A literature review of the health effects of fracking


1.       Introduction

As the international community comes to terms with the realities of anthropogenic climate change, the need to reduce carbon dioxide emission levels is driving demand for clean, efficient, and safe energy (Finkel & Hays).  Due to this rising demand for alternatives to oil and coal, some deposits of natural gas that were previously deemed either insufficiently accessible and/or economically inefficient due to the complexity of production are now being considered as viable options to meet the world’s energy needs (Carey, Redmond, & Haswell, 2014).  Unconventional gas development is an example of demand driven expansion in the mining and energy sector to find alternatives and/or supplementary sources of energy, made possible by advances in extraction technology (Rafferty & Limonik, 2013).

Unconventional gas exploration and extraction is described by its proponents as an  efficient method to access hitherto untapped pockets of natural gas, helping to address the problems of energy supply (Mackie, Johnman, & Sim, 2013). However as the practice has expanded, the published literature shows an increasing level of alarm over the potential risks to both the natural environment and human health (Rafferty & Limonik, 2013). This paper attempts to provide a summary of the evidence on the health and environmental impacts of unconventional gas extraction, limitations of current research, and possible future directions from contemporary published literature.

2.       What is unconventional gas and how is it extracted?

To fully explore the health and environmental issues related to unconventional gas extraction, it is useful to both define some of the terms used to describe the process and also understand the extraction methodology. Conventional natural gas is readily accessible for extraction, resting in subsurface natural reservoirs (Geoscience Australia, 2014). Conversely unconventional gas is an umbrella term for gas resources that are stored in more complex systems that require capital, energy and technology intensive extraction methods (Rafferty & Limonik, 2013). Unconventional gases include coal seam gas, shale gas, gas hydrates and tight gas, all of which are only able to be exploited with significantly greater effort, time and technology than has traditionally been the case (CSIRO, 2013).

Shale and coal seam gasses are contained within the source rock, rather than having shifted to a reservoir deposit as is the case with conventional gas. Tight gas refers to gas that is contained in reservoir, but one with low permeability such as sandstone and limestone which hampers access (CSIRO, 2013). Extraction of these resources is made possible via hydraulic fracturing, a process sometimes known as fracking (Chen, Al-Wadei, Kennedy, & Terry, 2014).

The purpose of hydraulic fracturing is to create fissures and fractures in the source rock so the gas therein can be released. This is achieved by drilling a series of deep boreholes and then pumping vast volumes of fluid at high pressure into the bores. Subsequently the gas is carried back to the surface via a well bore where is it captured and processed (A Kibble, 2014). The fluid that is pumped into the bores is called fracturing fluid, and is comprised of a combination of water, sand and various chemicals (A Kibble, 2014; Finkel & Hays).

3.       Environmental and Health Impacts

There are hundreds of studies in the literature that examine various aspects of unconventional gas development.  Upon examination, the majority of research in this area coalesces around three main aspects of the extraction process, namely the potential for water contamination, air pollution and issues associated with waste management (A Kibble, 2014; Chen et al., 2014; Gordalla, Ewers, & Frimmel, 2013; Mackie et al., 2013; McKenzie, Witter, Newman, & Adgate, 2012; Swarthout, 2014). Each of these aspects are considered below. Impacts on both human health and on the natural environment are discussed contemporaneously as environmental hazards are frequently linked with both direct and indirect effects on public health (Mackie et al., 2013).


3.1.    Water

Water management is one of the key issues that dominate debate around unconventional gas development, both in terms of health and environment (Vidic, Brantley, Vandenbossche, Yoxtheimer, & Abad, 2013). There are a number of issues related to water that are raised in the literature – namely the impact of withdrawal of local water required to support the mining operation, potential for contamination of drinking water via the fracturing process and the complications associated with wastewater treatment and disposal after the extraction has been completed (Chen et al., 2014; Gordalla et al., 2013; Vidic et al., 2013).

In current practice, large volumes of water are required to undertake hydraulic fracturing, so access to local water reserves as part of the production process is pivotal (Chen et al., 2014). Finkel and Hays in their 2014 paper posit that the potential for aquifer depletion is a risk of fracking - stating that droughts and diminished water levels may represent a serious unintended consequence, both in terms of maintaining the ecology of the natural environment and ensuring access to adequate water for human consumption (Finkel & Hays). Similar concerns are raised by Chen et al (2014) who outline that because water is usually extracted from single location proximate to the hydraulic fracturing operation, there is the possibility of a real and significant impact on the amount of water available for crops, livestock and human consumption, particularly in locations with distinct wet and dry seasons (Chen et al., 2014).  Further to this, the potential for water withdrawals to affect water quality is examined by Cooley and Donnelly (2012), who suggest that groundwater quality may be detrimentally impacted by the migration of naturally occurring substances into the water supply, and also by the promotion of bacterial growth, when aquifers are depleted. In turn, the authors advance, this not only affects the quality of the remaining water but also changes the hydrological profile of the source water (Cooley & Donnelly, 2012)

Various studies demonstrate that both the fracturing fluid used to stimulate gas extraction and the waste water produced subsequently – ‘flowback water’  -  contain material that can have deleterious effects at high concentrations (Chen et al., 2014; Gordalla et al., 2013; Rafferty & Limonik, 2013; Vidic et al., 2013). Gordalla et al (2013) advance that the components found in flowback water are the most problematic in terms of human health, because of the fluids’ exposure to organic contaminants via the fossil deposit during the fracking process, and the presence of heavy metals. Flowback may include a number of known or suspected carcinogens and the chemicals benzene, toluene, ethylene and xylene (‘BTEX’), all of which are considered hazardous at high concentrations or with chronic exposure in drinking water (Chen et al., 2014; Rafferty & Limonik, 2013). Whilst unconventional gas deposits are located well below sources of ground drinking water, access to the gas is gained only by drilling through drinking water sources (Cooley & Donnelly, 2012). This being the case, despite safeguards such as steel pipe that is inserted into a recently drilled section of a borehole to stabilize the hole, prevent contamination of groundwater, and isolate different subsurface zones - there remains the possibility of the very large volumes of toxic material contaminating both ground and surface water (Finkel & Hays; Vidic et al., 2013).

3.2.    Air

Studies undertaken in the US and Europe suggest that unconventional gas extraction produces air pollutants at a number of points during production, including both direct emissions (venting, gas capture) and fugitive emissions (unplanned leaks from valves and pumps) (Kibble, 2014). Pollutants include volatile organic compounds, methane, nitrogen dioxide, carbon monoxide and particulate matter (Kibble, 2014). Volatile organic compounds in particular are problematic not only because of the detrimental effects on human health but also their impact on the climate via ground-level ozone or secondary organic aerosols (Swarthout, 2014).


