8th June 2018, Volume 131 Number 1476

Stephen Randerson, Sally Casswell, Taisia Huckle

Alcohol is a leading preventable cause of premature mortality, disability and social harm.1 In New Zealand, 5.4% of all premature deaths have been attributed to alcohol, and the Māori mortality rate is 2.5 times that of non-Māori.2 The economic cost of alcohol-related harm was estimated at $5.3 billion per year in 2005.3 Research towards reducing harm has identified aspects of the alcohol environment that influence consumption, including alcohol availability, marketing, price and enforcement of alcohol controls. Most of these factors may be modified by alcohol policy at relatively low cost to reduce harm.4

Between 1989 and 2000, alcohol policy in New Zealand was liberalised and began to lag behind most other OECD countries with regard to effective measures to reduce harm.5 These changes were associated with increased traffic crash injuries among 15 to 19 year-olds,6,7 and in 2010, the New Zealand Law Commission reported the Sale of Liquor Act 1989 had no health focus, had liberalised alcohol availability and concluded that it should be replaced.8

In response, the Government developed the Sale and Supply of Alcohol Act 2012 (SSAA), which introduced minimisation of harm from excessive or inappropriate consumption of alcohol as a key objective. However, the SSAA made little or no change to the most cost-effective policy areas for reducing harm, including alcohol taxation, the minimum purchase age and control of alcohol marketing.4,9 The SSAA established two measures to constrain alcohol availability: default trading hour limits of 8am to 4am for on-licences and 7am to 11pm for off-licences, and a provision enabling territorial authorities (TAs) to develop a Local Alcohol Policy (LAP) through public consultation. LAPs may limit outlet locations and density, set alternative maximum hours of trade and were central to the Government’s intention to improve community input to licensing decisions through the SSAA.10

New risk-based licence fees and small changes to licensing procedures may also affect availability. Notably, the SSAA introduced a requirement to consider the impact of alcohol outlets on amenity and good order near their location, and made one-way door policies legally enforceable.

The SSAA extended existing social supply regulations to prohibit supply to minors in private settings, unless the alcohol is supplied responsibly and by either the guardian of the minor, or someone who believes they have the consent of a guardian. The SSAA also defined intoxication in primary legislation. With regard to alcohol marketing outside premises, discounts over 25% were prohibited under the SSAA. Inside supermarkets and grocery stores alcohol displays were to be limited to a single area.

The present study aims to improve our understanding of the impact of the SSAA by documenting perceived changes in the alcohol environment before and after its implementation. These include changes in enforcement of existing regulations amended by the SSAA, and changes in compliance. No studies to date have assessed multiple aspects of the alcohol environment in New Zealand across this time period. Findings may support improvements to the law and its implementation, and will support interpretation of results from studies of consumption behaviour and harms, specifically data collected as part of the International Alcohol Control (IAC) study.11

Enforcement and compliance are important because the alcohol environment is not only affected by the law, but also by how it is implemented.12–15 Responsive regulatory theory indicates that policy compliance interacts with attitudes towards a policy, and with how a policy is enforced formally and informally.16,17 Accordingly, regular enforcement has yielded significant improvements in compliance; for example, enforcement of purchase age regulations can deter sales of alcohol to minors, thereby reducing availability of alcohol to young people.18,19

Method

Data were gathered for 2013 and 2015 to identify changes over time. Although implementation of the SSAA began in 2013, changes to marketing and promotion, maximum trading hours, social supply and supply to intoxicated persons did not come into force until 19 December 2013, or later in the case of LAPs.

Data collection utilised the Alcohol Environment Protocol (AEP) (previously called the Policy Analysis Protocol), a standardised way to assess alcohol environments and policy implementation across countries. This tool was developed as part of the IAC study into alcohol use and related behaviour.11 The protocol documents policy, enforcement, compliance and aspects of the alcohol environment, specifically: number of alcohol licences, hours of sale, alcohol marketing, restrictions on purchase, supply to minors and intoxicated persons and drink driving. Items were added in 2016 regarding LAPs, ease of obtaining an alcohol licence and amenity and good order criteria. Drink driving was assessed because the maximum blood alcohol concentration (BAC) for drivers aged 20 years and older was reduced from .08 to .05 by the Land Transport Amendment Act in December 2014.

