regulations in the areas that relate to them, such as sales of alcohol to underaged or drunk individuals. There is a need for advocacy at this level, as well as for the translation of scientific findings to stakeholders, who seem to lack knowledge of alcohol policy and of evidence that supports particular alcohol policy interventions. 5 Conclusions The aim of our research was to study stakeholders' views on the impact and importance of alcohol policy in reducing alcohol-related harm. These opinions reflect interests of different interest groups and the government related to the issue of alcohol. In our opinion, acquiring information about different opinions on alcohol policy measures is the first and the very fundamental step in the process of developing an effective national alcohol policy. In order to develop and implement effective alcohol policies it is essential to identify common grounds and possible difficulties in negotiations. The study was based on the research on alcohol policy in Europe by Anderson and Baumberg. (3, 34) Our results show, similarly to their observations, that stakeholders are motivated by different interests in relation to particular alcohol policy measures. (3, 12) Stakeholders participating in our study, however, were more similar in their statements (and interests) than stakeholder groups at the EU level. (3, 34) Alcohol policy is influenced by all stakeholders. They all play an important part in formulating and implementing alcohol policies, acting either as individuals or as members of stakeholder coalitions. The government, however, is the stakeholder that posseses legitimate power, and we think that the adopted alcohol policy should reflect interests of the government. Our research has identified many common grounds where different stakeholders can work together to formulate more effective alcohol harm prevention policies. Education was found to be one of the platforms characterized by smallest differences in opinions and we suggest that at the start the stakeholders' efforts should be focused on this particular area. Collaboration in this field may yield good results in the process of policy management, as well as in building better relations among different stakeholders and in implementing specific, already existing alcohol policies and programmes, such as restricted access to alcohol for those under the drinking age and for drunk individuals. This is in tune with the WHO recommendations, which underline the importance of training programmes in responsible service practice for all those involved in the alcohol sales chain. The principal aim is to ensure responsibility in adhering to the legislation, reducing hazardous drinking and restricting alcohol availability for those under the drinking age. 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