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Due to typically heavy patterns of drinking as well as differences in alcohol sensitivities and risk-taking behaviours, adolescents experience disproportionately more harm from their drinking than older drinkers.1 New Zealand secondary school students report experiencing a range of acute alcohol-related harms, with significant inequities suffered by students of Māori and Pacific ethnicity and/or living in socio-economic disadvantage.2 In 2017/2018, one in every eight presentations among those aged 15 to 19 years to Auckland Hospital’s Emergency Department was found to be alcohol-related.3 Heavy drinking is also associated with poor mental health and suicidal ideation.4

Long-term harms of drinking can include irreversible impairment of brain structure and cognitive functioning, as the maturing brain is sensitive to the neurotoxic effects of alcohol.5 Other significant chronic harms include seven types of cancer,6 with research indicating that exposure to alcohol between menarche and first pregnancy may be important in the development of breast cancer, as breast tissue is likely to be at its most vulnerable stage.7 Finally, adolescence is a period of increased risk of alcohol abuse and dependence.8 In New Zealand, almost 50% of cases of alcohol abuse and dependence were found to have developed by the age of 20 years and 70% by the age of 25.9

Although the discourse surrounding adolescent drinking commonly focuses on binge drinking, there is no safe level of consumption for children and young people.1 This underpins the Health Promotion Agency’s low-risk drinking advice that recommends “not drinking alcohol is the safest option for children and young people under 18 years”.10

Encouragingly, New Zealand adolescents are mirroring global trends and showing significant reductions in alcohol use that have been maintained over time.11 For example, between 2006/07 and 2011/12, significant declines in the prevalence of past-year drinking (from 74.5% to 59.6%) and hazardous drinking (from 19.5% to 11.7%) were found among 15 to 17 year-olds.12 However, profound inequities remain persistent and preventable, with rangatahi Māori males and females reporting a substantially higher (two to three times) prevalence of hazardous drinking than non-Maori.13

Given the known risks of alcohol harm to this group, there are substantial benefits from prevention and early intervention. To reduce harms (and inequities), evidence-based and cost-effective policies are required. These include increasing alcohol prices, reducing availability, restricting alcohol advertising and sponsorship and increasing the legal purchase age.14

Evidence pertaining to the effectiveness of school-based education is less consistent and often contains methodological limitations.15 Despite the large number of studies in this area, few show long-term behavioural change. Evidence-based recommendations16 for school-based alcohol education draw from a limited number of high-quality studies, describing the need to: 1) use a spiral curriculum (whereby students study the same topics in ever-increasing complexity throughout their time at school to reinforce previous lessons), 2) integrate alcohol education into a whole-school approach to wellbeing, 3) link classroom health education curriculum activities with pastoral support of students, 4) create a supportive environment through development of school alcohol and wider policies (eg, school climate), and 5) incorporate activities that involve parents/guardians, families and communities. It is further recommended that teachers and others require sufficient planning time and training, that the use of scare tactics be avoided, and external providers only be used if they offer content that is consistent with the whole-school approach and are quality-assured.

Alcohol industry involvement in school-based health education

Alcohol companies have a long history of delivering alcohol education in schools. Powell17,18 offers extensive critique of ‘corporate philanthropy’—the practice of commercial agents entering into pedagogical spaces. In New Zealand, the Health and Physical Education learning area (curriculum) space is an attractive site for a wide range of food and beverage corporations (among others) who develop resources for teachers and learners, provide teachers with professional learning and development opportunities, and enter the classroom to teach students directly.18

Powell describes the use of corporate philanthropy as a strategy to divert public attention from less altruistic practices (marketing, lobbying, avoidance of stricter regulations, requirement to make a profit, etc.) and rather shape their corporate image to being trusted, caring, socially responsible and even healthy.17 A similar approach is currently occurring in New Zealand via the increasing number of alcohol industry partnerships with cancer, mental health, wellbeing and environmental charities. For decades, tobacco control advocates have warned of the tobacco industry embracing teenage prevention campaigns, knowing perfectly well that any education programme won’t hurt their profits but will show them to be ‘doing something’.19

One example of corporate philanthropy in the school-based AoD education space is Smashed, entitled “A responsible drinking education programme”. Sponsored by Diageo (a multi-national alcohol company), it commenced in the UK in 2005 and has so far engaged more than half a million students internationally.20 A common approach to get political buy-in has been to hold a parliamentary reception to launch the programme.20

Smashed has now made its way to New Zealand, almost 15 years since its inception. Smashed utilises a ‘theatre in education’ approach, with three paid actors providing a 30-minute live theatre performance followed by a 30-minute interactive workshop to consolidate the information provided. As described on its website and teacher resources, the programme seeks to raise awareness of personal responsibility in making informed decisions around alcohol.21 The objectives of the programme are to explore key themes of alcohol awareness, potential risks of underage drinking (such as physical and mental health issues, anti-social behaviour, accidents and injury), as well as impacts on relationships and school. Causes of underage drinking are explored, such as peer pressure, and local resources and support services available are signposted. A set of teacher resources are also available, should they choose to carry out any sessions before or after the main session. There is no evidence that the use of the lesson plans is compulsory.

In 2019, Smashed was delivered to 20,463 Year 9 students across 94 New Zealand high schools in 135 performances, and information suggests is to be further rolled out nationally in 2020 and beyond. In New Zealand, it is funded by the Tomorrow Project, a group comprising the multinational beer, wine and spirits makers. It is delivered in high schools via partnership with Life Education Trust, a group that has been reported to have had previous partnerships with Lion and British American Tobacco.22

Critique of Smashed: alcohol harm reduction perspective

At first glance, many would read the teacher resources and consider them to be suitable for school-based AoD education. They contain common educational components such as the health risks from alcohol misuse, the negative impact of peer pressure, available support services and so forth. However, an examination of the (often subtle) messaging throughout Smashed is recognisable as common strategies used by alcohol industry programmes internationally. The teacher resources also highlight an obvious language discrepancy, as ‘underage drinking’ is irrelevant in New Zealand given there is no legal drinking age (in contrast to other countries, eg, US). In New Zealand, the focus of interest is consumption and associated harm, not the health or safety risks in terms of disobedience.

One common thread throughout the teacher resources is the strong focus on “personal responsibility”. Other terms used in Smashed include “make responsible choices” and “drinking responsibly”. Literature describes the long history of this industry approach, showing that it is used to individualise alcohol problems, while neglecting the role of the wider alcogenic environment that plays a much stronger role in enabling risk behaviours.23 The personal responsibility approach is strategically ambiguous,24 encourages the drinker to shift responsibility to others23 and has the potential to sustain stigma for those with alcohol problems.25 From a brain development perspective, there is an obvious conflict between an adolescent’s ability to make ‘responsible choices’ and consider long-term risks, when the required part of the brain to undertake those tasks is under-developed. It is also obvious that the ability to make ‘responsible choices’ is severely compromised once under the influence of an intoxicating drug.

The use of the term ‘personal responsibility’ is not isolated to school-based programmes; it is echoed in policy debates. For example, in its submission to the Law Commission, New Zealand’s largest alcohol producer, Lion, stated that “individual responsibility is key to behaviour change” (p.4),26 and rejected evidence-based population-based policies to reduce the harms from adolescent drinking, such as increasing the price of alcohol or restricting alcohol advertising.

A second feature of the resources is the omission of information. For example, in the Smashed resources, only cancers of the mouth and throat are included as cancer-related health risks from alcohol. More prevalent breast and bowel cancers are omitted, despite breast cancer being the leading cause of alcohol-related death in New Zealand women.27 Omission of alcohol-cancer links, especially for breast and bowel cancer, has also been found among alcohol industry websites.28 This important omission contradicts the notion that adolescents can make informed and ‘responsible choices’ as a result of participation in the Smashed programme.