The current evidence suggests that taken individually, the level of pollutants emanating from unconventional gas wells are intermittent and relatively low, however when there are a number of wells located within reasonable distance of each other, cumulative exposure increases risk significantly (Kibble, 2014). In terms of human health, there is evidence that proximity to unconventional gas production sites is a significant risk factor. McKenzie et al. (2012) advance that the greatest potential for health effects is the subchronic exposure that can occur during the well completion phase, and further, that data collected during their study indicates that residents that live less than half a mile from wells are at greater risk than those living at a greater distance. More compelling is their analysis that estimates that less than half mile proximity to an unconventional gas well increases the lifetime risk of cancer from 6/1 million to 10/1 million (McKenzie et al., 2012) Studies referenced by Finkel et al demonstrate that up to 7.9% of the methane generated in unconventional gas production - a gas that is considered a serious contributor to climate change – escapes via venting and leaking. Jointly considering the above studies, not only are there conditions for medium term health impacts such as cancer, endocrine disruption and respiratory illness, but contributions by unconventional gas development to climate change will impact human health in a broader and more global sense – water scarcity, population displacement, and food security (Finkel & Hays; Kibble, 2014; McKenzie et al., 2012)


3.3.    Waste

Both Vidic et al. (2013) and Cooley & Donnelly (2012) provide an overview of the risks associated with the storage of waste water after the gas extraction is complete.  Appropriate wastewater management is required to prevent heavy metals leaching into soil – if this does occur it can have long term health (cancer, neurological, endocrinogical) and environmental (soil degredation, food contamination) impacts. In the United States, current practice is to first store the drilling muds and waste fluids, and then treat them for recycling and reuse (Kibble, 2014). Usually, storage is via underground injection into pits, but sometimes in open pits or ponds on site (Cooley & Donnelly, 2012; Schmidt, 2013). Harmful substances from the stored waste water have the potential to contaminate surface water, and can contribute to air pollution when volatile organic compounds evaporate (Finkel & Hays; Kibble, 2014).


4.       Limitations of current research

Action to further regulate unconventional gas development to protect the health of the environment and the community is hampered by a lack of large epidemiological studies that explore the association between extraction activities and adverse impacts (Finkel & Hays). Whilst anecdotal evidence is myriad, as extensively outlined in Rafferty and Limonik (2013) the rapid growth of unconventional gas development has meant that the evidence base is lagging and it is evident that further work is required (Rafferty & Limonik, 2013). In particular, as highlighted in Chen et al. (2014) the full disclosure by unconventional gas operators about the chemicals that they are using as part of the extraction is pivotal – to date the composition of fracturing fluid has been confidential for competitive and commercial reasons. Long term monitoring and data dissemination is identified by many studies as important in managing risks both to environment and health (Chen et al., 2014; Finkel & Hays; Gordalla et al., 2013; Rafferty & Limonik, 2013). Some of the activities that are argued in the public health literature as causative are disputed elsewhere, for example (Warner et al., 2012) present evidence that pathways between shale formations and the aquifers above occur naturally in some locations, unrelated to drilling activity. Interestingly, Mackie (2013) provides a counterintuitive but nonetheless thought provoking question, that is, what is the interaction between the likely public and environmental health consequences of unconventional gas development and other known health impacts associated with the absence of affordable fuel? This broader approach is worthy of consideration when moving forward with the next phase of research.


5.       Conclusion

Concern over unsustainable, high carbon output energy sources has driven a rapid increase in demand for unconventional natural gas (Coram, Moss, & Blashki, 2014). There is a strong argument that this has occurred without a full exploration of the potentially serious public health and environmental issues (Finkel & Hays). Current evidence suggests unconventional gas development activities have the potential to contaminate groundwater, release air pollutants and generate toxic waste all of which represents a hazard both to the environment and to human health, and a challenge for regulators and mine operators (Ladd, 2013). Both the immediate, long term and broader cumulative effects need to be examined and further data collected, however as argued by Finkel & Hays (2013)  a precautionary approach should adopted, as  ‘it should not be concluded that an absence of data implies that no harm is being done’





A Kibble, T. C., Z Daraktchieva, T Gooding, J Smithard, G Kowalczyk, N P McColl, M Singh, L Mitchem, P Lamb, S Vardoulakis and R Kamanyire (2014). Review of the Potential Public Health Impacts of Exposures to Chemical and Radioactive Pollutants as a Result of the Shale Gas Extraction Process London: Public Health England.

Carey, M. G., Redmond, H., & Haswell, M. R. (2014). Harms unknown: health uncertainties cast doubt on the role of unconventional gas in Australia's energy future. Med J Aust, 200(9), 523-524.

Chen, J., Al-Wadei, M. H., Kennedy, R. C. M., & Terry, P. D. (2014). Hydraulic Fracturing: Paving the Way for a Sustainable Future? Journal of Environmental and Public Health, 2014, 10. doi: 10.1155/2014/656824

Cooley, H., & Donnelly, K. (2012). Hydraulic Fracturing and Water Resources: Separating the Frack from the Fiction. http://www.pacinst.org/wpcontent/uploads/2013/02/fullreport35.pdf

Coram, A., Moss, J., & Blashki, G. (2014). Harms unknown: health uncertainties cast doubt on the role of unconventional gas in Australia's energy future. Med J Aust, 200(4), 210-213.

Finkel, M. L., & Hays, J. The implications of unconventional drilling for natural gas: a global public health concern. Public Health, 127(10), 889-893. doi: 10.1016/j.puhe.2013.07.005

Gordalla, B. C., Ewers, U., & Frimmel, F. H. (2013). Hydraulic fracturing: a toxicological threat for groundwater and drinking-water? Environmental Earth Sciences, 70(8), 3875-3893. doi: http://dx.doi.org/10.1007/s12665-013-2672-9

Kibble, A., Cabianca, T., Z Daraktchieva, T Gooding, J Smithard, G Kowalczyk, N P McColl, M Singh, L Mitchem, P Lamb, S Vardoulakis and R Kamanyire (2014). Review of the Potential Public Health Impacts of Exposures to Chemical and Radioactive Pollutants as a Result of the Shale Gas Extraction Process London: Public Health England.


Mackie, P., Johnman, C., & Sim, F. (2013). Hydraulic fracturing: a new public health problem 138 years in the making? Public Health, 127(10), 887-888. doi: 10.1016/j.puhe.2013.09.009

McKenzie, L. M., Witter, R. Z., Newman, L. S., & Adgate, J. L. (2012). Human health risk assessment of air emissions from development of unconventional natural gas resources. Sci Total Environ, 424, 79-87. doi: 10.1016/j.scitotenv.2012.02.018

Rafferty, M. A., & Limonik, E. (2013). Is shale gas drilling an energy solution or public health crisis? Public Health Nurs, 30(5), 454-462. doi: 10.1111/phn.12036

Schmidt, C. W. (2013). Estimating wastewater impacts from fracking. Environ Health Perspect, 121(4), A117. doi: 10.1289/ehp.121-a117

Swarthout, R. F. (2014). Volatile organic compound emissions from unconventional natural gas production: Source signatures and air quality impacts. (3581211 Ph.D.), University of New Hampshire, Ann Arbor. Retrieved from http://search.proquest.com/docview/1548319412?accountid=10382

http://link.library.curtin.edu.au/openurl??url_ver=Z39.88-2004&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertation&genre=dissertations+%26+theses&sid=ProQ:ProQuest+Dissertations+%26+Theses+Full+Text&atitle=&title=Volatile+organic+compound+emissions+from+unconventional+natural+gas+production%3A+Source+signatures+and+air+quality+impacts&issn=&date=2014-01-01&volume=&issue=&spage=&au=Swarthout%2C+Robert+F.&isbn=9781321101140&jtitle=&btitle=&rft_id=info:eric/&rft_id=info:doi/ ProQuest Dissertations & Theses Full Text database.

