House of Commons - Alcohol - Health Committee

Alcohol - Health Committee Contents

4 The Government's strategy

67. In the face of the increasing consumption of alcohol and growing alcohol-related problems, Governments were surprisingly inactive from the 1970s onwards, allowing alcohol to become more affordable and restricting their actions to undertaking occasional studies such as that undertaken by an Inter-Departmental Working Group which was published as Sensible Drinking, in 1995.[91]

Key documents relating to alcohol since 2000
2001 Annual report of the CMO (drew attention to the extent of alcohol-related harm.)[92]
2001 'Alcohol: Can the NHS Afford It'? (Royal College of Physicians)
2004 'Calling Time' (The Academy of Medical Sciences)
2003 Alcohol No Ordinary Commodity: Research and Public Policy (Thomas Babor et al—funded by WHO)
2003 Alcohol misuse: How much does it cost? (The PM's Strategy Unit)
2004 'The Alcohol Harm Reduction Strategy for England' (The PM's Strategy Unit)
2005 Alcohol Needs Assessment Research Project (ANARP): The 2004 national alcohol needs assessment for England (Dept. of Health);
2006 Alcohol in Europe (A report for the European Commission)
2007 Early Adolescent Exposure to Alcohol Advertising and its Relationship to Underage Drinking (RAND)
2007: Safe. Sensible. Social. The next steps in the National Alcohol Strategy (DH and Home Office, 2007
2008 Review of the Social Responsibility Standards for the production and sale of Alcoholic Drinks (commissioned by Home Office from KPMG)
2008 Independent Review of the Effects of Alcohol Pricing and Promotion (independent review commissioned by the Department of Health from ScHARR)
2009 Annual report of the CMO (which called for minimum pricing)
2009 Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol, Anderson et al (Lancet)
2009 Under the influence (The BMA)
2009 Does marketing communication impact on the volume and patterns of consumption of alcoholic beverages, especially by young people? - (Science Group of the European Alcohol and Health Forum)

68. However, over the last decade, pressure on the Government to act has mounted with the publication of a series of reports by leading clinicians at the beginning of this millennium, including the Chief Medical Officer, the Royal College of Physicians, and the Academy of Medical Sciences. The box above lists a number of the key publications of the last decade.

69. In 2003 the Government published Alcohol misuse: How much does it cost? which was a detailed and impressive assessment of the costs of, and harm done by, alcohol. Then, in March 2004 the Government published The Alcohol Harm Reduction Strategy for England The Government's strategy "aimed to:

tackle alcohol-related disorder in town and city centres
improve treatment and support for people with alcohol problems
clamp down on irresponsible promotions by the industry
provide better information to consumers about the dangers of alcohol misuse', including advice about daily units."

70. In a foreword the Prime Minister wrote:

increasingly, alcohol misuse by a small minority [our emphasis] is causing two major, and largely distinct problems: on the one hand crime and anti-social behaviour in town and city centres, and on the other harm to health as a result of binge- and chronic drinking.[93]

71. These comments were surprising unless the Prime Minister was only referring to those who caused the crime and disorder and those who were clearly alcoholics since the report showed that misuse was not a problem for a small minority: it stated that "a quarter of the population drink above the weekly guidelines of 14 units for women and 21 units for men. It also observed that 5.9m adults were 'binge drinking'. The Prime Minister himself acknowledged that 'The Strategy Unit's analysis last year showed that alcohol-related harm is costing around £20bn a year, and that some of the harms associated with alcohol are getting worse'.

72. The Strategy proposed that progress be reviewed in 2007. The review was published in Safe. Sensible. Social. The next steps in the Government's Alcohol Strategy (Dept of Health and Home Office). The document stated that significant progress had been made.[94] Levels of violent crime had fallen, and levels of alcohol consumption were no longer rising, but public concern about the harm caused by alcohol had risen as had the incidence of liver disease and deaths caused by excessive drinking. While the strategy remained essentially the same, there were perhaps some differences in emphasis. In 2007 alcohol was not a problem for a small minority, but rather there was a "significant [our emphasis] minority who don't know when to stop drinking".

73. The renewed alcohol strategy announced that the Government would carry out three reviews of industry practice and then consult on whether there was a need for further regulation of alcohol retailing. These were:

an independent national review of evidence on the relationship between alcohol price, promotion and harm, [which], following public consultation, [would] consider the need for regulatory change in the future, if necessary

A review and consultation … on the effectiveness of the industry's Social Responsibility Standards in contributing to a reduction in alcohol harm … following public consultation, [this would] consider the need for regulatory change in the future, if necessary

Consultation … in 2008 on the need for legislation in relation to alcohol labelling, depending on the implementation of the scheme to include information on sensible drinking and drinking while pregnant on alcohol labels and containers

74. The Department of Health's description of the strategy is set out in the box below.[95]

Informing and supporting people to make healthier and more responsible choices

public health education campaigns to improve understanding of alcohol units and health risks; and to challenge binge drinking and tolerance of drunkenness
planned campaigns from 2009 for children and their parents
publication of The Chief Medical Officer's Guidance on the Consumption of Alcohol by Children and Young People.