A third feature, and common to the alcohol industry internationally, is the incorrect construction of a dichotomy of alcohol drinking patterns or subpopulations into ‘misuse’ versus ‘responsible drinking’. As the name (ie, Smashed) perhaps suggests, a focus on alcohol misuse, abuse and binge drinking is found within the programme, although there is a conspicuous absence of definitions of these terms, especially in terms of actual amounts of alcohol. Of particular concern is the lack of discussion in the teacher resources pertaining to the importance of not starting drinking, as recommended in New Zealand’s low-risk drinking advice.10

It is suggested that the strategy of dichotomisation is used by the industry to convey a straightforward but over-simplified separation of drinking patterns, into those who use and misuse.29 The former is to represent a non-problematic population, while the latter a minority who drink in an uncontrolled manner and experience the range of health and social problems.29 This approach is also reinforced within policy debates, with Lion’s submission to the Law Commission26 stating “the problem at issue is alcohol abuse and related harm… measures are required to fix the behaviour of a minority, by making excessive drinking socially unacceptable” (p.3).

In reality, there is consistent evidence that no simple dichotomy exists. Risk curves describing the relationship between alcohol use and harms (eg, cancers30) show a continuum of harm across different patterns of drinking. There is no magic point where alcohol harms suddenly appear.31 For this reason, public health professionals dismiss the validity of an alcohol consumption dichotomy that boxes off alcohol harms from the majority of consumers, while the alcohol industry rejects the continuous model of harm in favour of interventions targeted at the relatively small group of heaviest drinking individuals at the extreme end of the continuum.29

A fourth feature is the lack of independent evaluation of Smashed, also reported to be common to alcohol industry programmes.32 In New Zealand, the evaluation is authored by the UK company that originally created the Smashed project.33 As detailed in the evaluation, the pre-programme response rate to the questionnaire was 27%, dropping to 15% post-programme. Any details about non-responders and/or limitations of poor response are not discussed in the evaluation report but should highlight the caution required when interpreting the claims relating to improvements in knowledge and understanding. Further concerns regarding the evaluation are discussed later.

From an alcohol harm reduction perspective, New Zealanders should be seriously concerned about programmes such as Smashed. Not only are they likely to be ineffective in reducing harm to our vulnerable populations, they are designed to whitewash the alcohol industry image. When approached for participation, principals and teachers should be critical of why multinational alcohol companies would choose to invest in school-based education in New Zealand. New Zealand can look to the strong statements made by Ireland’s Health Minister34 and Education Minister35 on the need to separate out the alcohol industry from being part of the conversation, with the former stating that “it’s completely and utterly bizarre that you’d have a body funded by the drinks industry educating our kids about the dangers of alcohol… I mean it’s ridiculous” (para. 3).34

Critique of Smashed: health education perspective

From a school-based health education perspective, programmes that offer pre-packaged resources and teaching activities (eg, Smashed) have the potential to contradict aspects of educational policy and guidelines for effective practice in AoD education, as well as undermine the professional practice and autonomy of trained health education teachers.

Health education is one of three subjects in the Health and Physical Education learning area (HPE) of The New Zealand Curriculum.36 As is the case in other learning areas, learning experiences in HPE are mandated until the end of year 10 (around 15 years of age). AoD education is located within the ‘mental health’ key area of learning within HPE, which indicates more than a sole biomedical focus for AoD. Stepping back from HPE, aspects of The New Zealand Curriculum are common to all learning areas. Included here are seven aspects of effective pedagogy—actions that a teacher takes to bring about student learning. While external providers do not make claims to fulfil all aspects of the curriculum, the extensive use in health education of programmes such as Smashed counteracts aspects of effective pedagogy. For example, teachers are expected to create a supportive learning environment, make connections to prior learning and experience and inquire into impact of their teaching.36 When an external provider makes their entry into the pedagogical space, these teacher actions are unable to take place, and—worst case scenario—previous work on the part of the teacher in enacting these aspects of effective pedagogy can unravel.

A second aspect of educational policy is ‘Our Code, Our Standards’, which contains the professional standards against which teachers are assessed for registration.37 For example, learning-focused culture prioritises aspects as safety, respect and students as active participants in learning. Design for learning requires planning for, carrying out and assessing the impact of pedagogical actions to meet learners’ needs and to show progression of learning. Teaching requires adaptations to meet diverse needs, feedback on progress for learners and a repertoire of teaching strategies.37 External providers may or may not be registered teachers and as such do not make claims to meet the professional standards for teachers. However, when pre-packaged programmes (especially those delivered by external providers) enter schools, the potential of a teacher to demonstrate evidence of meeting the expected standards might be diminished, because a lot of the teacher’s work is effectively done for them. This is particularly an issue when teachers of subjects such as health education over-rely on external providers and/or pre-packaged programmes.

Perhaps a more compelling argument central to a health education critique arises when we examine the messages contained within the array of guidance documents that have been written to support teaching in AoD education contexts. Here, the guidelines for teachers and schools published by the Ministry of Education,38 New Zealand Health Education Association39 and Tūturu/NZ Drug Foundation40 further cement this critique. A message common to each group’s assertions is that one-off sessions are educationally ineffective. Furthermore, the groups press the point that any external providers entering the teaching space need to connect and add value to the health education programme already in place, as well as revise content to meet the needs of individual schools based on the learners’ needs therein. Student learning needs should drive the planning and teaching and “a positive classroom environment for AoD education, with social interaction promoting respect, concern for others and shared responsibility for learning, is important (p.10)”.38 Smashed is typically delivered to large groups of students at one time (for example, all year 9 students in a school), and has set dates for their tour across the country. This is problematic for two reasons. First, it undermines the need for an established safe and supportive learning environment. Second, teachers may either change the timing of health education teaching units to align with when the tour is in town, or potentially teach unrelated content in health education at the time of the visit, with Smashed a disconnected add-on. The latter is particularly an issue when people other than health education teachers in a school agree to book the session, and give the health education staff little or no notice about its occurrence. It is therefore not difficult to conclude that pre-packaged programmes such as Smashed are—from an educational perspective if nothing else–problematic and troubling.

Over the past year, many health education teachers have become more critical consumers of the organisations that knock on their classroom doors, are increasingly inquiring into the place, purpose and added value of programmes they are offered, and are seeking student or others’ feedback before making decisions about who enters their health education learning environment. While external providers at times offer valuable support to health education and its teachers,39 programmes such as Smashed need to be critiqued by teachers and schools to ensure that they complement and connect to the overall health education teaching programme and meet learners’ needs.

Finally, an educational critique of the evaluation of Smashed’s 2019 performances in New Zealand finds it to be based on UK measures33 and learning outcomes for students that do not align with a New Zealand curriculum understanding of HPE, health education or AoD education. Coupled with its issues relating to lack of independence and poor response rate, any application of evaluation findings to the current context is problematic.

Conclusion

Evidence-based alcohol education resources exist for use in high school settings in New Zealand. This critique of the alcohol industry Smashed programme should signal strong caution to schools seeking to engage the services of these external providers. Though a school’s interest in preventing alcohol harm to young people is absolutely commendable, engagement in this programme has the ability to undermine effective education principles and can inadvertently contribute to further delays in the adoption of evidence-based policies to effectively protect current and future generations of New Zealand children from alcohol harm. Students deserve more than edutainment on New Zealand’s most harmful drug; they deserve best practice. The diversity among students, classes and schools also presents an issue as to how a one-size-fits-all programme can ever truly meet the needs of rangatahi in Aotearoa, or, indeed, anywhere else in the world.

Summary

Abstract

Adolescence marks a developmental period with heightened vulnerability to alcohol use and its consequences. In this viewpoint paper, we examine the involvement of the alcohol industry in alcohol and other drug (AoD) education from both an alcohol harm reduction and a school-based health education perspective, using the example of the Smashed programme to illustrate our critique. We issue caution to schools that are invited to participate.

Aim

Method

Results

Conclusion

Author Information

Nicki Jackson, School of Population Health, Faculty of Medical and Health Sciences, The University of Auckland; Rachael Dixon, School of Health Sciences, College of Education, Health and Human Development, University of Canterbury; Co-chairperson of the New Zealand Health Education Association.

Acknowledgements

Correspondence

Nicki Jackson, Honorary Academic, School of Population Health, Faculty of Medical and Health Sciences.