Key informant interviews with police, liquor licensing inspectors and public health officers were the main source of data. All informants were employed in alcohol regulatory roles in 2013 and 2015, which involved monitoring licensed environments, enforcing alcohol regulations, checking licence conditions and reviewing alcohol licence applications. Interviews were conducted in early 2014 and early 2016 with 36 informants, 26 of whom were interviewed on both occasions. Informants worked in eight urban areas (populations greater than 30,000) and 11 ‘non-urban’ areas across New Zealand. Many worked across multiple urban and rural locations. Additionally, five drink-drive enforcement officers were interviewed in 2016 regarding drink-drive enforcement only.

Key informants rated physical aspects of the alcohol environment, regulatory enforcement (monitoring and prosecution together) and compliance on 10-point scales. The reasons for ratings were requested. In 2016, items regarding change in numbers of premises and hours of trade were added to compensate for a flaw in alcohol licence records after 2014. Ordinal logistic regression was used to test the difference in ratings between the years. Qualitative comments were thematically analysed, whereby similar responses were grouped into themes and the number of respondents mentioning each theme counted. To complement key informant perceptions, quantitative information was collected from the Ministry of Justice’s 2013 alcohol licence data, Police enforcement statistics and Ministry of Transport survey results.

Results

Perceived changes to availability 2013 to 2015

Overall availability

There was little change in the very high levels of alcohol availability reported by key informants in 2013 and 2015, although a slight reduction was noted in urban areas (Table 1). No change was seen in the total number of licensed premises. However, many informants noted the new drink driving limit had led to increases in supply and sale of low-alcohol and mid-strength beer across a wider range of brands, and an increase in premises focusing their business on food and entertainment. Perceived levels of enforcement and compliance with alcohol regulations in general remained high.

Table 1: Changes in the New Zealand alcohol environment 2013 to 2015.

 

Policy change

2013 rating

2015 rating

Change

SSAA contribution to change

All regulations

Enforcement1

 

9

9

None

 

Compliance2

 

8

8

None

 

Availability

Overall

Availability in urban areas3

 

10

9

↓*

Partial

Availability in non-urban areas3

 

8.5

8

None

 

Number of outlets8

No

-

-

None

 

Trading hours

Yes

 

 

 

 

Enforcement of licensed hours

 

9.5

10

None

 

Compliance with licensed hours

 

9.5

9.5

None

 

Change in licensed hours8

 

-

-

Yes

Change in operating hours8

 

-

-

Partial

One-way door enforcement

Yes

8.5

10

↑*

Yes

One-way door compliance

 

9

9

None

 

Licensing process

Yes

 

 

 

 

Difficulty of obtaining new licence8

 

-

-

Yes

Use of amenity and good order criteria in licence decisions4

New element

-

7

 

 

Supply to minors

Purchase age enforcement

No

9

9

None

 

Purchase age compliance

 

8

8

None

 

Ease of purchase by a minor5

 

3

3

None

 

Social supply enforcement

Yes

4

4

None

 

Social supply compliance

 

4

5

Possible

Ease of obtaining via social supply5

 

8

8

None

 

Supply to intoxicated persons

No

 

 

 

 

Enforcement

 

7

7

None

 

Compliance

 

6

6.5

None

 

Ease of purchase if intoxicated5

 

6

6

None

 

Point-of-sale marketing

Yes

 

 

 

 

Enforcement

 

8

6.5

↓*

Unclear

Compliance

 

8

6.5

Unclear

Extent inside on-licensed premises6

 

5

5

None

 

Extent inside off-licensed premises6

 

8

10

↑*

Unclear

Single area condition enforcement

New

-

7.5

 

 

Single area condition compliance

 

-

5.5

 

 

Drink driving

Yes

 

 

 

Land Transport Amendment Act

Enforcement of BAC limit

 

-

-

↓ 7

 

Compliance with BAC limit

 

-

-

↑ 7

Yes

1Enforcement ratings are the median response on a scale from 1 (not enforced) to 10 (always enforced).
2Compliance ratings are the median response on a scale from 1 (completely ignored) to 10 (complete compliance).
3Median response on a scale from 1 (completely unavailable) to 10 (completely available).
4Median response on a scale from 1 (not at all) to 10 (in all cases).
5Median score on a scale of 1 (not at all easy) to 10 (very easy).
6Median score on a scale of 1 (nowhere) to 10 (everywhere).
7Ministry of Transport data.
8Change assessed retrospectively in 2016 only.
* p<0.05.
 