Vidic, R. D., Brantley, S. L., Vandenbossche, J. M., Yoxtheimer, D., & Abad, J. D. (2013). Impact of shale gas development on regional water quality. Science, 340(6134), 1235009. doi: 10.1126/science.1235009

Warner, N. R., Jackson, R. B., Darrah, T. H., Osborn, S. G., Down, A., Zhao, K., . . . Vengosh, A. (2012). Geochemical evidence for possible natural migration of Marcellus Formation brine to shallow aquifers in Pennsylvania. Proceedings of the National Academy of Sciences, 109(30), 11961-11966. doi: 10.1073/pnas.1121181109

Geoscience Australia (2014) Scientific Topics: Energy Resources - Gas Retrieved 18 September 2014. Commonwealth of Australiahttp://www.ga.gov.au/scientific-topics/energy/resources/petroleum-resources/gas

CSIRO (2013) Energy from Oil and Gas http://www.csiro.au/Outcomes/Energy/Energy-from-oil-and-gas/What-is-coal-seam-gas.aspx#Forms

Cooley, H and Donnelly, K (2012) Hydraulic Fracturing and Water Resources: Separating the Frack from the Fiction http://pacinst.org/wp-content/uploads/sites/21/2014/04/fracking-water-sources.pdf?bcsi_scan_c221d61a0ea4ff4c=0&bcsi_scan_filename=fracking-water-sources.pdf

I made a cake

I dont cook very much. I quite like it - but i never feel I get enough time to make it anything other than a chore.

A few weeks ago my friend Annette offered me a lesson in making italian meringue buttercream icing. We attempted this amazing cake and it actually turned out beautifully. 

Armed with my new found meringue skills, i put the KitchenAId that we recieved as a wedding present from my folks and made a cake for a moring tea at work

It is a strawberry cake, with italian meringue buttercream icing and it is delicious. I made a few variations to the recipe, so I am calling it MY Strawberry meringue cake, which is as follows


Yields: 1 2-layer cake or 24 cupcakes


  • ¾ cup strawberry puree (you can make this from putting either fresh strawberries or frozen ones that have been thawed into the blender)
  • 1/4 cup coconut milk, at room temperature
  • 6 large egg whites, room temperature 
  • 1 tsp vanilla extract
  • 1 tsp strawberry extract
  • 2 1/4 cup plain flour
  • 1 3/4 cup sugar
  • 4 tsp baking powder
  • 1 tsp salt
  • 12 Tbsp unsalted butter (170g), at room temp


  1. Preheat oven to 180degrees and grease and flour two 25cm pans 
  2. Combine strawberry puree, coconut milk, egg, vanilla and mix with fork until well blended.
  3. In the bowl of a stand mixer, add flour, sugar, baking powder and salt and mix to combine.
  4. Beat at slow speed and add butter.
  5. Mix until combined and resembling moist crumbs .
  6. Add wet ingredients and beat at medium speed for about 3 minutes or until full and evenly combined. Stop mixer to scrape down the sides of the bowl and hand beat for 30 more seconds.
  7. Divide the batter evenly among the pans.
  8. Bake for about 25 minutes or until a toothpick inserted in the center comes out clean (time will vary).
  9. Once removed from the oven, let cakes rest in pan for about 10 minutes and turn out onto wire racks to cool completely.

The icing is this recipie that was given to me by my American friend Kati - who is an excellent cook. There is a YouTube video that you can watch if it looks intimidating http://www.youtube.com/watch?v=SIRk8NKWa-k  (But seriously, if I can make it? ANYONE can. 


adapted from Rose Levy Beranbaum's recipe. delicious!

  • 2 cups/1 lb/454 grams unsalted butter, softened but cool (65degreesF)
  • 1 cup/7 oz/200 grams sugar
  • 1/4 liquid cup/2 oz/60 grams water
  • 5 large/5.25 oz/150 grams egg whites, room temp.
  • 1/2 + 1/8 tsp. cream of tartar
  • 1 tsp. pure almond extract
  • 6 oz melted and cooled white chocolate, pref. Tobler Narcisse

Makes 4.5 cups/1 lb 14 oz/858 grams (enough to fill and frost two 9-inch by 1 1/2-inch layer or three 9-inch by 1-inch layers)

  1. In a mixing bowl beat the butter until smooth and creamy and set aside in a cool place

  2. Have ready a heatproof glass measure near the range. In a small heavy saucepan heat 3/4 cup sugar and 1/4 cup water, stirring constantly, until the sugar dissolves and the mixture is bubbling. Stop stirring and reduce the heat to low. (if using an electric range remove from the heat.)

  3. In another mixing bowl beat egg whites until foamy, add cream of tartar, and beat until soft peaks form when the beater is raised. Gradually beat in the remaining 1/4 cup sugar until stiff peaks form when the beater is raised slowly. Increase the heat and boil the syrup until a thermometer registers 248degreesF to 250degreesF (firm-ball stage). Immediately transfer the syrup to the glass measure to stop the cooking

  4. If using a hand-held mixer beat the syrup into the whites in a steady stream. Don't allow the syrup to fall on the beaters or they will spin it onto the sides of the bowl. If using a stand mixer, pour a small amount of syrup over the whites with the mixer off. Immediately beat at high speed for 5 seconds. Stop the mixer and add a larger amount of syrup. Beat at high speed for 5 seconds. Continue with the remaining syrup. For the last addition, use a rubber scraper to remove the syrup clinging to the glass measure. Lower speed to medium and continue beating up to 2 minutes or until cool. If not completely cool, continue beating on lowest speed.

  5. Beat in the butter at medium speed 1 tablespoon at a time. At first the mixture will seem thinner but will thicken beautifully by the time all the butter is added. If at any time the mixture looks slightly curdled, increase the speed slightly and beat until smooth before continuing to add more butter.

  6. Lower the speed slightly and drizzle in the almond extract. Beat in 6 ounces melted and cooled white chocolate. Place in an airtight bowl. Rebeat lightly from time to time to maintain silky texture. Buttercream becomes spongy on standing.


So the lovely Amanda at Bimble & Pimble is hosting a super fun photo a day thingy! 

The schedule is.... 





So I am *slightly* late, but here is my little sewing space. Its small, and I do my cutting on the dining table, but I love it :)


Clover, Haechstmass, Merchant and Mills, Gutermann - my favourite things! 

Clover, Haechstmass, Merchant and Mills, Gutermann - my favourite things! 

Bohn pin cushion, Olfa rotary cutter.

Bohn pin cushion, Olfa rotary cutter.

It is hard to keep tidy! 

It is hard to keep tidy! 

I'm looking forward to the rest of the month! 

Spring of 1000 Shirtdresses

Over at idlefancy.com, Mary is hosting a not-quite-sew-along on the McCalls 6696 pattern


I actually have been working on a wearable muslin of this, but unfortunately the first iteration was a total disaster. Not even worth posting pics :-(

But today i bought some super cute poplin with paper cranes on it, so i'm hoping to turn it into a shirtdress that actually fits. Woo


Anyway I'll be following along on the idlefancy blog, there is even a cute button!