Correspondence Email

nicki.jackson@auckland.ac.nz

Competing Interests

Rachael Dixon reports that in 2018 Cheers funded her travel to Sydney to preview and give advice on Smashed.

1. National Health and Medical Research Council. Australian guidelines to reduce health risks from drinking alcohol. Canberra: Australia; 2009.

2. Ameratunga S, Waayer D, Robinson E, et al. Youth ’07: The health and wellbeing of secondary school students in New Zealand. Young people and alcohol. Auckland: New Zealand: The University of Auckland, Adolescent Health Research Group, 2011.

3. Svensen G, Kool B, Buller S. The burden of alcohol-related presentations to a busy urban New Zealand hospital emergency department. New Zealand Medical Journal 2019; 132:56–66.

4. The University of Adelaide. Evidence evaluation report – Systematic literature review on the association between alcohol consumption and mental health disorders. Adelaide, Australia: Adelaide Health Technology Assessment, 2018.

5. Spear LP. Adolescents and alcohol: Acute sensitivities, enhanced intake, and later consequences. Neurotoxicology and Teratology 1; 41:51–9.

6. Connor J. Alcohol consumption as a cause of cancer. Addiction. 2017; 112(2):222–8.

7. Liu Y, Nguyen N, Colditz GA. Links between alcohol consumption and breast cancer: a look at the evidence. Women’s health 2015; 11:65–77.

8. Thatcher DL, Clark DB. Adolescents at risk for substance use disorders: Role of psychological dysregulation, endophenotypes, and environmental influences. Alcohol Research & Health 2008; 31:168.

9. Rapsey CM, Wells JE, Bharat MC, Glantz M, Kessler RC, Scott KM. Transitions Through Stages of Alcohol Use, Use Disorder and Remission: Findings from Te Rau Hinengaro, The New Zealand Mental Health Survey. Alcohol and Alcoholism 2018; 54:87–96.

10. Health Promotion Agency. Low-risk alcohol drinking advice. Available from http://alcohol.org.nz/help-advice/advice-on-alcohol/low-risk-alcohol-drinking-advice [cited January 20, 2020].

11. Ball J, Sim D, Edwards R, et al. Declining adolescent cannabis use occurred across all demographic groups and was accompanied by declining use of other psychoactive drugs, New Zealand, 2001–2012. The New Zealand Medical Journal 2019; 132:12–24.

12. Ministry of Health. Annual Update of Key Results 2015/16: New Zealand Health Survey. 2016. Wellington: Author.

13. Health Promotion Agency. Hazardous drinking in New Zealand: Māori and non-Māori. Wellington, N.Z, 2019. Available from http://www.hpa.org.nz/sites/default/files/Hazardous-drinking-Maori-non-Maori-factsheet.pdf [cited January 20, 2020].

14. Babor T, Caetano R, Casswell S, et al. Alcohol: No ordinary commodity: Research and public policy. Oxford: Oxford University Press; 2010.

15. Lee NK, Cameron J, Battams S, Roche A. What works in school-based alcohol education: A systematic review. Health Education Journal 2016; 75:780–798.

16. National Institute for Health and Clinical Excellence. Alcohol interventions in secondary and further education: NICE Guidance [NG135]. London, U.K: NICE, 2019. Available from http://www.nice.org.uk/guidance/ng135 [accessed January 20, 2020].

17. Powell D. The ‘will to give’: corporations, philanthropy and schools. Journal of Education Policy 2019; 34:195–214.

18. Powell D. Schools, Corporations, and the War on Childhood Obesity: How Corporate Philanthropy Shapes Public Health and Education. London: Routledge; 2019.

19. Chapman S. Public health advocacy and tobacco control: making smoking history. John Wiley & Sons, 2008.

20. Spirits Europe drinksinitiatives.eu. Smashed. n.d. Available from http://drinksinitiatives.eu/initiative/smashed [cited January 20, 2020].

21. Life Education Trust. Smashed Project: Breaking the culture of underage drinking. n.d. Available from http://www.smashed.org.nz/ [cited January 20, 2020].

22. TVNZ Sunday. Trust defends tobacco’s funding. 2003. Available from http://tvnz.co.nz/content/159717/2591764.xhtml [cited January 20, 2020].

23. Smith SW, Atkin CK, Roznowski J. Are” drink responsibly” alcohol campaigns strategically ambiguous? Health communication 2006; 20:1–11.

24. Wolburg JM. How responsible are “responsible” drinking campaigns for preventing alcohol abuse? Journal of Consumer Marketing 2005; 22(4):176–177.

25. Aviram RB. Stigma and alcohol misuse during adolescence. International Journal of Adolescent Medicine and Health 2006; 18:27–30.

26. Lion Nathan. Submission to the Law Commission: Alcohol in our lives. Auckland, N.Z.: Lion Nathan New Zealand, 2009.

27. Connor J, Kydd R, Maclennan B, Shield K, Rehm J. Alcohol-attributable cancer deaths under 80 years of age in New Zealand. Drug and Alcohol Review 2017; 36:415–423.

28. Petticrew M, Maani Hessari N, Knai C, Weiderpass E. How alcohol industry organisations mislead the public about alcohol and cancer. Drug and alcohol review 2018; 37:293–303.

29. Butler S, Elmeland K, Thom B, Nicholls J. Alcohol, Power and Public Health: A Comparative Study of Alcohol Policy. London: Routledge, 2017.

30. Griswold MG, Fullman N, Hawley C, et al. Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet 2018; 392:1015–1035.

31. Adamson S. The problem with drinking: public attitudes, the severity continuum and treatment needs. A commentary on MacFarlane and Tuffin (2010) and Pulford et al.(2010). NZ J Psychol 2010; 39:56–8.

32. Bonnie RJ. Reducing underage drinking: A collective responsibility. Dev Mental Health L 2004; 23:1.

33. Collingwood Learning. Smashed Project New Zealand Evaluation Executive Summary 2019. 2019. Available from http://www.smashed.org.nz/uploads/8/8/1/3/88131662/smashed_project_new_zealand_evaluation_executive_summary_2019.pdf [cited January 20, 2020].

34. O’Brien, C. Harris criticises drinks industry role in educating schoolchildren about alcohol. The Irish Times. 2019; published online Nov 27. Available from http://www.irishtimes.com/news/education/harris-criticises-drinks-industry-role-in-educating-schoolchildren-about-alcohol-1.4097195 [cited January 20, 2020).

35. Department of Health. Ministers for Health and Education launch ‘Know the Score’ – a new educational resource on drugs and alcohol for senior cycle students. Dublin, Ireland: Government of Ireland, 2019. Available from http://www.gov.ie/en/news/593c30-ministers-for-health-and-education-launch-know-the-score-a-new-educa/ [cited January 20, 2020).

36. Ministry of Education. The New Zealand Curriculum. Wellington, N.Z: Learning Media, 2007.

37. Education Council. Our Code, Our Standards: Code of Professional Responsibility and Standards for the Teaching Profession. 2017. Available from http://educationcouncil.org.nz/sites/default/files/Our%20Code%20Our%20Standards%20web%20booklet%20FINAL.pdf [cited January 20, 2020].

38. Ministry of Education. Alcohol and other drug education programmes - guide for schools. 2014. Available from http://health.tki.org.nz/Teaching-in-HPE/Policy-guidelines/Alcohol-and-other-drug-education-programmes [cited January 20, 2020].

39. New Zealand Health Education Association. Mental Health education in the New Zealand Curriculum: NZHEA position statement. 2019. Available from http://healtheducation.org.nz/wp-content/uploads/2019/11/NZHEA-position-statement-on-MENTAL-HEALTH-Nov-2019.pdf [cited January 20, 2020].

40. Tūturu. Workshop Facilitation Guide: How to facilitate classroom discussions about alcohol and other drugs (for non-health teachers). 2017. Available from http://www.tuturu.org.nz/assets/uploads/Facilitating-safe-discussions-around-AoD-contexts-updated-working-document.pdf [cited January 20, 2020].