Trading hours and one-way doors

Inconsistencies in administrative data after 2014 prevented comparisons of 2013 and 2015 alcohol licence hours. Most key informants perceived slight reductions in licence hours due to the maximum trading hours specified in the SSAA, but not in all regions. Some reported their region had already established earlier closing times via local agreements or policies.

Operating hours were different to licensed hours. Informants noted that some premises rarely opened to the extent of their licence: “Businesses do like to keep their maximum trading hours for special occasions like the holiday season”. They reported a slight reduction in operating hours between 2013 and 2015 for off-licensed and on-licensed premises. This was most frequently attributed to weak economic conditions, followed by risk-based licence fees, with several informants reporting that licence holders applied for shorter licence hours to reduce the licence fee. Only three informants (two from major cities) cited the SSAA’s maximum trading hours as a reason for shorter operating hours. Outside the larger cities, the economic base was often reported as insufficient to allow premises to open to the new maximum hours. Four informants stated the lower blood alcohol limit caused on-licence premises to close earlier. Perceived enforcement and compliance with trading hour limits remained very high from 2013 to 2015.

Perceived enforcement of one-way door policies increased from 2013 to 2015. In 2013, the one-way door policy agreements reached between regulatory agencies and local premises were described as “toothless”, as no formal sanctions could be applied. By 2015, the SSAA had made the policies legally enforceable, and there were fewer very low ratings of compliance.

Licensing process changes

There was strong agreement among informants that it had become slightly more difficult to obtain a new licence, particularly for off-licences under the SSAA. The most frequently mentioned reason was increased public opposition to new outlets (other than licensed cafes and restaurants), with comments that public awareness of the licensing process was heightened by implementation of the Act, the new grounds for opposition, media stories and advice from agencies. Public opposition was seen to have the greatest effect before a District Licensing Committee (DLC) hearing took place, with some applications withdrawn at this stage. Conversely, it was described as challenging for the public to participate in DLC hearings effectively without significant support. Other perceived impacts of the SSAA on licensing were an increased focus on alcohol-related harm due to involvement of public health officers in the evaluation of applications; the amenity and good order criteria; and extended application forms requiring host responsibility and venue safety plans.

In 2015, informants perceived the new amenity and good order criteria were being taken into account in just over half of all decisions to grant a licence. The criteria were also used to argue for suitable trading hours. The most common barrier to using the criteria to oppose a new licence was difficulty gathering sufficient evidence, partly due to available resources: “[Agency] haven’t been able to show a difference in crime rates… it’s harder to keep track in smaller townships (which) don’t have the resources to monitor or report on these things”. Others suggested the standard of proof sought by DLCs was unreasonably high: “There was alcohol-related rubbish and broken glass all over a park that had a bottle store near it. [The agency] took this to the DLC who then asked how they knew that the broken glass and rubbish came from the bottle store even though it was right next to the park”.

Local alcohol policies

Only five LAPs were in force by the end of 2015, although 32 of 67 territorial authorities had produced a draft or provisional policy by this time (pers. comm. Jackson, 2016). Appeals were the most commonly reported impediment to developing an LAP. Some local authorities halted or deferred developing a LAP until appeals in other districts had been decided. Other difficulties cited were finding a compromise between the commercial goals of businesses and alcohol-related harm in the community; opposition from business interests, including the hospitality industry and supermarket chains; and time and cost.

Perceived changes in supply practices

Supply to minors

It was reported to be easy for minors to access alcohol through social supply in both 2013 and 2015. Social supply regulations were perceived to have relatively poor compliance and to be almost “unenforceable”, both before and after the changes introduced by the SSAA. The most commonly mentioned difficulty was that social supply typically occurs in private and is rarely reported, so is hard to detect. A lack of public concern was believed to compound this issue, and regulatory staff also had difficulty finding witnesses prepared to give evidence: “The (new) definition is hard to enact as it relies on others bringing these issues to police attention, which doesn’t happen that often due to the public not really perceiving social supply as a problem”.

In contrast, the alcohol purchase age was reported to have very strong enforcement via use of controlled purchase operations. Compliance with the purchase age was high and it was seen as difficult to purchase alcohol when underage.