Supplier induced demand - an essay thing.

I wrote the thing below for uni last year (so don't steal it, Turnitin will get you REAL QUICK) and I think it is an interesting thing to consider in the current Australian context given the possible introduction of a $7 Co-Payment for visits to a general practitioner and a range of other primary care services (blood tests, imaging etc). Namely as discussed below, that normative supplier induced demand (SID) may  arise even if doctors act in the perceived interests of their patients. For example, if a doctor inadvertently underestimates the financial burden to a patient in paying for various consults, treatments and test, the level of care recommended may exceed that which the patient would have chosen for themselves


Supplier induced demand (SID) refers to the notion that given the information asymmetry that exists between clinicians and their patients, that there is capacity for doctors and other health professionals to engage in inducement of consumption of healthcare services. In theory, this demand inducement would result in a higher amount of health care services being consumed than would normally be expected by an informed patient. (Bickerdyke et al, 2002).  This paper sets out to critically evaluate the arguments for and against the theory of supplier induced demand in health care, and examine closely some of the various (often conflicting) theoretical models and empirical tests of clinician behavior that have been put forward to support one idea or the other.Ö

The issue of SID is important to the analysis of competition in healthcare. If health professionals can generate demand for their care, they possess far more market power than could ordinarily be expected, as price-setting ability is normally constrained by a fixed demand curve. (Feldman and Sloan, 1988)

SID is commonly thought to take the form of an increase in the number of medical examinations or treatments that provided to a patient. In a 2002 paper, Bickerdyke et al suggested that SID can relate to two broad types of medical service — direct consultations and referrals for tests (for example, pathology and diagnostic imaging). Ö

How does SID arise? Medical market characteristics

Some characteristics particular to medical markets distinguish them from orthodox 'competitive’ markets and allow for the potential for SID, including;

Information asymmetry
Information asymmetry between supplier and consumer is not unique to medical or health care markets but the gap in knowledge between doctor and patient is one of the broadest (Guinness & Wiseman, 2011) Because most medical information is technically complex, ppatients are prepared to devolve significant decision making to physicians.  As such, care very vulnerable to inducements for services/procedures that they are not equipped to make informed decisions about whether they need services prescribed for them (Bickerdyke, 2002)

Agency Theory
The agency relationship is particularly important in health care. A patient, in almost all cases, empowers a health professional to act on their behalf by recommending a course of treatment that result in the best outcome for their condition. (Guinness & Wiseman, 2011) However, capacity exists for the agent (in this case a health care professional) to seek to exploit this weak {C}[DH1]{C} agency relationship - maximize their income via recommending unnecessary care or treatments, or minimize effort (for example time spent examining the patient) thereby gaining leisure time. The settings above create an environment where SID can be encountered (Labelle, 1994)Ö

Clinical uncertainty
Supplier induced demand arises not simply because of information asymmetry (on the part of the patient) but can also arise from the ‘more care is better care’ judgment on the part of clinicians (Bickerdyke, 2002).  Richardson & Peacock in their 2006 paper suggest that the rise in emphasis of evidence based medicine and the uncertainty that accompanies it has contributed to creating a SID environment, where tests are ordered ‘just to be sure’ (Richardson & Peacock, 2006)

It is important in examining these factors; information asymmetry, the doctor patient agency relationship and clinical uncertainty on the part of health professional create only the economic conditions in the market in which supplier induced demand may occur. They do not of course; guarantee the presence of SID in medical markets.

The idea that SID exists in practice is still one of the most hotly contested ideas in the health economic literature (Van Dijk et al 2013). In fact the debate has been called ‘unwieldy and unproductive’ (Labelle et al 1994) but still it continues.

Framing the debate – Different views of SID

Lack of agreement among health economists is pervasive in the discussion of SID. A commonly cited motive for SID is self-interest on the part of the treating doctor. Because consumers do not have the information to determine whether the treatment recommended by the treating clinician is optimal, this scenario could potentially be manipulated to the health professionals advantage -  suggesting that they are driven primarily by financial considerations, rather than by an impartial assessment of the medical necessity of the treatment (Bickerdyke, 2002).

The idea that doctors suggest additional treatment, driven primarily by a desire to boost their incomes is, somewhat understandably, met with fierce resistance by many practitioners who see themselves as acting solely in the best interests of their patients.

What is clear is that an orthodox demand/supply model - even if doctors act in the perceived interests of their patients - does not adequately explain the health care market. Various arguments, theoretical models and empirical data analysis have been provided by a number of researchers in an attempt to provide evidence for the SID effect. (Sorensen & Grytten, 2001)

As an example of the intractability of the debate in the literature, it has been suggested that there has been little progress towards consensus on the extent of the existence of SID in large part because it has not actually been consistently defined by researchers. (Labelle, 1994) In their 1994 article, Labelle et al attempt to separate the differences in definition of SID between normative and positive definitions. Similarly Bickerdyke et al (2002) use this approach in order to try and unpack the various SID hypotheses and compare across the literature.

 Normative definitions

Normative definitions depict SID as a deleterious phenomenon – that is, that health professionals will act to exploit the information asymmetry or weak agency relationship due to financial incentives from ‘extra’ services, treatments or consultations (Labelle, 1994). Some have argued that this in fact constitutes market failure. (Bradford & Martin 1995) Part of the hostility in the argument in the literature is that this normative model casts health professionals in a somewhat unflattering light – suggesting that they exploit the doctor/patient information asymmetry and imperfect agency relationship for their own purposes, which can be considered unethical behavior. The central theory of SID relies on the assumptions that under certain conditions health professionals will be motivated to recommend treatments whose costs outweigh their medical benefits purely for financial gain. It is for this reason that SID is equated with undesirable behavior and widely associated with unethical behavior (Richardson and Peacock 1999)

Normative SID may also arise even if doctors act in the perceived interests of their patients. For example, if a doctor inadvertently underestimates the financial burden to a patient in paying for various consults, treatments and test, the level of care recommended may exceed that which the patient would have nominated. (Bickerdyke, 2002) 

Positive definitions

Because of these negative connotations, many models of SID make an attempt to account for the complexity of the motivations of clinicians with regard to the agency relationship – the intrinsic motivation to provide the best possible level of care for patients overrides their wish for financial gain whilst still asserting that SID does (theoretically) exist (Guinness & Wiseman 2011)

While SID is usually regarded as an undesirable market phenomenon with negative impacts for the community at large, there is an argument that it can have a positive effect. Encouraging patients to participate in clinical trials of new drugs could be classified as supplier induced demand in some models, but the benefit to the patient is clear.

As previously indicated, Richardson and Peacock (2006) propose an explanation of SID that is consistent with ethical behavior, and as such a positive definition for the phenomena. Using empirical Australian evidence, they explore the idea that in fact due to the rise in emphasis on evidence based medicine  health professionals face more uncertainty in making clinical judgments, and as such act consistently with the ‘more care is better than less’ notion.