Contact diana@nzma.org.nz
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Due to typically heavy patterns of drinking as well as differences in alcohol sensitivities and risk-taking behaviours, adolescents experience disproportionately more harm from their drinking than older drinkers.1 New Zealand secondary school students report experiencing a range of acute alcohol-related harms, with significant inequities suffered by students of Māori and Pacific ethnicity and/or living in socio-economic disadvantage.2 In 2017/2018, one in every eight presentations among those aged 15 to 19 years to Auckland Hospital’s Emergency Department was found to be alcohol-related.3 Heavy drinking is also associated with poor mental health and suicidal ideation.4

Long-term harms of drinking can include irreversible impairment of brain structure and cognitive functioning, as the maturing brain is sensitive to the neurotoxic effects of alcohol.5 Other significant chronic harms include seven types of cancer,6 with research indicating that exposure to alcohol between menarche and first pregnancy may be important in the development of breast cancer, as breast tissue is likely to be at its most vulnerable stage.7 Finally, adolescence is a period of increased risk of alcohol abuse and dependence.8 In New Zealand, almost 50% of cases of alcohol abuse and dependence were found to have developed by the age of 20 years and 70% by the age of 25.9

Although the discourse surrounding adolescent drinking commonly focuses on binge drinking, there is no safe level of consumption for children and young people.1 This underpins the Health Promotion Agency’s low-risk drinking advice that recommends “not drinking alcohol is the safest option for children and young people under 18 years”.10

Encouragingly, New Zealand adolescents are mirroring global trends and showing significant reductions in alcohol use that have been maintained over time.11 For example, between 2006/07 and 2011/12, significant declines in the prevalence of past-year drinking (from 74.5% to 59.6%) and hazardous drinking (from 19.5% to 11.7%) were found among 15 to 17 year-olds.12 However, profound inequities remain persistent and preventable, with rangatahi Māori males and females reporting a substantially higher (two to three times) prevalence of hazardous drinking than non-Maori.13

Given the known risks of alcohol harm to this group, there are substantial benefits from prevention and early intervention. To reduce harms (and inequities), evidence-based and cost-effective policies are required. These include increasing alcohol prices, reducing availability, restricting alcohol advertising and sponsorship and increasing the legal purchase age.14

Evidence pertaining to the effectiveness of school-based education is less consistent and often contains methodological limitations.15 Despite the large number of studies in this area, few show long-term behavioural change. Evidence-based recommendations16 for school-based alcohol education draw from a limited number of high-quality studies, describing the need to: 1) use a spiral curriculum (whereby students study the same topics in ever-increasing complexity throughout their time at school to reinforce previous lessons), 2) integrate alcohol education into a whole-school approach to wellbeing, 3) link classroom health education curriculum activities with pastoral support of students, 4) create a supportive environment through development of school alcohol and wider policies (eg, school climate), and 5) incorporate activities that involve parents/guardians, families and communities. It is further recommended that teachers and others require sufficient planning time and training, that the use of scare tactics be avoided, and external providers only be used if they offer content that is consistent with the whole-school approach and are quality-assured.

Alcohol industry involvement in school-based health education

Alcohol companies have a long history of delivering alcohol education in schools. Powell17,18 offers extensive critique of ‘corporate philanthropy’—the practice of commercial agents entering into pedagogical spaces. In New Zealand, the Health and Physical Education learning area (curriculum) space is an attractive site for a wide range of food and beverage corporations (among others) who develop resources for teachers and learners, provide teachers with professional learning and development opportunities, and enter the classroom to teach students directly.18

Powell describes the use of corporate philanthropy as a strategy to divert public attention from less altruistic practices (marketing, lobbying, avoidance of stricter regulations, requirement to make a profit, etc.) and rather shape their corporate image to being trusted, caring, socially responsible and even healthy.17 A similar approach is currently occurring in New Zealand via the increasing number of alcohol industry partnerships with cancer, mental health, wellbeing and environmental charities. For decades, tobacco control advocates have warned of the tobacco industry embracing teenage prevention campaigns, knowing perfectly well that any education programme won’t hurt their profits but will show them to be ‘doing something’.19

One example of corporate philanthropy in the school-based AoD education space is Smashed, entitled “A responsible drinking education programme”. Sponsored by Diageo (a multi-national alcohol company), it commenced in the UK in 2005 and has so far engaged more than half a million students internationally.20 A common approach to get political buy-in has been to hold a parliamentary reception to launch the programme.20

Smashed has now made its way to New Zealand, almost 15 years since its inception. Smashed utilises a ‘theatre in education’ approach, with three paid actors providing a 30-minute live theatre performance followed by a 30-minute interactive workshop to consolidate the information provided. As described on its website and teacher resources, the programme seeks to raise awareness of personal responsibility in making informed decisions around alcohol.21 The objectives of the programme are to explore key themes of alcohol awareness, potential risks of underage drinking (such as physical and mental health issues, anti-social behaviour, accidents and injury), as well as impacts on relationships and school. Causes of underage drinking are explored, such as peer pressure, and local resources and support services available are signposted. A set of teacher resources are also available, should they choose to carry out any sessions before or after the main session. There is no evidence that the use of the lesson plans is compulsory.

In 2019, Smashed was delivered to 20,463 Year 9 students across 94 New Zealand high schools in 135 performances, and information suggests is to be further rolled out nationally in 2020 and beyond. In New Zealand, it is funded by the Tomorrow Project, a group comprising the multinational beer, wine and spirits makers. It is delivered in high schools via partnership with Life Education Trust, a group that has been reported to have had previous partnerships with Lion and British American Tobacco.22

Critique of Smashed: alcohol harm reduction perspective

At first glance, many would read the teacher resources and consider them to be suitable for school-based AoD education. They contain common educational components such as the health risks from alcohol misuse, the negative impact of peer pressure, available support services and so forth. However, an examination of the (often subtle) messaging throughout Smashed is recognisable as common strategies used by alcohol industry programmes internationally. The teacher resources also highlight an obvious language discrepancy, as ‘underage drinking’ is irrelevant in New Zealand given there is no legal drinking age (in contrast to other countries, eg, US). In New Zealand, the focus of interest is consumption and associated harm, not the health or safety risks in terms of disobedience.

One common thread throughout the teacher resources is the strong focus on “personal responsibility”. Other terms used in Smashed include “make responsible choices” and “drinking responsibly”. Literature describes the long history of this industry approach, showing that it is used to individualise alcohol problems, while neglecting the role of the wider alcogenic environment that plays a much stronger role in enabling risk behaviours.23 The personal responsibility approach is strategically ambiguous,24 encourages the drinker to shift responsibility to others23 and has the potential to sustain stigma for those with alcohol problems.25 From a brain development perspective, there is an obvious conflict between an adolescent’s ability to make ‘responsible choices’ and consider long-term risks, when the required part of the brain to undertake those tasks is under-developed. It is also obvious that the ability to make ‘responsible choices’ is severely compromised once under the influence of an intoxicating drug.

The use of the term ‘personal responsibility’ is not isolated to school-based programmes; it is echoed in policy debates. For example, in its submission to the Law Commission, New Zealand’s largest alcohol producer, Lion, stated that “individual responsibility is key to behaviour change” (p.4),26 and rejected evidence-based population-based policies to reduce the harms from adolescent drinking, such as increasing the price of alcohol or restricting alcohol advertising.

A second feature of the resources is the omission of information. For example, in the Smashed resources, only cancers of the mouth and throat are included as cancer-related health risks from alcohol. More prevalent breast and bowel cancers are omitted, despite breast cancer being the leading cause of alcohol-related death in New Zealand women.27 Omission of alcohol-cancer links, especially for breast and bowel cancer, has also been found among alcohol industry websites.28 This important omission contradicts the notion that adolescents can make informed and ‘responsible choices’ as a result of participation in the Smashed programme.

