Conclusions and recommendations
History
1. The
history of the consumption of alcohol over the last 500 years
has been one of fluctuations, of peaks and troughs. From the late
17th century to the mid-19th the trend was for consumption per
head to decline despite brief periods of increased consumption
such as the gin craze. From the mid- to the late 19th century
there was a sharp increase in consumption which was followed by
a long and steep decline in consumption until the mid 20th century.
(Paragraph 29)
2. The variations
in consumption are associated both with changes in affordability
and availability, but also changes in taste. Alternative drinks
such as tea and alternative pastimes affected consumption. Different
groups drank very different amounts. Government has played a significant
role both positive and negative, for example in reducing consumption
in the First World War as well as in stimulating the 18th century
gin craze by encouraging the consumption of cheap gin instead
of French brandy. (Paragraph 30)
3. From the 1960s
consumption rose again. At its lowest levels in the 1930s and
-40s annual per capita consumption was about 3 litres of pure
alcohol; by 2005 it was over 9 litres. These changes are, as in
past centuries, associated with changing fashion and an increase
in affordability, availability and expenditure on marketing. Just
as Government policy played a part in encouraging the gin craze,
successive Government policies have played a part in encouraging
the increase in alcohol consumption over the last 50 years. Currently
over 10 million adults drink more than the recommended limits.
These people drink 75% of all the alcohol consumed. 2.6 million
adults drink more than twice the recommended limits. The alcohol
industry emphasises that these figures represent a minority of
the population; health professionals stress that they are a very
large number of people who are putting themselves at risk. We
share these concerns. (Paragraph 31)
4. One of the biggest
changes over the last 60 years has been in the drinking habits
of young people, including students. While individual cases of
student drunkenness are regrettable and cannot be condoned, we
consider that their actions are quite clearly a product of the
society and culture to which they belong. The National Union of
Students and the universities themselves appear to recognise the
existence of a student binge drinking culture, but all too often
their approach appears much too passive and tolerant. We recommend
that universities take a much more active role in discouraging
irresponsible drinking amongst students. They should ensure that
students are not subjected to marketing activity that promotes
dangerous binge drinking. The first step must be for universities
to acknowledge that they do indeed have a most important moral
"duty of care" to their students, and for them to take
this duty far more seriously than they do at present (Paragraph
32)
5. Since 2004 there
has been a slight fall in total consumption but it is unclear
whether this represents a watershed or a temporary blip as in
the early 1990s. (Paragraph 33)
The impact of alcohol on health, the NHS and Society
6. The
fact that alcohol has been enjoyed by humans since the dawn of
civilization has tended to obscure the fact that it is also a
toxic, dependence inducing teratogenic and carcinogenic drug to
which more than one million people in the UK are addicted. The
ill effects of alcohol misuse affect the young and middle aged.
For men aged between 16 and 55 between 10% and 27% of deaths are
alcohol related, for women the figures are 6% and 15%. (Paragraph
64)
7. Alcohol has a massive
impact on the families and children of heavy drinkers, and on
innocent bystanders caught up in the damage inflicted by binge
drinking. Nearly half of all violent offences are alcohol related
and more than 1.3 million children suffer alcohol related abuse
or neglect. (Paragraph 65)
8. The costs to the
NHS are huge, but the costs to society as a whole are even higher,
all of these harms are increasing and all are directly related
to the overall levels of alcohol consumption within society. (Paragraph
66)
The Government's strategy
9. 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. (Paragraph 88)
10. 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. (Paragraph
89)
11. 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. (Paragraph 90)
12. We are concerned
that Government policies are much closer to, and too influenced
by, that 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. (Paragraph
91)
13. 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. (Paragraph
92)
NHS policies to address alcohol-related problems
14. Alcohol
related-ill health has increased as alcohol consumption has increased,
but there are no more services to deal with these problems. Indeed
in many cases there are fewer, partly as a result of the shift
in resources to addressing dependency on illegal drugs. The most
effective way to deal with alcohol related ill-health will be
to reduce overall consumption, but existing patients deserve at
least as good a service as that provided to users of illegal drugs,
with similar levels of access and waiting times. (Paragraph 142)
15. Early detection
and intervention is both effective and cost effective, and could
be easily built into existing healthcare screening initiatives.
However, the dire state of alcohol treatment services is a significant
disincentive for primary care services to detect alcohol-related
problems at an early stage before the serious and expensive health
consequences of regular heavy drinking have developed. (Paragraph
143)
16. The solution is
to link alcohol interventions in primary and secondary care with
improved treatment services for patients developing alcohol dependency.
In time we believe such a strategy will result in significant
savings for the NHS but will require pump priming and intelligent
commissioning of services. Specifically, the NHS needs to improve
treatment and prevention services as follows
treatment services:
Each PCT should have an alcohol strategy with robust
needs assessment, and accurate data collection.
Targets for reducing alcohol related admissions should
be mandatory.
Acute hospital services should be linked to specialist
alcohol treatment services and community services via teams of
specialist nurses.
There should be more alcohol nurse hospital specialists.
Treatment budgets should be pooled to allow the cost
savings from reduced admissions to be fed back into treatment
and prevention, with centrally provided 'bridge' funding to enable
service development.
Access to community based alcohol treatment must
be improved to be at least comparable to treatment for illegal
drug addiction.
These improved alcohol treatment services must be
more proactive in seeking and retaining subjects in treatment
with detailed long term treatment outcome profiling.
Funding should be provided for the National Liver
Plan.
prevention services:
Improved access to treatment for alcohol dependency
is a key step in the development of early detection and intervention
in primary care.
Clinical staff in all parts of the NHS need better
training in alcohol interventions.
Early detection and brief advice should be undertaken
in primary care and appropriate secondary care and other settings.