Creating an environment in which the healthier and more responsible choice is the easier choice:

a review of the provisions of the Licensing Act published in March 2008
toughened enforcement to clamp down on alcohol fuelled crime and disorder and under-age sales
an independent review commissioned by the Home Office of the effectiveness of the alcohol industry's social responsibility standards published in July 2008
an independent review commissioned by the Department of Health on the effects of alcohol pricing and promotion, published in December 2008

· proposals in the Policing and Crime Bill for a mandatory code for alcohol retailing …
Providing advice and support for people most at risk:
· development of the evidence on effectiveness of brief advice and specialist alcohol treatment
A delivery system that effectively prioritises and delivers action on alcohol misuse:

a new Public Service Agreement (PSA) indicator ..to ..address alcohol-related hospital admissions
the Alcohol Improvement Programme, central and regional support for PCTs to help them commission and deliver improvements… linking to the World Class Commissioning programme.

75. Subsequently, a number of other changes have been made. In July 2009 on the day that the Minister for Public Health appeared before this Committee, the 'Biggest ever campaign to encourage responsible drinking' was announced. It had been agreed that the Drinkaware Trust would run the Campaign for Smarter Drinking.[96]

76. The most important changes are made by the Policing and Crime Act 2009 which, according to the Government, seeks to prevent the sale of alcohol to young people, introduces a mandatory code in respect of promotions and allows local authorities to act against irresponsible premises. Health campaigners welcomed the Bill, but were disappointed that a number of additional measures which had originally been planned were dropped. The Bill is discussed in more detail in chapter 8.

77. The Government claimed that its strategy was starting to work:

We are delivering the commitments we made in those publications (the 2004 strategy and 2007 renewed strategy) and the latest data available (2007) show a small fall in the numbers of alcohol-related deaths in England. Total consumption may have plateaued since 2005.[97]

78. However, health professionals who had pressed for the alcohol strategy were critical of it when it appeared in 2004 and the 2007 review was thought to be little better. Many submissions to this inquiry, for example those of Duncan Raistrick, Alcohol Concern and NICE itself were critical.

79. In response to claims that the recent fall or levelling out in consumption suggested the strategy was working, critics argued, first, as we have seen, that it was unclear whether the decline was a temporary phenomenon and, secondly, that there was no evidence that the fall was caused by the Government's strategy. Moreover, the level of consumption still remained considerably higher than it had been even in the 1990s.

80. Health professionals argued that it was clear what policies were effective and surprising that they had not formed part of the strategy: Professor Anderson told us that the Government had failed to make use of the available evidence:

We can learn that there is overwhelming evidence for what kind of policy options work….What we know is that price is very, very important. If the price of alcohol goes down, consumption and harm go up and vice versa. … We know that the availability matters. In general the more available alcohol is in terms of the number of outlets, the density of outlets and the days and hours of sale, the more consumption and harm there is. The converse is that availability is restricted and there is less harm. We also know that marketing has an impact. It is smaller than the impact of price and availability but there is an impact. … Finally, the other very important area is the work done by the healthcare system and service. There are a lot of people who do have hazardous and harmful patterns of drinking for whom some early identification and brief advice from a GP or a practice nurse or someone else is effective in helping them change their drinking.[98]

Professor Gilmore told us:

"In 2004 in building up towards the alcohol harm reduction strategy for England they got a very good evidence base together but they failed to deliver on some of the evidence around price and availability and emphasised too much the voluntary partners in industry".[99]

81. A comprehensive strategy was necessary, using all the tools available to Government. Information should be part of the strategy, but it would not change behaviour on its own. More emphasis should have been given to more effective policies, namely increases in price, restrictions on availability and control of marketing.

82. While some observers have claimed that much of the difference between the Government and health professionals in their approach to the price mechanism reflects lobbying by the drinks industry and supermarkets and electoral considerations, it is also underpinned by a different philosophy. On the one hand Government and the industry stress that the problem is down to a minority of irresponsible drinkers. Accordingly, increasing prices would penalise the vast majority of sensible drinkers; the best policy is to change the habits of the small minority through better information, education and enforcement along the lines used in the drink-driving campaign.[100] In contrast, health professionals argue that we are not dealing with a small minority of the population, pointing out that over 10m adults drink more than the recommended limits and 2.6 m drink at even riskier levels of double the limits. Alcohol Concern informed us that the Strategy "mistakenly viewed alcohol misuse as the preserve of a small minority".[101]

83. Health professionals also point to the 'whole population theory' first propounded by the French mathematician, Ledermann, who argued that there was a fixed relationship between average per capita consumption of alcohol and the number of problem drinkers and the amount of alcohol related harm. Thus alcohol is a societal problem: the more drinking is seen as the norm, the more those prone to drink are likely to become problem drinkers. Ledermann predicted that doubling or trebling average consumption would lead to a four or nine fold increase in the numbers of problem drinkers.[102] Professor Sir John Marsh noted that the problems associated with alcohol were

deeply related to cultural norms within society. Cultural patterns have changed to reduce the constraints on alcohol abuse. Incomes have risen allowing members of cultural groups where excess drinking is acceptable to consume more alcohol.[103]

84. In contrast, the industry's view, as the Portman Group put it, is that

policy approaches that seek to tackle the problems of alcohol misuse by making the population as a whole drink less are untargeted, unfair and unlikely to succeed. Instead, measures should focus on addressing the minority that drink irresponsibly.[104]

The different philosophies are reflected in different approaches by the Governments in England and Scotland: in England the minority is targeted, in Scotland society as a whole.