Supply to intoxicated persons

Informants believed it was moderately easy to purchase alcohol while intoxicated in 2013, and this did not change in 2015. Likewise, perceived compliance with the law on supply to intoxicated persons remained middling in 2013 and 2015. Descriptions ranged from reasonable compliance in a majority of premises to overt non-compliance: “Bar staff will turn a blind eye if they think they can get away with it, which many still do”. Enforcement was reported to be lower than for most regulations investigated, often due to insufficient staffing or low priority. Some shifts in enforcement attitudes and approach were evident. In 2013, four informants reported intoxication on licensed premises was somewhat tolerated: “Even within [agency name], there has been quite an accepted attitude that people go to the pub to get intoxicated”. Others noted a reactive approach: “It is enforced when and if it comes to our attention, like if a licensee phones us or the intoxicated person brings the attention to themselves”. No comments of this type were provided in 2015, and some proactive efforts to educate licensees were mentioned. When offences were detected, enforcement responses were usually graduated over two levels—first, providing education and further monitoring, and second, formal applications to a judicial authority for fines or licence suspensions.

Subjectivity in assessing intoxication was commonly reported to hinder enforcement and prosecution in 2013. In 2015, after the definition of intoxication was added to the SSAA, only one informant described the definition as “vague and easy to get around if businesses have the money to do so”, while three informants commented that a problem for enforcement was that “the process for determining intoxication is left with the bar staff to determine”.

Perceived changes in point-of-sale marketing

Ratings of the extent of advertising inside off-licensed premises rose to ‘everywhere’ in 2015, whereas no change was reported in on-licensed premises. In 2015, informants provided slightly lower ratings of both enforcement and compliance with point-of-sale restrictions than in 2013, however, only 16 informants rated this item in 2013. Although two informants reported the SSAA had made enforcement easier by banning specific types of promotion, several low ratings of enforcement in both years were attributed to insufficient resources for monitoring.

In supermarkets and grocery stores where a single area condition applied, enforcement was reported to be moderately extensive, but compliance was viewed as middling (relatively few premises would have been subject to the condition because it was applied upon licence issue or renewal, and this process was halted nationally from late 2014 to 2016 by court proceedings).

Perceived changes in drink-driving enforcement and compliance

Between 2013 and 2015, the annual total number of breath tests conducted reduced by 12%, from 2.90 to 2.56 million.20,21 In the same period, there was a 24% reduction in apprehensions of drivers with a BAC of .08,22 and 35% of drivers reported drinking less before driving after the law change.23 Drink driving enforcement officers also reported a slight improvement in compliance after the law change, finding lower breath alcohol levels in general and that more people were deciding not to drink at all before driving in order to “stay safely under the limit”. The informants believed the overall extent of enforcement operations and resourcing was no different after 2014; this may have been due to the high volume of ongoing operations, or it is possible that less change occurred in their districts.

Discussion

Changes in perceived enforcement and compliance with alcohol regulations

Little change was reported in the overall extent of enforcement of pre-existing alcohol regulations between 2013 and 2015, and resources for enforcement did not increase. Some changes were seen in the focus of enforcement, with assessment of licence applications placing a greater emphasis on harm and increased attention on host responsibility practices in licensed premises. In addition, new elements of the SSAA, namely one-way doors and single alcohol area conditions (although few of the latter existed), were perceived as being well enforced.

The results identify trading hours, one-way door restrictions and the purchase age as the most extensively enforced regulations in each year, with associated high levels of compliance. As with drink-driving enforcement, these restrictions had formalised monitoring programmes such as controlled purchase operations, or were inherently simple to assess, such as closing times. Despite new definitions in the SSAA, social supply and supply to intoxicated persons remained among the least well-enforced of the regulations investigated and had the lowest perceived compliance in both 2013 and 2015.

Data available to 2014 indicate that intoxication offences were seldom penalised. In 2014, seven enforcement applications were made to the Alcohol Regulatory Licensing Authority (ARLA) for supply to intoxicated persons, alongside 28 applications for allowing intoxicated people to remain on licensed premises.24 The informants reported insufficient prioritisation of resources to enforcement was a persistent challenge. Comments that “the process for assessing intoxication was left to bar staff to determine” may need examination, as they imply limited monitoring, and possibly uncertainty over the regulatory procedure. In addition, supply to an intoxicated person seems unlikely to be witnessed, as regulatory inspections were generally conducted in uniform.

