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
|Key documents relating to alcohol since 2000
2001 Annual report of the CMO (drew attention to the extent of alcohol-related harm.)
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 alfunded 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
- tackle alcohol-related disorder
in town and city centres
- improve treatment and support for people with
- clamp down on irresponsible promotions by the
- 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.
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
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.
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,
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.
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.
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.
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
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.
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".
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
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.
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".
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
Sir John Marsh noted that the problems associated with alcohol
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.
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.
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.
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
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
||Alcohol Harm Reduction|
Strategy and Licensing Act
|Taxation and Pricing
||High||"More complex than price"
||High||24 hour availability
|Limiting density of outlets
|Lower BAC driving limits
|Graduated licensing for young drivers
|Minimum drinking age
||Medium||"Lack of evidence"needs assessment; evidence review, Alcohol service framework
|Safer drinking environment
||Medium||Voluntary codes: safer glasses
||Antisocial behaviour orders, on the spot fines
|Public education campaigns
||Low||Change safe drinking message, unit labelling
|School based education
|Voluntary advertising restrictions
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%.
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.
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.
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
93. In the following chapters we deal first with
the role of the NHS and then look at the other measures to reduce
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
The CMO's report drew attention to the extent of alcohol-related
harm, in particular cirrhosis of the liver. Back
Our bold Back
The Government stated that of the 41 actions in the original strategy,
26 have been delivered and a further 14 are underway. Back
AL 01 Back
http://www.drinkaware.co.uk/ /biggest-ever-campaign-to-encourage-responsible-drinking-announced Back
AL 01 Back
Q 45 Back
Q 51 Back
Ev 124-6 Back
AL 13 Back
DH, Sensible Drinking: The Report of an Inter-Departmental
Working Group, 1995. Back
Ev 34 Back
AL 35 Back
AL 20 Back
Ev 171 Back
AL 62A Back