Zero alcohol,but not zero risk?

Zero-alcohol products (ZAPs) are rising in availability and popularity in Australia (Drinkwise Australia, 2023). Internationally, no- and low-alcohol beverages (NoLos) comprise a group of products containing up to 3.7% alcohol by volume (ABV). In Australia, ZAPs contain under 0.05% ABV. A range of beer, wine and spirits products are available and are manufactured to look, smell and taste the same as alcohol-containing products. However, ZAPs are not subject to the same liquor-licencing legislations and are classified as soft drinks, which are regulated under the food standards (Australia New Zealand Food Standards, 2016). This means they are available on the shelves of supermarkets and convenience stores and may even be accessible to minors.

ZAPs are often manufactured by the alcohol industry and are being marketed as a safer, healthier alternative to alcohol (Miller et al., 2022). But are these interventions safe for all, including those individuals with a history of alcohol use disorder (AUD) or co-occurring mental health disorders? In addition, what are the potential risks associated with these interventions at the individual, community and population levels?

Psychiatrists may be asked for their opinion about whether they support the consumption of ZAPs, either by their patients or within residential or bed-based service settings. On the one hand, ZAPs have lower health risks than alcohol-containing products, with only negligible amounts of alcohol content, lower calories and no interaction with psychotropic medications. As alcohol consumption often plays a central role in the Australian social landscape, ZAPs may provide a non-alcoholic alternative while still supporting the social connection and cultural experience that is often associated with drinking. On the other hand, although ZAPs have been proposed to reduce alcohol intake by the substitution of these products to their alcohol-containing counterparts, this has not yet been supported by research (World Health Organization, 2023). To date, there has been no rigorous research testing the safety or efficacy of ZAPs as a substitute in hazardous or dependent drinkers, and the role of ZAPs as a harm-reduction measure needs further investigation (Miller et al., 2022).

There is a need to be cognisant of the potential risks that arise with consumption of ZAPs, as these products may be of lower risk but not zero risk. This is particularly the case for certain groups of individuals, such as those with a history of AUD. The consumption and exposure to ZAPs or low-alcohol products have been shown to increase cravings and physiological responses for alcohol for people with an AUD (Caballeria et al., 2022). Further exploration is needed to understand the potential for ZAPs to act as cues for drinking among individuals with risk factors for AUD such as depression or anxiety disorders, other substance use disorders, a history of trauma or personality vulnerabilities such as behavioural disinhibition and low emotional constraint (Castillo-Carniglia et al., 2019). Exposure to and witnessing the consumption of ZAPs by others may influence vulnerable individuals to drink. In addition, the substitution to ZAPs as an alternative to alcohol does not address factors that may strongly influence drinking in individuals with AUD such as the sociocultural environment and peer influences. Psychiatrists need to carefully consider the potential risks associated with ZAPs for each individual patient and consider relevant psychosocial, environmental and contextual factors.

It is also important to consider the public health risks in the context of rising availability and promotion of ZAPs. ZAPs are often packaged to look like their equivalent alcohol products, with prominently displayed branding and labelling that may appear very similar to their alcoholic counterparts. This is an example of ‘alibi marketing’, which is an intentional practice by the alcohol industry aimed at promoting the brand identity of the manufacturer, extending its reach to populations and places where alcohol advertising is otherwise restricted (World Health Organization, 2023). There have been concerns that ZAPs may increase brand familiarity and awareness of alcohol products, even among non-drinkers such as children and adolescents (Miller et al., 2022). Concerns have also been raised that ZAPs have been marketed in a way to condone and encourage alcohol consumption in situations and by individuals where it would be considered risky, such as in pregnant women or in occupational or legal situations where abstinence is mandated (Miller et al., 2022). This may lead to confusing messaging where the consumption of alcohol may appear to be endorsed or normalized and send the message that equivalent alcohol-containing products are safe and harmless. There is a need to be vigilant about how these products are being promoted and marketed. Individuals with mental health disorders that affect cognitive functioning and judgement may be particularly vulnerable and susceptible to marketing influence.

Psychiatrists need to be aware of the undue influence on patients through the promotion of ZAPs by advertisements and marketing strategies. Psychoeducation for both patients and staff about the potential risks and limitations of ZAPs is crucial. In residential settings, decisions on whether the consumption of ZAPs in the unit is permitted require careful assessment of the potential risks for individual patients and at a broader service level. The content and placement of alcohol and ZAP marketing in Australia are regulated by various regulatory codes, and potential risks associated with the advertising of ZAPs among a vulnerable patient population need to be monitored, particularly if alcohol consumption is being normalized or encouraged through messaging, branding and promotion. Education to the wider community about these risks is required, along with advocating for the responsible marketing of ZAPs. When concerns about potential breaches of advertising codes arise, concerns or objections can be raised via the relevant regulatory systems and processes.

In conclusion, psychiatrists may be called upon to provide our professional opinion and judgement in relation to ZAPs by our patients, services and the wider community. Although this is an area of limited research, emerging concerns highlight that ZAPs may not be zero risk. ZAPs carry the risk of precipitating and promoting alcohol consumption, particularly in certain vulnerable or at-risk populations. In determining whether ZAPs should be supported for our patients, a formulation of the biopsychosocial vulnerabilities and situational context of each individual is required, along with keeping up to date with emerging research findings on this topic. In residential settings, there may be broader sociocultural and environmental risks associated with ZAPs, and a collaborative approach to addressing these risks should be taken, including the views and opinions of the broader patient population, staff and the organization. Finally, from a public health perspective, there is a role for psychiatrists to both educate others about the wider public health risks and harms due to ZAPs and advocate for appropriate and responsible marketing.