Enhanced enforcement methods could improve compliance with intoxication regulations. Compared to recommended strategies for increasing responsible alcohol service,25,26 the SSAA lacks low-level penalties for intoxication offences that can be applied when initial education efforts and monitoring fail. Introducing smaller on-the-spot fines would enable swifter and more frequent enforcement, avoiding lengthy applications to ARLA for licence suspensions or large fines. A well-publicised programme of plain-clothes inspections could also improve the impact of present monitoring efforts.

The implementation of the lower maximum BAC for drivers highlighted the role that stronger legislative limits, when well-promoted and effectively enforced, can play in changing risky behaviour. After the .05 BAC limit was implemented, and even though breath testing volumes reduced, the public continued to believe that the odds of being tested for drink driving were high23 and drink driving apprehensions at the .08 BAC level fell. Likewise, our informants found more people were choosing to drink less (or not to drink) before driving to avoid breaking the new limit. This outcome was likely supported by news of the law change, and the ongoing strategy of keeping perceptions of enforcement high by using media campaigns to publicise breath testing operations, with checkpoints directed to both targeted and high visibility locations.27

Changes in alcohol availability and promotion

A slight reduction in on-licensed premises’ operating hours in main cities was the main impact of the SSAA on alcohol availability identified in this study. Specifically, new default maximum trading hours reduced the operating hours of bars and night clubs that traded after 4am in city entertainment districts. The extent of change was limited by the very late hours restricted; national alcohol licence data for 2013 indicated only 6% of on-licensed premises (almost entirely in urban areas) would be impacted by 4am closing. This change may have contributed to the slight reduction in overall alcohol availability reported for urban areas.

We did not identify any other wide-reaching changes in alcohol availability by 2015 resulting from the SSAA. The small reduction perceived in off-licensed premises operating hours was more often attributed to a lack of business than the SSAA’s default trading hours. Although 2013 records showed 29% of premises would have their maximum off-licence closing time reduced under 11pm closing, it is uncertain how extensively this affected actual operating hours. More than half of the potentially affected premises were located in rural areas, where informants more frequently reported outlets did not trade to the full extent of their licensed hours. It is also unknown how many premises reduced their hours in response to risk-based licence fees. The introduction of risk-based fees in the Australian Capital Territory was not believed to affect trading hours in a significant number of premises.28 Further, the fees seem too low to motivate a business to significantly cut profitable hours of trade.

LAPs have significant potential to restrict trading hours, outlet density and location, but too few were in force in 2015 to affect the alcohol environment nationally. Appeals against LAPs deterred and delayed their implementation. Although medical officers of health and police mounted several appeals, appeals from off-licence alcohol suppliers were more widespread, and most commonly resulted in the relaxation or removal of restrictions from LAPs.29 In light of the substantial commercial conflict of interest which alcohol suppliers have with the SSAA’s aim of minimising harm from the excessive consumption of alcohol,30 steps to protect the LAP development process from their influence appear desirable. This could facilitate policies which are more likely to reduce alcohol-related harm, and reduce development time and cost.

Despite observations that obtaining alcohol licences had become slightly more difficult, the prevalence of licensed premises was not perceived to have changed from 2013 to 2015. This is consistent with the very minor change in total alcohol licence numbers from 2007 to mid-2014.31 Total alcohol available for consumption in New Zealand fell by 5.3% from 2013 to 2015,32 but the contribution of the SSAA to this fall is unknown.

Two areas for improving the alcohol licensing process were identified. First, better processes to support public participation in DLC hearings would assist the government’s aim of giving community members more say in licensing decisions. Second, the difficulties proving the impact of a licence on amenity and good order suggest a more pragmatic standard for assessing these criteria is needed, consistent with the harm minimisation goals of the Act.

Perceptions of youth access to alcohol did not change between 2013 and 2015. Notably, access via social supply was seen to remain easy, although the informants reported limited opportunities to observe social supply in practice. A recent study found fewer suppliers reported supplying friends under 18 years after 2013 (30% in 2013 and 22% in 2015).33 Publicity surrounding the new law may have created some change, but this may not be sustained without continued monitoring, which is reportedly difficult. As such, community efforts are likely to remain important to encouraging greater compliance.