Doctors are imperfect agents, and their ability to directly induce demand for health care services directly conflicts with the orthodox model of demand and supply, regardless of the intrinsic motivations of health professionals to provide the best possible care for their patients. (Richardson and Peacock, 1999)

Richardson and Peacock (1999, 2006) make a compelling argument that the most persuasive support for the theory of SID has always been, and remains, that SID provides the most satisfactory explanation of the major facts of the medical market.Ö

Measuring SID – conflicting interpretations of data

Debate in the literature about SID is not only limited to values based discussions about whether clinicians would act to influence demand, maliciously or otherwise. A parallel debate explores the robustness of methodology for testing for SID effects – of course these are intrinsically linked, the more methodological issues identified in one or the other sides of the debate, the less likely an consensus will likely to be reached (Richardson and Peacock, 1999)

According to Labelle, et al, 1994 despite the numerous research projects investigating SID, the ‘studies often yield contradictory evidence, are not generalizable, and are subject to conflicting interpretations’. Individual analyst’s ideological predispositions, particularly the degree of commitment to neoclassical economic theory, can impact on the interpretations of results and generate controversy. (LaBelle, 1994)

In the literature, ideology around SID among health economists is split into two broad groupings, the ‘Bs’ (broad economists) and the ‘Ns’ (narrow economists). A number of studies use this classification (Labelle et al, 1994, Feldman & Sloan, 1988, Evans, 1987, Bickerdyke, 2002)

In their oft cited 1988 paper, Feldman & Sloan (1988) suggest that the key issue dividing these groups was whether the demand curve for physician services is subject to shifts induced by physicians in pursuit of their own interests: the Ns argued that it was not and the Bs argued that it was. The categorisation of researchers and their ideologies was not at issue, but their conclusions in that landmark paper were controversial and were swiftly rebutted by Rice and Labelle in their 1989 paper in response.

 Broad economists challenge the view that SID does not impact in health care markets and are critical of studies that little or no evidence of inducement. The so called ‘Narrow economists’ assert that studies that do find evidence of widespread inducement are flawed. (Rice & Labelle, 1989)

Empirical investigation and analysis of SID is a challenging and controversial are of health economic study. Complexities of the health care market combined with the range of opinions about what constitutes inducement contribute to the difficulty in reaching consensus. (Bickerdyke et al 2002)

The demand effect of the SID hypothesis is not directly measurable. Given this complexity, researcher has developed variety of theoretical models and empirical tests that display varying degrees of sophistication and support for the hypothesis. (Bickerdyke et al 2002)

 Testing for absolute SID involves the impossible task of observing a perfectly informed patient (Mooney 1994). Therefore, it has been marginal SID, i.e. inducement upon entry or upon a change in fee, which has been tested for, involving the additional assumption that physicians induce more as their income gets under pressure. (De Jaegher and Jegers 2000)

 The test used most often to explain the SID effect is the use of doctor/population ratios. It involves examining how the utilisation or price of medical services changes in response to changes the density of clinicians in an area. The hypothesis underlying the test is that, in response to an increase in the doctor/population ratio (increasing competition) exerting downward pressure on their incomes, doctors will seek to induce demand or raise their fees so as to maintain their incomes. A large number of studies using aggregate data have examined this hypothesis some have found evidence in support of inducement, while others have not. This is indicative of the B vs. N debate that means that 2 analysts can look at the same set of data and reach a different conclusion (Bickerdyke et al 2002)

Some studies have been useful in identifying and quantifying SID when a regulatory change or pricing/remuneration change has happened in a particular healthcare market. For example, changes in cost sharing arrangements in the Netherlands in 2006 led to clear financial incentives for general practitioners. Previously the country had separate remuneration for systems for ‘socially’ insured (government assisted) consumers (serviced via a capitation model) and privately insured patients (fee-for service). This was changed to a combined system of capitation and fee for service for both groups. The study concluded that, among other things that the introduction of fee-for-service billing for socially insured patients led to an increase in physician initiated utilization, pointing to an effect of supplier induced demand (Van Dijk et al 2013) Of course it could also be argued that once the capitation was removed, doctors were able to provide an optimal level of service – a level that was kept artificially low due to the effect of the capitation model.Ö


 In practice, the likelihood of SID occurring and the magnitude of its impacts will be shaped by the interaction of a range of factors that affect doctor and patient behaviour and the effect of institutional and regulatory arrangements on the market for medical services.(Bickerdyke et al 2002)

Recently, Labelle et al. (1994) have argued that more attention should be paid to the consequences of SID. If additional health services result in improved health status or better access to health care, then SID may be beneficial to society irrespective of physicians’ motives for generating more services. Similarly it can be argued that patient satisfaction may in fact be improved by additional supply of health services, even if the additional services are induced. (Carlsen & Grytten, 2000)

Richardson and Peacock (1999, 2006) make a compelling argument that the most persuasive support for the theory of SID has always been, and remains, that SID provides the most satisfactory explanation of the major facts of the medical market.

Bickerdyke, I., Dolamore, R., Monday, I. and Preston, R. (2002) Supplier-Induced Demand for Medical Services, Productivity Commission Staff Working Paper, Canberra, November.

Bradford, WD and Martin, R (1995) Supplier Induced Demand and Quality Competition: An empirical investigation Eastern Economic Journal 21 (4) 491-503

Carlsen, F and Grytten, J. (2000), Consumer Satisfaction and Supplier Induced Demand. Journal of Health Economics 19 2000 731-751

De Jaegher, K. and Jegers, M (2000) A model of physican behaviour with demand inducement. Journal of Health Economics 19:2000 231-258

Feldman, R. and Sloan, F.  (1988) Competition among Physicians: Revisited
Journal of Health Politics, Policy and Law, Vol. 13, No. 2,

Grytten, J and Sorenson, R. (2001) Type of Contract and supplier-induced demand  for Primary Physicians in Norway Journal of Health Economics 20: 379-393

Guinness L, and Wiseman, V (2011) Introduction to Health Economics 2nd Edition London, UK. Open University Press

 Labelle, R., Stoddart, G. and Rice, T (1994) A re-examination of the meaning and importance of supplier induced demand Journal of Health Economics 13: 347-368

Peacock, S and Richardson, J (2007) Supplier Induced demand: re-examining identification and misspecification in cross sectional analysis European Journal of Health Economics 8: 267-277

Van Dijk, C, Van den berg, B., Verheija,R., Spreeuwenberga, P.,  Groenewegena, P., a and De Bakkera, D. (2013) Moral Hazard and Supplier Induced demand: Empirical evidence in General Practice Health Economics 22: 340-352

Richardson, J and Peacock, S (2006) Supplier induced demand: reconsidering the theories and new Australian Evidence Appl Health Econ Health Policy 5 (2) 87-98

Sorenson, R and Grytten, J (1999) Competition and Supplier-Induced Demand in a Health Care System with Fixed Fees Health Economics 8: 497-50

A Short thing on Obesity & Junk Food Advertising

Tackling obesity presents a crucial example of the complicated nature of effective government intervention into a health issue that is largely viewed as one of personal responsibility rather than a condition requiring a community wide response. Public health policy, in particular government intervention into particular aspects of health, necessitates careful navigation of the tension between libertarian ideas of individual rights and responsibilities and the social, economic and environmental determinants of ill health. {C}(Armstrong, 2007; Bayer, 1986). Whilst there is an entrenched view that individuals alone are directly and personally responsible for weight gain (Magnusson, 2008 p.10) there is significant evidence that in fact there are broader contextual issues that mean that government intervention is not only desirable but vital on the grounds of equity and the responsibility governments have to all persons in the community (Bayer & Moreno, 1996) As such government imposed bans on the marketing of obesogenic, high energy food (‘junk food’) on television before 9pm may form part of an effective obesity prevention strategy, drawing on of the experiences of tobacco control efforts and also international evidence of advertising restrictions (Bayer, 1986; Moodie, 2006).