85. We were told that the Government's Alcohol Strategy put the interests of alcohol producers and retailers above the health of UK citizens.[105] The Government's strategy is seen as closer to the policies put forward by the drinks industry than those proposed by health professionals. Our adviser, Nick Sheron, examined the industry's memos to the Committee and found that they supported the policies which are seen as least effective by clinicians:

No more regulations

Partnership approaches

Information campaigns

Education

These are also the main policies promoted by the Alcohol Strategy. The World Health Organisation reviewed the effectiveness of a range of alcohol policy approaches in 2003 (Babor et al 2003). The Royal College of Psychiatrists compared the Alcohol Harm Reduction Strategy for England with the WHO findings, arguing that the Strategy eschewed the most effective policies and adopted the least effective.

Table 2: The Alcohol Harm Reduction Strategy mapped against Babor et al. (2003) analysis of effective alcohol strategies[106]

Strategy Impact Alcohol Harm Reduction
Strategy and Licensing Act

Taxation and Pricing High "More complex than price"

Restricting availability High 24 hour availability

Limiting density of outlets High "Local planning"

Lower BAC driving limits High No change

Graduated licensing for young drivers High No

Minimum drinking age High No

Brief interventions/treatment Medium "Lack of evidence"—needs assessment; evidence review, Alcohol service framework

Safer drinking environment Medium Voluntary codes: safer glasses

Heavier policing Medium Antisocial behaviour orders, on the spot fines

Public education campaigns Low Change safe drinking message, unit labelling

School based education Low More education

Voluntary advertising restrictions Low Yes

Source: Drummond and Chengappa 2006

86. Thus health professionals are concerned that the drinks industry supports those policies which are least likely to lead to a reduction in the sale of drinks and are least likely to be effective.

87. Since about 10 million people drink more than the recommended levels and 75% of all the alcohol consumed is drunk by people who drink more than the recommended limits, there are doubts about how keen the industry really is on encouraging sensible drinking. Petra Meier of Sheffield University calculated for the Committee the drop in sales if everyone kept to the recommended limits. She concluded that if everyone who currently drinks over the limit became just compliant with moderate drinking guidelines, the total alcohol consumption would drop by 40%.[107] The figure is enormous. Since UK alcohol sales were worth £33.7 billion in 2006/07, if sales also fell by 40%, this would amount to over £13 bn.

88. We congratulate the Government on the impressive research it has undertaken and commissioned and its analysis of the effects and costs of alcohol. It has analysed the health risks and shown them to be significant and found the costs of alcohol to society to be about £20 bn each year. It has also commissioned research into the effectiveness of a range of policies for reducing consumption.

89. Unfortunately, the Government's Alcohol Strategy failed to take account of this research. Despite all the evidence to the contrary, in its 2004 Strategy the Government stated that alcohol was a problem for a small minority; we assume it meant that a small minority committed alcohol-related crime and were chronic alcoholics. We are pleased that it has subsequently recognised that the problem affects a significant minority as medical opinion indicates.

90. Unfortunately, too, the Government has given greatest emphasis to the least effective policies (education and information) and too little emphasis to the most effective policies (pricing, availability and marketing controls); in fact, by freezing the duty on spirits from 1997 to 2007 the Government encouraged consumption.

91. We are concerned that Government policies are much closer to, and too influenced by those of the drinks industry and the supermarkets than those of expert health professionals such as the Royal College of Physicians or the CMO. The alcohol industry should not carry more weight in determining health policy than the CMO. Alcohol consumption has increased to the stage where the drinks industry has become dependent on hazardous drinkers for almost half its sales.

92. In view of the scale and nature of the problem, we agree with the health professionals that a more comprehensive alcohol policy is required, which makes use of all the mechanisms available to policy makers: the price mechanism, controls on availability and marketing and improvements in NHS services as well education and information. There is a relationship which needs to be addressed between how much we drink as a society and the number of people who drink too much.

93. In the following chapters we deal first with the role of the NHS and then look at the other measures to reduce harmful consumption.

91 The study reviewed both the medical and scientific evidence on the long term effects of drinking and the sensible drinking message; it recommended setting a daily rather than weekly limit. Back

92 The CMO's report drew attention to the extent of alcohol-related harm, in particular cirrhosis of the liver. Back

93 Our bold Back

94 The Government stated that of the 41 actions in the original strategy, 26 have been delivered and a further 14 are underway. Back

95 AL 01 Back

96 http://www.drinkaware.co.uk/ /biggest-ever-campaign-to-encourage-responsible-drinking-announced Back

97 AL 01 Back

98 Q 45 Back

99 Q 51 Back

100 Ev 124-6 Back

101 AL 13 Back