We found little evidence that new marketing restrictions in the SSAA had affected the extent of advertising inside outlets, but this may be related to the slow introduction of single alcohol areas. Perceptions of low compliance with single alcohol area conditions may have been due to delayed implementation, as the SSAA allows additional time for outlets to reconfigure their displays to meet the conditions.

In contrast, the lower BAC limit introduced by the Land Transport Amendment Act was observed to quickly deliver considerable changes to both drink-driving behaviour and on-licensed environments, including greater availability and sale of low-alcohol beer and a stronger focus on food and entertainment in on-licensed premises.

Limitations in the study include, first, the self-report nature of the enforcement and compliance ratings. Second, retrospective ratings of change over time may have been affected by the respondents’ personal expectations surrounding these changes. Lastly, some changes in practices concerning regulation and compliance may have begun prior to implementation of the SSAA, potentially limiting the extent of change seen after 2013.

In conclusion, we found the SSAA had little impact on the alcohol environment between 2013 and 2015, other than a small reduction in on-licence trading hours in urban centres. The impact of LAPs was delayed and muted by litigation, particularly from alcohol suppliers. Regulations with systematic and objective monitoring processes were associated with higher compliance, but resourcing remained a challenge to enforcement. This highlights the continued relevance of effective national policy measures with lower monitoring costs, such as increases to alcohol taxation and the purchase age and restricting alcohol advertising, as originally recommended by the Law Commission in 2010.8

Summary

The Sale and Supply of Alcohol Act was implemented during 2013, with the new aim of minimising harm from excessive consumption of alcohol. We assessed the impact of the Act on the drinking environment by reviewing public datasets and reports and interviewing alcohol regulatory staff. We found little evidence that the Act had affected the alcohol environment between 2013 and 2015, other than a small reduction in on-licence trading hours in New Zealand’s main cities. The process of establishing local alcohol policies to protect health has been subverted by the appeals by the alcohol suppliers whose resources are greater than those of local authorities and health agencies.

Abstract

Aim

To assess the impact of the Sale and Supply of Alcohol Act 2012 (SSAA) on the alcohol environment from 2013 to 2015.

Method

A mixed methods study incorporating key informant interviews and administrative data to assess changes between 2013 and 2015. Perceptions of the alcohol environment, policy enforcement and policy compliance were thematically analysed and quantitative ratings summarised. Concurrent changes to drink driving law were included.

Results

The SSAA led to a slight reduction in very late night availability in urban centres via the national 4am limit for on-licensed premises trading, which had strong compliance and enforcement. A slight increase in the perceived difficulty of obtaining licences was attributed to increased public opposition, licensing procedures and expanded application criteria. Proposed local alcohol policy (LAP) limits on trading hours and premise locations were delayed and weakened by extensive legal appeals from alcohol retailers. Only five LAPs were in force by 2015. No impact on number of premises, supply to minors or marketing was identified. Reductions in drink drive behaviour and increased availability of lower-strength beer were attributed to the lower legal blood alcohol limit for driving.

Conclusion

Maximum trading hours were the only element of the SSAA found to create a swift change in the alcohol environment, by slightly reducing availability in main cities. LAPs and new licence criteria may gradually constrain future availability, but the strength of LAPs has been muted by alcohol industry appeals. Introducing national, evidence-based policy measures would assist the SSAA to achieve its aim of minimising harm more swiftly, as would measures to protect the LAP development process from alcohol industry influence.

Author Information

Stephen Randerson, Research Officer, SHORE & Whariki Research Centre, College of Health, Massey University, Auckland; Sally Casswell, Co-Director, SHORE & Whariki Research Centre, College of Health, Massey University, Auckland; Taisia Huckle, Senior Researcher, SHORE & Whariki Research Centre, College of Health, Massey University, Auckland.

Acknowledgements

This research was funded by the Health Research Council of New Zealand (#12/448 and #14/494). We acknowledge the experience of the regulatory personnel interviewed for this study and thank them for their participation. We also thank Martin Wall, Lanuola Asiasiga, Mirinia McVay, Jolyon Sutherland, Thomas Graydon-Guy and Phil Donovan from the SHORE & Whariki Research Centre for their contributions. 

Correspondence

Stephen Randerson, SHORE & Whariki Research Centre, Massey University, PO Box 6137, Wellesley Street, Auckland 1141.

Correspondence Email

s.j.randerson@massey.ac.nz

Competing Interests

All authors report grants from the Health Research Council of New Zealand during the conduct of the study.

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