It is important to examine the economic and commercial drivers which create an environment where government intervention is required – because as highlighted by Armstrong (2007), currently consumers are expected to make healthy choices against a background of persuasive, pervasive and ever more sophisticated marketing of unhealthy, energy dense food. Moodie et al (2006) present a strong case that high level of consumption of obesogenic products is in fact an example of market failure in which consumers have little power to resist. In essence, basic economic theory dictates that people will make rational choices in their best interests. However, consumption of energy dense, low nutritional value products is not in the long term health interests of consumers, it is an irrational choice in economic terms. As such this represents an example of market failure (Moodie, 2006). Considering rising rates of obesity within this context, that is, one where not all responsibility for weight gain lies solely with the individual, there is a strong case that the only possible correction for these market forces is via government intervention – starting with the marketing of obesogenic food and beverage products – to make healthy choices easy choices (Armstrong, 2007; MacKay, 2009; Moodie, 2006).

Currently food advertising in Australia is self-regulated by industry, but evidence of significant deficiencies in this scheme – such as inadequate compliance mechanisms, lack of consumer and stakeholder involvement/consultation in the development of the regulations, and the failure to impose clear obligations on advertisers that are effective in protecting consumers, gives a strong mandate for  government intervention, particularly with regard to marketing junk food to children (MacKay, 2009). If the intensity of junk food marketing is problematic for adults making food choices, it is exponentially more so for children – a vulnerable audience lacking the faculty to critically analyse advertisements (MacKay, 2009). Government intervention is vigorously resisted by the food and beverage industry given that they have a strong commercial interest in encouraging people to consume their products (Magnusson, 2008). Self-regulation is often fraught – the major barrier to efficacy being the conflict between advertisers wanting to increase sales and the public health community wanting to decrease the influences that lead to increased sales, a reduction in consumption (MacKay, 2009 p.146)

The international experience of introducing strict regulation for advertisements for high energy, low nutritional value food and beverages on commercial television to children appears has shown to be a moderately effective government response to the increasing levels of obesity in this group (Mackay, 2007). As such there is an evidentiary basis for introducing a ban on junk food advertising in Australia on television before 9pm, given the economic and commercial factors at play, and an expectation that it would have a positive effect on reducing childhood obesity. (MacKay, 2009). However in isolation this cannot be expected to have anything but a modest effect. Magnusson (2008,  outlines how an effective approach to population weight gain necessarily involves an ecologic policy framework – one that addresses the underlying economic and environmental risk factors that are contributing to rising obesity rates, including, importantly the socio economic ‘gradient’ that shows a strong correlation between poverty and obesity. By favouring an ecological framework approach and establishing an effective arsenal of government policy solutions and interventions (of which banning advertising before 9pm on television would form a part) including, potentially, taxing, spending, health education and investment, legislative changes and incentives as part of a multi-sectoral, whole of government approach, rising rates of obesity in the population can be more effectively addressed.   (Magnusson, 2008)



{C}Armstrong, R. M. (2007). Obesity, law and personal responsibility. Medical Journal of Australia, 186(1), 20.

Bayer, R. a. M., J.D. (1986). Health promotion: ethical and social dilemmas of government policy. Health affairs, 5(2), 72-85.

MacKay, S. (2009). Food advertising and obesity in Australia : to what extent can self-regulation protect the interests of children? Monash University law review, 35(1), 118-125.

Magnusson, R. S. S. (2008). What's law got to do with it? Part 1: A framework for obesity prevention. Australia & new zealand health policy, 5(1), 10-10.

Moodie, R., Swinburn, B., Richardson, J. and Somaini, B. (2006). Childhood obesity–a sign of commercial success, but a market failure. International Journal of Pediatric Obesity, 1(3), 133-138.


Random essay on implementation of an alcohol tax in Australia

Consumption of alcohol in Australia is consistently rated as one of the highest per capita in the developed world (AIHW, 2011) The World Health Organisation estimates that harmful consumption of alcohol is the third leading risk factor for poor health globally – and one of the most preventable causes of death, disability and injury (NHMRC, 2009). Increasingly, there is evidence that even relatively modest amounts of alcohol consumption can cause adverse health outcomes to individuals including heart disease, gastro intestinal cancers and mental illness (Stockwell, 2012). Further, contemporary research has considered the cumulative effect of alcohol consumption on society more broadly and has found it to be deleterious to the community in a number of aspects (Laslett & Catalano et al 2010).  Given that this is the case, ideas and policy initiatives to broadly curb alcohol consumption have gained traction with clinicians, public health researchers, policy makers and advocacy groups. One of the ‘levers’ that governments have at their disposal in influencing alcohol consumption is to increase sales tax on alcoholic beverages. The nature and extent of alcohol related harm in Australia that has been documented in relevant literature allows a strong case to be made that the Australian Government should pursue a legislative change to increase tax on cheap alcoholic beverages.

It is not enough to focus purely on the efficacy of an increased sales tax; issues of equity and personal responsibility must also be incorporated (Etzioni, 2009).  In considering a thoughtful policy approach and appropriate public health response to alcohol consumption in the Australian context there are a number of important aspects that need to be addressed. Attention must be paid to whether or not there is evidence that there is in fact a ‘safe’ level of consumption of alcohol – both at an individual and population level. The social determinants of alcohol use and abuse must also be examined, as well as the ‘drinking culture’ in the Australian setting, where consumption of alcohol is consistently framed as a central component of the way in which people connect and socialise (NHMRC, 2009; Allsop 2013). This paper explores these ideas in more depth and also briefly examines the mechanisms by which the increased sales tax could be applied in the marketplace (WHO, 2010)

Alcohol consumption, like smoking and tackling rising rates of obesity presents an example of the complicated nature of government intervention into a health issue that is largely viewed as one of personal responsibility rather than a condition requiring a community wide response (Moodie, 2013). Compounding this is the fact that consumption of alcohol is ubiquitous in Australian society. Alcoholic beverages are a product that are very easily procured, legal (above 18+ years) and can be purchased and consumed at an uncapped amount. Even the fact that there are very few restrictions on advertising for alcoholic beverages contributes to its pervasiveness as a social norm (Allsop, 2013). The notion that an activity that is so normalised - drinking alcohol - could be detrimental to health and wellbeing even at low levels of consumption frustrates efforts to change patterns of behaviour both at an individual and community level (NHMRC, 2009). People simply do not believe that a product that is legal and available so readily could be all that harmful (Allsop, 2013). But it is harmful.