A third feature, and common to the alcohol industry internationally, is the incorrect construction of a dichotomy of alcohol drinking patterns or subpopulations into ‘misuse’ versus ‘responsible drinking’. As the name (ie, Smashed) perhaps suggests, a focus on alcohol misuse, abuse and binge drinking is found within the programme, although there is a conspicuous absence of definitions of these terms, especially in terms of actual amounts of alcohol. Of particular concern is the lack of discussion in the teacher resources pertaining to the importance of not starting drinking, as recommended in New Zealand’s low-risk drinking advice.10

It is suggested that the strategy of dichotomisation is used by the industry to convey a straightforward but over-simplified separation of drinking patterns, into those who use and misuse.29 The former is to represent a non-problematic population, while the latter a minority who drink in an uncontrolled manner and experience the range of health and social problems.29 This approach is also reinforced within policy debates, with Lion’s submission to the Law Commission26 stating “the problem at issue is alcohol abuse and related harm… measures are required to fix the behaviour of a minority, by making excessive drinking socially unacceptable” (p.3).

In reality, there is consistent evidence that no simple dichotomy exists. Risk curves describing the relationship between alcohol use and harms (eg, cancers30) show a continuum of harm across different patterns of drinking. There is no magic point where alcohol harms suddenly appear.31 For this reason, public health professionals dismiss the validity of an alcohol consumption dichotomy that boxes off alcohol harms from the majority of consumers, while the alcohol industry rejects the continuous model of harm in favour of interventions targeted at the relatively small group of heaviest drinking individuals at the extreme end of the continuum.29

A fourth feature is the lack of independent evaluation of Smashed, also reported to be common to alcohol industry programmes.32 In New Zealand, the evaluation is authored by the UK company that originally created the Smashed project.33 As detailed in the evaluation, the pre-programme response rate to the questionnaire was 27%, dropping to 15% post-programme. Any details about non-responders and/or limitations of poor response are not discussed in the evaluation report but should highlight the caution required when interpreting the claims relating to improvements in knowledge and understanding. Further concerns regarding the evaluation are discussed later.

From an alcohol harm reduction perspective, New Zealanders should be seriously concerned about programmes such as Smashed. Not only are they likely to be ineffective in reducing harm to our vulnerable populations, they are designed to whitewash the alcohol industry image. When approached for participation, principals and teachers should be critical of why multinational alcohol companies would choose to invest in school-based education in New Zealand. New Zealand can look to the strong statements made by Ireland’s Health Minister34 and Education Minister35 on the need to separate out the alcohol industry from being part of the conversation, with the former stating that “it’s completely and utterly bizarre that you’d have a body funded by the drinks industry educating our kids about the dangers of alcohol… I mean it’s ridiculous” (para. 3).34

Critique of Smashed: health education perspective

From a school-based health education perspective, programmes that offer pre-packaged resources and teaching activities (eg, Smashed) have the potential to contradict aspects of educational policy and guidelines for effective practice in AoD education, as well as undermine the professional practice and autonomy of trained health education teachers.

Health education is one of three subjects in the Health and Physical Education learning area (HPE) of The New Zealand Curriculum.36 As is the case in other learning areas, learning experiences in HPE are mandated until the end of year 10 (around 15 years of age). AoD education is located within the ‘mental health’ key area of learning within HPE, which indicates more than a sole biomedical focus for AoD. Stepping back from HPE, aspects of The New Zealand Curriculum are common to all learning areas. Included here are seven aspects of effective pedagogy—actions that a teacher takes to bring about student learning. While external providers do not make claims to fulfil all aspects of the curriculum, the extensive use in health education of programmes such as Smashed counteracts aspects of effective pedagogy. For example, teachers are expected to create a supportive learning environment, make connections to prior learning and experience and inquire into impact of their teaching.36 When an external provider makes their entry into the pedagogical space, these teacher actions are unable to take place, and—worst case scenario—previous work on the part of the teacher in enacting these aspects of effective pedagogy can unravel.

A second aspect of educational policy is ‘Our Code, Our Standards’, which contains the professional standards against which teachers are assessed for registration.37 For example, learning-focused culture prioritises aspects as safety, respect and students as active participants in learning. Design for learning requires planning for, carrying out and assessing the impact of pedagogical actions to meet learners’ needs and to show progression of learning. Teaching requires adaptations to meet diverse needs, feedback on progress for learners and a repertoire of teaching strategies.37 External providers may or may not be registered teachers and as such do not make claims to meet the professional standards for teachers. However, when pre-packaged programmes (especially those delivered by external providers) enter schools, the potential of a teacher to demonstrate evidence of meeting the expected standards might be diminished, because a lot of the teacher’s work is effectively done for them. This is particularly an issue when teachers of subjects such as health education over-rely on external providers and/or pre-packaged programmes.

Perhaps a more compelling argument central to a health education critique arises when we examine the messages contained within the array of guidance documents that have been written to support teaching in AoD education contexts. Here, the guidelines for teachers and schools published by the Ministry of Education,38 New Zealand Health Education Association39 and Tūturu/NZ Drug Foundation40 further cement this critique. A message common to each group’s assertions is that one-off sessions are educationally ineffective. Furthermore, the groups press the point that any external providers entering the teaching space need to connect and add value to the health education programme already in place, as well as revise content to meet the needs of individual schools based on the learners’ needs therein. Student learning needs should drive the planning and teaching and “a positive classroom environment for AoD education, with social interaction promoting respect, concern for others and shared responsibility for learning, is important (p.10)”.38 Smashed is typically delivered to large groups of students at one time (for example, all year 9 students in a school), and has set dates for their tour across the country. This is problematic for two reasons. First, it undermines the need for an established safe and supportive learning environment. Second, teachers may either change the timing of health education teaching units to align with when the tour is in town, or potentially teach unrelated content in health education at the time of the visit, with Smashed a disconnected add-on. The latter is particularly an issue when people other than health education teachers in a school agree to book the session, and give the health education staff little or no notice about its occurrence. It is therefore not difficult to conclude that pre-packaged programmes such as Smashed are—from an educational perspective if nothing else–problematic and troubling.

Over the past year, many health education teachers have become more critical consumers of the organisations that knock on their classroom doors, are increasingly inquiring into the place, purpose and added value of programmes they are offered, and are seeking student or others’ feedback before making decisions about who enters their health education learning environment. While external providers at times offer valuable support to health education and its teachers,39 programmes such as Smashed need to be critiqued by teachers and schools to ensure that they complement and connect to the overall health education teaching programme and meet learners’ needs.

Finally, an educational critique of the evaluation of Smashed’s 2019 performances in New Zealand finds it to be based on UK measures33 and learning outcomes for students that do not align with a New Zealand curriculum understanding of HPE, health education or AoD education. Coupled with its issues relating to lack of independence and poor response rate, any application of evaluation findings to the current context is problematic.

Conclusion

Evidence-based alcohol education resources exist for use in high school settings in New Zealand. This critique of the alcohol industry Smashed programme should signal strong caution to schools seeking to engage the services of these external providers. Though a school’s interest in preventing alcohol harm to young people is absolutely commendable, engagement in this programme has the ability to undermine effective education principles and can inadvertently contribute to further delays in the adoption of evidence-based policies to effectively protect current and future generations of New Zealand children from alcohol harm. Students deserve more than edutainment on New Zealand’s most harmful drug; they deserve best practice. The diversity among students, classes and schools also presents an issue as to how a one-size-fits-all programme can ever truly meet the needs of rangatahi in Aotearoa, or, indeed, anywhere else in the world.

Summary

Abstract

Adolescence marks a developmental period with heightened vulnerability to alcohol use and its consequences. In this viewpoint paper, we examine the involvement of the alcohol industry in alcohol and other drug (AoD) education from both an alcohol harm reduction and a school-based health education perspective, using the example of the Smashed programme to illustrate our critique. We issue caution to schools that are invited to participate.

Aim

Method

Results

Conclusion

Author Information

Nicki Jackson, School of Population Health, Faculty of Medical and Health Sciences, The University of Auckland; Rachael Dixon, School of Health Sciences, College of Education, Health and Human Development, University of Canterbury; Co-chairperson of the New Zealand Health Education Association.

Acknowledgements

Correspondence

Nicki Jackson, Honorary Academic, School of Population Health, Faculty of Medical and Health Sciences.

Correspondence Email

nicki.jackson@auckland.ac.nz

Competing Interests

Rachael Dixon reports that in 2018 Cheers funded her travel to Sydney to preview and give advice on Smashed.