The role of alcohol in Australia is complex. Most Australians drink at levels that do not cause them immediate harm. Drinking is, for most, a pleasurable experience associated with socialising and relaxation (NHMRC, 2009).  Australian values and attitudes towards drinking have been shaped by the history of alcohol consumption. At the time of European settlement, heavy drinking was normalised (Lewis 1992). Whilst the British government was dealing with the ‘Gin Craze’ (drunkenness at almost epidemic levels brought on by the amount and price of gin available to working people following market deregulation), European settlers in Australia were being paid in rum (Lewis, 1992). During this time, two drinking practices were established that still persist today – one is the ‘shout’ where the group is supplied with a round of drinks by each person in turn, and the other is the phenomena that we now refer to as binge drinking  - a period of abstinence followed by a bout of heavy drinking. (Moodie, 2013)

These two culturally ingrained practices in particular are problematic because of the resultant confusion about what constitutes a ‘safe’ level of consumption (Allsop, 2013). The convention of ‘shouting’ dictates that if there are six people in the group, every person will consume six drinks – each person buying a ‘round’ in turn (Moodie, 2013).  Recent guidelines from the National Health and Medical Research Council state that “for healthy men and women, drinking no more than two standard drinks on any day reduces the lifetime risk of harm from alcohol-related disease or injury, [and that] drinking no more than four standard drinks on a single occasion reduces the risk of alcohol-related injury arising from that occasion” (NHMRC, 2009). However in our hypothetical group of six persons, it rapidly becomes apparent that consuming only two, or even four drinks, is both culturally and practically fraught. Persons that decline participation in ‘shouts’, depending on the time point at which they opt out will invariably be labelled alternately ‘wowsers’ (to use a somewhat antiquated term meaning boring or conventional) or cheap (Lewis, 1992). Evidence suggests that binge drinking culture is of particular concern in the 15-25 age group (Allsop, 2013, Room & Mäkelä, 2000). Not only has drinking to intoxication at a young age been associated with physical injury, risky sexual behaviour, adverse behavioural patterns and poorer academic outcomes, it has also been linked with continuing heavy drinking in adulthood (NHMRC, 2009). While binge drinking is perceived as a particular problem for young adults, a 2004 study by Jefferis et al highlights this type of drinking is often continued into adulthood. In particular, men who continue to binge drinking in later life tend to suffer lifelong physical and social consequences.(Jefferis et al 2004). This Australian drinking culture that is so pervasive is not without significant negative consequences – and young people are most susceptible to them.  A 2013 report from the Foundation for Alcohol Education and Research stated that ‘In 2010, one in five Australians 14 years of age or over drank at levels that placed them at lifetime risk of alcohol-related disease or injury. This equates to 3.7 million Australians drinking at long-term risky levels, compared to 3.5 million Australians in 2007” (FARE, 2013).  Framed in this way, and given that the vast majority of alcohol related harm is preventable, acting to curb consumption via mechanisms such as increasing the sales tax on the price of alcohol to seem not only prudent but necessary.

Public health policy, in particular government intervention into certain aspects of health, necessitates careful navigation of the tension between libertarian ideas of individual rights and responsibilities and the social, economic and environmental determinants of ill health in the population (Armstrong, 2007; Bayer, 1986){C}{C}. These considerations are of course familiar. Reform of sale, consumption and marketing of tobacco provides a useful case study in balancing individual rights and responsibilities and population health (Bayer, 1986). However additionally, attempts to curb alcohol consumption not only must navigate the usual tensions, but also the historical aspects of the temperance movement and prohibition – over consumption of alcohol is viewed not only as a health issue but also reflection of an individual’s moral values (Dorsey, 2010). A primary argument against government intervention is based on ethical considerations: the claim that such taxes are unfair, discriminatory, and restrict an individual’s freedoms - paternalistic policy that seeks to impose its values on a certain segment of the population (Dorsey, 2010). Why shouldn’t individuals be allowed to drink to excess regularly if they so choose without incurring a cost impost from sales tax? Should government, albeit somewhat indirectly be interfering with an individual’s choice about whether to drink or not?  (Room et al 2000). To answer this question we need to consider the broad impact of alcohol consumption. Many Australians require medical treatment, and some die, as a result of their own drinking or that of others. There is a not insignificant burden placed on the health system due to alcohol consumption and alcohol related harm which results in an increase in expenditure by hospitals and health services that is potentially preventable. Chikritzhs et al. (2003) and the Australian Burden of Disease study (Begg et al., 2007) outline the broad impact of alcohol consumption and Collins and Lapsley (2008) calculate the cost to the health system from alcohol. In making decisions about alcohol policy, shouldn’t we examine the effects at the population level? What is the impact on the community more broadly from alcohol consumption?

In their 2010 study Laslett and Catalano considered these kinds of questions and set out to quantify, for the first time, the ripple effects of alcohol use and misuse. They considered not just the acute health effects for the individual, but the burden borne by the community in many iterations – ranging from intimate partner violence, to noise and nuisance, to motor vehicle accidents. The authors assert that “seventy per cent of Australians have been affected by strangers’ drinking” (Lasset & Catalano, 2010). The report was commissioned by the Foundation for Alcohol Research and Education -  a body whose primary objective is to change the drinking habits of Australians, which whilst it is important to note when critically evaluating their research, the robustness of the data makes a compelling case that alcohol related harm has wide ranging and often severe effects.  Treatment of individuals that have experienced alcohol related ill health is borne by the public hospital system, funded from tax revenue. Similarly to taxes applied to tobacco products – there is an inherent argument that individuals that consume alcohol and then experience poor health as a result should contribute to the costs of that treatment, given that it is a preventable condition.


In considering the implementation of a sales tax on alcoholic beverages, policy making must be underpinned with an acknowledgement of the social determinants of health to allow full exploration of equity issues (Bayer, 1986). The 2009 NHMRC “Australian Guidelines to reduce health risks from Drinking Alcohol” provide evidence that individuals that misuse or abuse alcohol are more likely to be poorer, less educated and more geographically isolated than the broader community(NHMRC, 2009). In the Australian context, it is well established that Aboriginal Australians have poorer health outcomes across a number of measures due to cyclical poverty, displacement and institutional racism. The NHMRC have found that “whilst in fact Aboriginal and Torres Strait Islander peoples are less likely to drink alcohol than other Australians, they are more likely than other Australians to drink at levels above the NHMRC 2001 guidelines if they do drink”(NHMRC, 2009). Given that those most affected by alcohol addiction issues are likely to have a lower socioeconomic status - the brunt of the cost impost of the tax is borne by those who can least afford it. For example, very heavy drinkers and those on low incomes, including young people, the older persons and Aboriginal persons feel price increases more acutely (CCA, 2011). This is an equity issue and is acknowledged as such by advocates lobbying for increasing the sales tax on alcoholic beverages. Both the Australian Medical Association (AMA - the peak professional body for medical doctors) and the Cancer Council of Australia (the peak cancer advocacy, education and support body) in advocating a sales tax suggest that revenue raised from its introduction are hypothecated for treating addiction, preventative programs for alcohol misuse and early intervention (AMA, 2012; CCA, 2011).


There is strong evidence that increasing tax on alcoholic beverage is an effective measure in curbing consumption of alcohol. Elder & Lawrence et al, make an assessment of the efficacy in of alcohol tax policy via a systematic review of the relevant literature, and found that even allowing for age, gender geographic location and study design differences, nearly all studies, stated that the introduction of a tax and (subsequent price increase of alcohol) resulted in an inverse relationship with excessive drinking or alcohol-related poor health outcomes. Importantly, they also found that young people were particularly susceptible to price increases. As discussed earlier in this paper, young people who binge drink in adolescence and young adulthood tend to carry this behaviour forward into later life with far more serious health consequences given the cumulative damage that is done by alcohol misuse (Jefferis, 2004). Importantly, we are also able to ascertain from the literature that the expectation is that the impact of the application of a tax is proportional to its percentage increase – allowing for factors such as demand elasticity and availability of disposable income (Elder & Lawrence, 2010).



The mechanisms by which the increased sales tax could be applied in the marketplace vary. Currently an excise tax is applied all alcoholic beverages produced or imported into Australia. The “rates of excise duty on tobacco, spirits, beer, and other excisable beverages are increased in February and August relative to CPI” (ATO, 2013) The AMA advocates taxing alcohol products on a volumetric basis – that is products with higher alcohol content will be taxed at a higher rate. They also note the potential that a volumetric alcohol tax has to influence and incentivise manufacturers to produce lower alcohol products (AMA, 2012). Relatedly, the AMA also suggest that “licensed premises should be compelled to set a ‘minimum floor price’ for alcohol to disallow alcohol promotions involving free or heavily discounted drinks”. The World Health Organisation has suggested other mechanisms such as incentivising production and sale of for non-alcoholic  beverages; and a reduction or discontinuation of subsidised production of alcohol (WHO, 2010).

In conclusion, it is worth noting that many ethical assumptions underlie public health approaches to reducing alcohol consumption. Although the impact of both the health of individuals and the broader societal consequences are explored in detail in the literature, what is less prominent is the pleasure many people derive from alcohol consumption, particularly as it relates to social settings. Policy in this area very much emphasises harm minimisation which is justifiable given that individuals have agency over their decisions about their level of consumption of alcoholic beverages. The govern­ment’s responsibility is to ensure the health and well-being of the community minimizing harm related to consumption (Room & Hall 2012). An increased tax on alcoholic beverages borne by the consumer is an effective method of acting to prevent harmful consumption of alcohol whilst still allowing people the individual freedoms to determine their own level of consumption.



Allsop, S. (2013) Social acceptance of alcohol allows us to ignore its harms. Retrieved from https://theconversation.com/social-acceptance-of-alcohol-allows-us-to-ignore-its-harms-10045

Armstrong, R. M. (2007). Obesity, law and personal responsibility.

Medical Journal of Australia, 186(1), 20.

Australian Institute of Health and Welfare (2011). 2010 National Drug Strategy Household Survey report. Drug statistics series no. 25. Cat. no. PHE 145. Canberra: AIHW.

Australian Medical Association (2012) Alcohol Consumption and Alcohol-Related Harms: Position paper. Retrieved on 14/10/2013 https://ama.com.au/position-statement/alcohol-consumption-and-alcohol-related-harms-2012


Bayer, R., & Moreno, J. (1986). Health Promotion: Ethical and Social Dilemmas of Government
 Health Affairs, 5(2), 78-85.

Begg, S., Vos, T., Barker, B., Stevenson, C., Stanley, L., Lopez, A.D., (2007). The burden of disease and injury in Australia 2003. PHE 82. AIHW, Brisbane.


Cancer Council of Australia (2011) Alcohol Pricing and Taxation Position Statement 25/10/2013 http://wiki.cancer.org.au/prevention/Position_statement_-_Alcohol_pricing_and_taxation


Chikritzhs, T., Catalano, P., Stockwell, P., Donath, S., Ngo, H., Young, D., Matthews, S., 2003. Australian Alcohol Indicators, 1990-2001: Patterns of alcohol use and related harms for Australian states and territories. National Drug Research Institute, Perth.

Collins, D.J., Lapsley, H.M., (2008) The costs of tobacco, alcohol and illicit drug abuse to Australian society in 2004/05. Australian Department of Health and Ageing, Canberra.


Dorsey, R. (2010) In Defense Of “Sin Taxes”: Tax Policy, Virtue Ethics, And Behavioral Economics
Southern Law Journal 54/Vol. XX/ Available from http://www.southernlawjournal.com/2010/3215_Chapter%203.pdf

Elder, R., Lawrence, B., Ferguson, A., Naimi, T., Brewer, R. and Sajal K. (2010) The Effectiveness of Tax Policy Interventions for Reducing Excessive Alcohol Consumption and Related Harms. American Journal for Preventative Medicine; 38(2)217–229


Etzioni, A. 1974. Human Nature and Transforming Society. International Journal of Group Tensions
4 (3): 284-312. 28 October 2013. Available from

Jefferis, B., Power C., & Manor, O. (2004). Adolescent drinking level and adult binge drinking in a national birth cohort Addiction, 100, 543–549

Laslett, A-M., Catalano, P., Chikritzhs, Y., Dale, C., Doran, C., Ferris, … (2010) The Range and Magnitude of Alcohol’s Harm to Others. Fitzroy, Victoria: AER Centre for Alcohol Policy Research, Turning Point Alcohol and Drug Centre, Eastern Health

Lewis, M (1992) A Rum State: Alcohol and State Policy in Australia 1788-1988 
              Canberra: Australian Government Publishing Service

Loxley, W., Toumbouro, Stockwell, T., Haines, B., Scott, K. and Godfrey, C. (2004) Prevention of Substance Use, Risk, and Harm in Australia: A Review of the Evidence. The National Drug Research Institute and the Centre for Adolescent Health

Moodie, R. (2013) A brief history of alcohol consumption in Australia
Retrieved from


National Health and Medical Research Council (2009) Australian Guidelines to reduce health risks from Drinking Alcohol. Commonwealth of Australia. Available from http://www.nhmrc.gov.au/guidelines/publications/ds10



Room, R and Hall, W. (2012). Population approaches to alcohol, tobacco and drugs: Effectiveness, ethics and interplay with addition neuroscience In Carter A, Hall, W. and Isles, J. (Eds.), Addiction Neuroethics: The Ethics of Addiction Neuroscience Research and Treatment (pp. 247 -260). Oxford, United Kingdom: Academic Press

Room, R. and Mäkelä, K. (2000) Typologies of the Cultural Position of Drinking.
Journal of Studies of Alcohol and Drugs
61: 475-483, Available from http://www.jsad.com/jsad/article/Typologies_of_the_Cultural_Position_of_Drinking/775.html

World Health Organisation(2010) Global strategy to reduce the harmful use of alcohol Retrieved on 14/10/2013 http://www.who.int/substance_abuse/msbalcstragegy.pdf


Fifty two in fifty two

My new year's resolution for 2014 was to make a website that allowed me to collect interesting bits and pieces from around the place (tick!) and to read 52 books in 52 weeks. It

It's week 6 and I am on track to finish my 6th book - David Sedaris' Me Talk Pretty One Day 

It has not been a walk in the park - reading a book a week, and suspect it will get harder when the semester starts. I dont think textbooks count!