1. National Health and Medical Research Council. Australian guidelines to reduce health risks from drinking alcohol. Canberra: Australia; 2009.

2. Ameratunga S, Waayer D, Robinson E, et al. Youth ’07: The health and wellbeing of secondary school students in New Zealand. Young people and alcohol. Auckland: New Zealand: The University of Auckland, Adolescent Health Research Group, 2011.

3. Svensen G, Kool B, Buller S. The burden of alcohol-related presentations to a busy urban New Zealand hospital emergency department. New Zealand Medical Journal 2019; 132:56–66.

4. The University of Adelaide. Evidence evaluation report – Systematic literature review on the association between alcohol consumption and mental health disorders. Adelaide, Australia: Adelaide Health Technology Assessment, 2018.

5. Spear LP. Adolescents and alcohol: Acute sensitivities, enhanced intake, and later consequences. Neurotoxicology and Teratology 1; 41:51–9.

6. Connor J. Alcohol consumption as a cause of cancer. Addiction. 2017; 112(2):222–8.

7. Liu Y, Nguyen N, Colditz GA. Links between alcohol consumption and breast cancer: a look at the evidence. Women’s health 2015; 11:65–77.

8. Thatcher DL, Clark DB. Adolescents at risk for substance use disorders: Role of psychological dysregulation, endophenotypes, and environmental influences. Alcohol Research & Health 2008; 31:168.

9. Rapsey CM, Wells JE, Bharat MC, Glantz M, Kessler RC, Scott KM. Transitions Through Stages of Alcohol Use, Use Disorder and Remission: Findings from Te Rau Hinengaro, The New Zealand Mental Health Survey. Alcohol and Alcoholism 2018; 54:87–96.

10. Health Promotion Agency. Low-risk alcohol drinking advice. Available from http://alcohol.org.nz/help-advice/advice-on-alcohol/low-risk-alcohol-drinking-advice [cited January 20, 2020].

11. Ball J, Sim D, Edwards R, et al. Declining adolescent cannabis use occurred across all demographic groups and was accompanied by declining use of other psychoactive drugs, New Zealand, 2001–2012. The New Zealand Medical Journal 2019; 132:12–24.

12. Ministry of Health. Annual Update of Key Results 2015/16: New Zealand Health Survey. 2016. Wellington: Author.

13. Health Promotion Agency. Hazardous drinking in New Zealand: Māori and non-Māori. Wellington, N.Z, 2019. Available from http://www.hpa.org.nz/sites/default/files/Hazardous-drinking-Maori-non-Maori-factsheet.pdf [cited January 20, 2020].

14. Babor T, Caetano R, Casswell S, et al. Alcohol: No ordinary commodity: Research and public policy. Oxford: Oxford University Press; 2010.

15. Lee NK, Cameron J, Battams S, Roche A. What works in school-based alcohol education: A systematic review. Health Education Journal 2016; 75:780–798.

16. National Institute for Health and Clinical Excellence. Alcohol interventions in secondary and further education: NICE Guidance [NG135]. London, U.K: NICE, 2019. Available from http://www.nice.org.uk/guidance/ng135 [accessed January 20, 2020].

17. Powell D. The ‘will to give’: corporations, philanthropy and schools. Journal of Education Policy 2019; 34:195–214.

18. Powell D. Schools, Corporations, and the War on Childhood Obesity: How Corporate Philanthropy Shapes Public Health and Education. London: Routledge; 2019.

19. Chapman S. Public health advocacy and tobacco control: making smoking history. John Wiley & Sons, 2008.

20. Spirits Europe drinksinitiatives.eu. Smashed. n.d. Available from http://drinksinitiatives.eu/initiative/smashed [cited January 20, 2020].

21. Life Education Trust. Smashed Project: Breaking the culture of underage drinking. n.d. Available from http://www.smashed.org.nz/ [cited January 20, 2020].

22. TVNZ Sunday. Trust defends tobacco’s funding. 2003. Available from http://tvnz.co.nz/content/159717/2591764.xhtml [cited January 20, 2020].

23. Smith SW, Atkin CK, Roznowski J. Are” drink responsibly” alcohol campaigns strategically ambiguous? Health communication 2006; 20:1–11.

24. Wolburg JM. How responsible are “responsible” drinking campaigns for preventing alcohol abuse? Journal of Consumer Marketing 2005; 22(4):176–177.

25. Aviram RB. Stigma and alcohol misuse during adolescence. International Journal of Adolescent Medicine and Health 2006; 18:27–30.

26. Lion Nathan. Submission to the Law Commission: Alcohol in our lives. Auckland, N.Z.: Lion Nathan New Zealand, 2009.

27. Connor J, Kydd R, Maclennan B, Shield K, Rehm J. Alcohol-attributable cancer deaths under 80 years of age in New Zealand. Drug and Alcohol Review 2017; 36:415–423.

28. Petticrew M, Maani Hessari N, Knai C, Weiderpass E. How alcohol industry organisations mislead the public about alcohol and cancer. Drug and alcohol review 2018; 37:293–303.

29. Butler S, Elmeland K, Thom B, Nicholls J. Alcohol, Power and Public Health: A Comparative Study of Alcohol Policy. London: Routledge, 2017.

30. Griswold MG, Fullman N, Hawley C, et al. Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet 2018; 392:1015–1035.

31. Adamson S. The problem with drinking: public attitudes, the severity continuum and treatment needs. A commentary on MacFarlane and Tuffin (2010) and Pulford et al.(2010). NZ J Psychol 2010; 39:56–8.

32. Bonnie RJ. Reducing underage drinking: A collective responsibility. Dev Mental Health L 2004; 23:1.

33. Collingwood Learning. Smashed Project New Zealand Evaluation Executive Summary 2019. 2019. Available from http://www.smashed.org.nz/uploads/8/8/1/3/88131662/smashed_project_new_zealand_evaluation_executive_summary_2019.pdf [cited January 20, 2020].

34. O’Brien, C. Harris criticises drinks industry role in educating schoolchildren about alcohol. The Irish Times. 2019; published online Nov 27. Available from http://www.irishtimes.com/news/education/harris-criticises-drinks-industry-role-in-educating-schoolchildren-about-alcohol-1.4097195 [cited January 20, 2020).

35. Department of Health. Ministers for Health and Education launch ‘Know the Score’ – a new educational resource on drugs and alcohol for senior cycle students. Dublin, Ireland: Government of Ireland, 2019. Available from http://www.gov.ie/en/news/593c30-ministers-for-health-and-education-launch-know-the-score-a-new-educa/ [cited January 20, 2020).

36. Ministry of Education. The New Zealand Curriculum. Wellington, N.Z: Learning Media, 2007.

37. Education Council. Our Code, Our Standards: Code of Professional Responsibility and Standards for the Teaching Profession. 2017. Available from http://educationcouncil.org.nz/sites/default/files/Our%20Code%20Our%20Standards%20web%20booklet%20FINAL.pdf [cited January 20, 2020].

38. Ministry of Education. Alcohol and other drug education programmes - guide for schools. 2014. Available from http://health.tki.org.nz/Teaching-in-HPE/Policy-guidelines/Alcohol-and-other-drug-education-programmes [cited January 20, 2020].

39. New Zealand Health Education Association. Mental Health education in the New Zealand Curriculum: NZHEA position statement. 2019. Available from http://healtheducation.org.nz/wp-content/uploads/2019/11/NZHEA-position-statement-on-MENTAL-HEALTH-Nov-2019.pdf [cited January 20, 2020].

40. Tūturu. Workshop Facilitation Guide: How to facilitate classroom discussions about alcohol and other drugs (for non-health teachers). 2017. Available from http://www.tuturu.org.nz/assets/uploads/Facilitating-safe-discussions-around-AoD-contexts-updated-working-document.pdf [cited January 20, 2020].

Contact diana@nzma.org.nz
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Due to typically heavy patterns of drinking as well as differences in alcohol sensitivities and risk-taking behaviours, adolescents experience disproportionately more harm from their drinking than older drinkers.1 New Zealand secondary school students report experiencing a range of acute alcohol-related harms, with significant inequities suffered by students of Māori and Pacific ethnicity and/or living in socio-economic disadvantage.2 In 2017/2018, one in every eight presentations among those aged 15 to 19 years to Auckland Hospital’s Emergency Department was found to be alcohol-related.3 Heavy drinking is also associated with poor mental health and suicidal ideation.4

Long-term harms of drinking can include irreversible impairment of brain structure and cognitive functioning, as the maturing brain is sensitive to the neurotoxic effects of alcohol.5 Other significant chronic harms include seven types of cancer,6 with research indicating that exposure to alcohol between menarche and first pregnancy may be important in the development of breast cancer, as breast tissue is likely to be at its most vulnerable stage.7 Finally, adolescence is a period of increased risk of alcohol abuse and dependence.8 In New Zealand, almost 50% of cases of alcohol abuse and dependence were found to have developed by the age of 20 years and 70% by the age of 25.9

Although the discourse surrounding adolescent drinking commonly focuses on binge drinking, there is no safe level of consumption for children and young people.1 This underpins the Health Promotion Agency’s low-risk drinking advice that recommends “not drinking alcohol is the safest option for children and young people under 18 years”.10

Encouragingly, New Zealand adolescents are mirroring global trends and showing significant reductions in alcohol use that have been maintained over time.11 For example, between 2006/07 and 2011/12, significant declines in the prevalence of past-year drinking (from 74.5% to 59.6%) and hazardous drinking (from 19.5% to 11.7%) were found among 15 to 17 year-olds.12 However, profound inequities remain persistent and preventable, with rangatahi Māori males and females reporting a substantially higher (two to three times) prevalence of hazardous drinking than non-Maori.13

Given the known risks of alcohol harm to this group, there are substantial benefits from prevention and early intervention. To reduce harms (and inequities), evidence-based and cost-effective policies are required. These include increasing alcohol prices, reducing availability, restricting alcohol advertising and sponsorship and increasing the legal purchase age.14

Evidence pertaining to the effectiveness of school-based education is less consistent and often contains methodological limitations.15 Despite the large number of studies in this area, few show long-term behavioural change. Evidence-based recommendations16 for school-based alcohol education draw from a limited number of high-quality studies, describing the need to: 1) use a spiral curriculum (whereby students study the same topics in ever-increasing complexity throughout their time at school to reinforce previous lessons), 2) integrate alcohol education into a whole-school approach to wellbeing, 3) link classroom health education curriculum activities with pastoral support of students, 4) create a supportive environment through development of school alcohol and wider policies (eg, school climate), and 5) incorporate activities that involve parents/guardians, families and communities. It is further recommended that teachers and others require sufficient planning time and training, that the use of scare tactics be avoided, and external providers only be used if they offer content that is consistent with the whole-school approach and are quality-assured.

Alcohol industry involvement in school-based health education

Alcohol companies have a long history of delivering alcohol education in schools. Powell17,18 offers extensive critique of ‘corporate philanthropy’—the practice of commercial agents entering into pedagogical spaces. In New Zealand, the Health and Physical Education learning area (curriculum) space is an attractive site for a wide range of food and beverage corporations (among others) who develop resources for teachers and learners, provide teachers with professional learning and development opportunities, and enter the classroom to teach students directly.18

Powell describes the use of corporate philanthropy as a strategy to divert public attention from less altruistic practices (marketing, lobbying, avoidance of stricter regulations, requirement to make a profit, etc.) and rather shape their corporate image to being trusted, caring, socially responsible and even healthy.17 A similar approach is currently occurring in New Zealand via the increasing number of alcohol industry partnerships with cancer, mental health, wellbeing and environmental charities. For decades, tobacco control advocates have warned of the tobacco industry embracing teenage prevention campaigns, knowing perfectly well that any education programme won’t hurt their profits but will show them to be ‘doing something’.19

One example of corporate philanthropy in the school-based AoD education space is Smashed, entitled “A responsible drinking education programme”. Sponsored by Diageo (a multi-national alcohol company), it commenced in the UK in 2005 and has so far engaged more than half a million students internationally.20 A common approach to get political buy-in has been to hold a parliamentary reception to launch the programme.20

Smashed has now made its way to New Zealand, almost 15 years since its inception. Smashed utilises a ‘theatre in education’ approach, with three paid actors providing a 30-minute live theatre performance followed by a 30-minute interactive workshop to consolidate the information provided. As described on its website and teacher resources, the programme seeks to raise awareness of personal responsibility in making informed decisions around alcohol.21 The objectives of the programme are to explore key themes of alcohol awareness, potential risks of underage drinking (such as physical and mental health issues, anti-social behaviour, accidents and injury), as well as impacts on relationships and school. Causes of underage drinking are explored, such as peer pressure, and local resources and support services available are signposted. A set of teacher resources are also available, should they choose to carry out any sessions before or after the main session. There is no evidence that the use of the lesson plans is compulsory.

In 2019, Smashed was delivered to 20,463 Year 9 students across 94 New Zealand high schools in 135 performances, and information suggests is to be further rolled out nationally in 2020 and beyond. In New Zealand, it is funded by the Tomorrow Project, a group comprising the multinational beer, wine and spirits makers. It is delivered in high schools via partnership with Life Education Trust, a group that has been reported to have had previous partnerships with Lion and British American Tobacco.22

Critique of Smashed: alcohol harm reduction perspective

At first glance, many would read the teacher resources and consider them to be suitable for school-based AoD education. They contain common educational components such as the health risks from alcohol misuse, the negative impact of peer pressure, available support services and so forth. However, an examination of the (often subtle) messaging throughout Smashed is recognisable as common strategies used by alcohol industry programmes internationally. The teacher resources also highlight an obvious language discrepancy, as ‘underage drinking’ is irrelevant in New Zealand given there is no legal drinking age (in contrast to other countries, eg, US). In New Zealand, the focus of interest is consumption and associated harm, not the health or safety risks in terms of disobedience.

One common thread throughout the teacher resources is the strong focus on “personal responsibility”. Other terms used in Smashed include “make responsible choices” and “drinking responsibly”. Literature describes the long history of this industry approach, showing that it is used to individualise alcohol problems, while neglecting the role of the wider alcogenic environment that plays a much stronger role in enabling risk behaviours.23 The personal responsibility approach is strategically ambiguous,24 encourages the drinker to shift responsibility to others23 and has the potential to sustain stigma for those with alcohol problems.25 From a brain development perspective, there is an obvious conflict between an adolescent’s ability to make ‘responsible choices’ and consider long-term risks, when the required part of the brain to undertake those tasks is under-developed. It is also obvious that the ability to make ‘responsible choices’ is severely compromised once under the influence of an intoxicating drug.

The use of the term ‘personal responsibility’ is not isolated to school-based programmes; it is echoed in policy debates. For example, in its submission to the Law Commission, New Zealand’s largest alcohol producer, Lion, stated that “individual responsibility is key to behaviour change” (p.4),26 and rejected evidence-based population-based policies to reduce the harms from adolescent drinking, such as increasing the price of alcohol or restricting alcohol advertising.

A second feature of the resources is the omission of information. For example, in the Smashed resources, only cancers of the mouth and throat are included as cancer-related health risks from alcohol. More prevalent breast and bowel cancers are omitted, despite breast cancer being the leading cause of alcohol-related death in New Zealand women.27 Omission of alcohol-cancer links, especially for breast and bowel cancer, has also been found among alcohol industry websites.28 This important omission contradicts the notion that adolescents can make informed and ‘responsible choices’ as a result of participation in the Smashed programme.

A third feature, and common to the alcohol industry internationally, is the incorrect construction of a dichotomy of alcohol drinking patterns or subpopulations into ‘misuse’ versus ‘responsible drinking’. As the name (ie, Smashed) perhaps suggests, a focus on alcohol misuse, abuse and binge drinking is found within the programme, although there is a conspicuous absence of definitions of these terms, especially in terms of actual amounts of alcohol. Of particular concern is the lack of discussion in the teacher resources pertaining to the importance of not starting drinking, as recommended in New Zealand’s low-risk drinking advice.10

It is suggested that the strategy of dichotomisation is used by the industry to convey a straightforward but over-simplified separation of drinking patterns, into those who use and misuse.29 The former is to represent a non-problematic population, while the latter a minority who drink in an uncontrolled manner and experience the range of health and social problems.29 This approach is also reinforced within policy debates, with Lion’s submission to the Law Commission26 stating “the problem at issue is alcohol abuse and related harm… measures are required to fix the behaviour of a minority, by making excessive drinking socially unacceptable” (p.3).

In reality, there is consistent evidence that no simple dichotomy exists. Risk curves describing the relationship between alcohol use and harms (eg, cancers30) show a continuum of harm across different patterns of drinking. There is no magic point where alcohol harms suddenly appear.31 For this reason, public health professionals dismiss the validity of an alcohol consumption dichotomy that boxes off alcohol harms from the majority of consumers, while the alcohol industry rejects the continuous model of harm in favour of interventions targeted at the relatively small group of heaviest drinking individuals at the extreme end of the continuum.29

A fourth feature is the lack of independent evaluation of Smashed, also reported to be common to alcohol industry programmes.32 In New Zealand, the evaluation is authored by the UK company that originally created the Smashed project.33 As detailed in the evaluation, the pre-programme response rate to the questionnaire was 27%, dropping to 15% post-programme. Any details about non-responders and/or limitations of poor response are not discussed in the evaluation report but should highlight the caution required when interpreting the claims relating to improvements in knowledge and understanding. Further concerns regarding the evaluation are discussed later.

From an alcohol harm reduction perspective, New Zealanders should be seriously concerned about programmes such as Smashed. Not only are they likely to be ineffective in reducing harm to our vulnerable populations, they are designed to whitewash the alcohol industry image. When approached for participation, principals and teachers should be critical of why multinational alcohol companies would choose to invest in school-based education in New Zealand. New Zealand can look to the strong statements made by Ireland’s Health Minister34 and Education Minister35 on the need to separate out the alcohol industry from being part of the conversation, with the former stating that “it’s completely and utterly bizarre that you’d have a body funded by the drinks industry educating our kids about the dangers of alcohol… I mean it’s ridiculous” (para. 3).34

Critique of Smashed: health education perspective

From a school-based health education perspective, programmes that offer pre-packaged resources and teaching activities (eg, Smashed) have the potential to contradict aspects of educational policy and guidelines for effective practice in AoD education, as well as undermine the professional practice and autonomy of trained health education teachers.

Health education is one of three subjects in the Health and Physical Education learning area (HPE) of The New Zealand Curriculum.36 As is the case in other learning areas, learning experiences in HPE are mandated until the end of year 10 (around 15 years of age). AoD education is located within the ‘mental health’ key area of learning within HPE, which indicates more than a sole biomedical focus for AoD. Stepping back from HPE, aspects of The New Zealand Curriculum are common to all learning areas. Included here are seven aspects of effective pedagogy—actions that a teacher takes to bring about student learning. While external providers do not make claims to fulfil all aspects of the curriculum, the extensive use in health education of programmes such as Smashed counteracts aspects of effective pedagogy. For example, teachers are expected to create a supportive learning environment, make connections to prior learning and experience and inquire into impact of their teaching.36 When an external provider makes their entry into the pedagogical space, these teacher actions are unable to take place, and—worst case scenario—previous work on the part of the teacher in enacting these aspects of effective pedagogy can unravel.

A second aspect of educational policy is ‘Our Code, Our Standards’, which contains the professional standards against which teachers are assessed for registration.37 For example, learning-focused culture prioritises aspects as safety, respect and students as active participants in learning. Design for learning requires planning for, carrying out and assessing the impact of pedagogical actions to meet learners’ needs and to show progression of learning. Teaching requires adaptations to meet diverse needs, feedback on progress for learners and a repertoire of teaching strategies.37 External providers may or may not be registered teachers and as such do not make claims to meet the professional standards for teachers. However, when pre-packaged programmes (especially those delivered by external providers) enter schools, the potential of a teacher to demonstrate evidence of meeting the expected standards might be diminished, because a lot of the teacher’s work is effectively done for them. This is particularly an issue when teachers of subjects such as health education over-rely on external providers and/or pre-packaged programmes.

Perhaps a more compelling argument central to a health education critique arises when we examine the messages contained within the array of guidance documents that have been written to support teaching in AoD education contexts. Here, the guidelines for teachers and schools published by the Ministry of Education,38 New Zealand Health Education Association39 and Tūturu/NZ Drug Foundation40 further cement this critique. A message common to each group’s assertions is that one-off sessions are educationally ineffective. Furthermore, the groups press the point that any external providers entering the teaching space need to connect and add value to the health education programme already in place, as well as revise content to meet the needs of individual schools based on the learners’ needs therein. Student learning needs should drive the planning and teaching and “a positive classroom environment for AoD education, with social interaction promoting respect, concern for others and shared responsibility for learning, is important (p.10)”.38 Smashed is typically delivered to large groups of students at one time (for example, all year 9 students in a school), and has set dates for their tour across the country. This is problematic for two reasons. First, it undermines the need for an established safe and supportive learning environment. Second, teachers may either change the timing of health education teaching units to align with when the tour is in town, or potentially teach unrelated content in health education at the time of the visit, with Smashed a disconnected add-on. The latter is particularly an issue when people other than health education teachers in a school agree to book the session, and give the health education staff little or no notice about its occurrence. It is therefore not difficult to conclude that pre-packaged programmes such as Smashed are—from an educational perspective if nothing else–problematic and troubling.

Over the past year, many health education teachers have become more critical consumers of the organisations that knock on their classroom doors, are increasingly inquiring into the place, purpose and added value of programmes they are offered, and are seeking student or others’ feedback before making decisions about who enters their health education learning environment. While external providers at times offer valuable support to health education and its teachers,39 programmes such as Smashed need to be critiqued by teachers and schools to ensure that they complement and connect to the overall health education teaching programme and meet learners’ needs.

Finally, an educational critique of the evaluation of Smashed’s 2019 performances in New Zealand finds it to be based on UK measures33 and learning outcomes for students that do not align with a New Zealand curriculum understanding of HPE, health education or AoD education. Coupled with its issues relating to lack of independence and poor response rate, any application of evaluation findings to the current context is problematic.

Conclusion

Evidence-based alcohol education resources exist for use in high school settings in New Zealand. This critique of the alcohol industry Smashed programme should signal strong caution to schools seeking to engage the services of these external providers. Though a school’s interest in preventing alcohol harm to young people is absolutely commendable, engagement in this programme has the ability to undermine effective education principles and can inadvertently contribute to further delays in the adoption of evidence-based policies to effectively protect current and future generations of New Zealand children from alcohol harm. Students deserve more than edutainment on New Zealand’s most harmful drug; they deserve best practice. The diversity among students, classes and schools also presents an issue as to how a one-size-fits-all programme can ever truly meet the needs of rangatahi in Aotearoa, or, indeed, anywhere else in the world.

Summary

Abstract

Adolescence marks a developmental period with heightened vulnerability to alcohol use and its consequences. In this viewpoint paper, we examine the involvement of the alcohol industry in alcohol and other drug (AoD) education from both an alcohol harm reduction and a school-based health education perspective, using the example of the Smashed programme to illustrate our critique. We issue caution to schools that are invited to participate.

Aim

Method

Results

Conclusion

Author Information

Nicki Jackson, School of Population Health, Faculty of Medical and Health Sciences, The University of Auckland; Rachael Dixon, School of Health Sciences, College of Education, Health and Human Development, University of Canterbury; Co-chairperson of the New Zealand Health Education Association.

Acknowledgements

Correspondence

Nicki Jackson, Honorary Academic, School of Population Health, Faculty of Medical and Health Sciences.

Correspondence Email

nicki.jackson@auckland.ac.nz

Competing Interests

Rachael Dixon reports that in 2018 Cheers funded her travel to Sydney to preview and give advice on Smashed.

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