Detection and advice should become part of the QOF.
Once detected patients with alcohol issues should
progress through a stepped program of care; seven out of eight
people do not respond to an early intervention and it is these
people who go on to develop significant health issues.
Research should be commissioned into developing early
detection and intervention in young people. (Paragraph 143)
Education and information policies
17. Better
education and information are the main planks of the Government's
alcohol strategy. Unfortunately, the evidence is that they are
not very effective. Moreover, the low level of Government spending
on alcohol information and education campaigns, which amounts
to £17.6m in 2009/10 makes it even more unlikely they will
have much effect. In contrast, the drinks industry is estimated
to spend £600-800m per annum on promoting alcohol. (Paragraph
154)
18. However, information
and education policies do have a role as part of a comprehensive
strategy to reduce alcohol consumption. They do not change behaviour
immediately, but can justify and make people more responsive to
more effective policies such as raising prices. Moreover, people
have a right to know the risks they are running. We recommend
that information and education policies be improved by giving
more emphasis to the number of units in drinks and the desirability
of having a couple of days per week without alcohol. We also recommend
that all containers of alcoholic drinks should have labels, which
should warn about the health risks, indicate the number of units
in the drink (eg 9 units in a bottle of wine), and the recommended
weekly limits, including the desirability of having two days drink-free
each week. We doubt whether a voluntary agreement would be adequate.
The Government should introduce a mandatory labelling scheme.
(Paragraph 155)
Marketing
19. The
current system of controls on alcohol advertising and promotion
is failing the young people it is intended to protect. The problem
is more the quantity of advertising and promotion than its content.
This has led public health experts to call for a ban. It is clear
that both the procedures and the scope need to be strengthened.
(Paragraph 204)
20. The regulation
of alcohol promotion should be completely independent of the alcohol
and advertising industries; this would match best practice in
other fields such as financial services and professional conduct.
In addition young people should themselves be formally involved
in the process of regulation: the best people to judge what a
particular communication is saying are those in the target audience.
(Paragraph 205)
21. The current controls
do not adequately cover sponsorship, a key platform for alcohol
promotion; the codes must be extended to fill this gap. The enquiry
also heard how dominant new media are becoming in alcohol promotion
and the particular regulatory challenges they present, including
the inadequacy of age controls and the problems presented by user
generated content. Expert guidance should therefore be sought
on how to improve the protection offered to young people in this
area. (Paragraph 206)
22. Finally, there
is a pressing need to restrict alcohol advertising and promotion
in places where children are likely to be affected by it. Specifically:
Billboards and posters should not be located
within 100 metres of any school (there used to be a similar rule
for tobacco).
A nine o'clock watershed should be introduced
for television advertising. (The current restrictions which limit
advertising around children's programming fail to protect the
relatively larger proportions of children who watch popular programmes
such as soaps).
Cinema advertising for alcohol should be restricted
to films classified as 18.
No medium should be used to advertise alcoholic
drinks if more than 10% of its audience/readership is under 18
years of age (the current figure is 25%).
No event should be sponsored if more than
10% of those attending are under 18 years of age
There must be more effective ways of restricting
young people's access to new media which promote alcohol
Alcohol promotion should not be permitted
on social networking sites.
Notwithstanding the inadequacies of age restrictions
on websites, they should be required on any site which includes
alcohol promotionthis would cover the sites of those receiving
alcohol sponsorship. This rule should also be extended to corporate
alcohol websites. Expert guidance
should be sought on how to make these age controls much more effective.
Alcohol advertising should be balanced by
public health messaging. Even a small adjustment would help: for
example, for every five television ads an advertiser should be
required to fund one public health advertisement. (Paragraph 207)
Licensing, binge-drinking, crime and disorder
23. Alcohol-related
crime and anti-social behaviour have increased over the last 20
years as a result of the development of the night time economy
with large concentrations of vertical drinking pubs in town centres;
under-age drinkers in the streets have also caused problems. The
Alcohol Strategy 2004 recognised these problems and claimed that
they were being addressed by a number of measures including the
Licensing Act 2003. In addition, the alcohol industry established
voluntary standards to govern the promotion and sale of alcohol.
(Paragraph 248)
24. The worst fears
of the Act's critics were not realised, but neither was the DCMS's
naive aspiration of establishing cafe society: violence and disorder
have remained at similar levels, although they have tended to
take place later at night. The principle of establishing democratic
control of licensing was not realised: the regulations governing
licensing gave the licensing authorities and local communities
too little control over either issuing or revoking licences, as
ACPO indicated. KPMG examined the alcohol industry's voluntary
code and found it had failed. (Paragraph 249)
25. Problems remained
and the 2007 Strategy introduced new measures. Partnership schemes
such as the St Neots Community Alcohol Partnership were established.
The main changes are being introduced by the Policing and Crime
Act 2009 which gives the police greater powers to confiscate alcohol
from under 18s, introduces a mandatory code in place of the industry's
voluntary code and has made it easier to review licences, giving
local authorities the right to instigate a review. We support
the introduction of mandatory conditions and urge the Government
to implement them as a matter of urgency. (Paragraph 250)
26. Despite the recent
improvements, much needs to be done given the scale of alcohol-related
disorder. It is of concern that section 141 of the Licensing Act
2003, which creates the offence of selling alcohol to a person
who is drunk, is effectively not enforced despite KPMG's finding
that this behaviour is frequently observed. We note the police
and Home Office's preference for partnerships and training, but
do not consider these actions should be an excuse for not enforcing
a law which could make a significant difference to alcohol-related
crime and disorder. We call on the police enforce s.141 of the
Licensing Act 2003 more effectively. (Paragraph 251)
27. We note the concerns
of ACPO and other witnesses about the difficulties local authorities
have in restricting and revoking licences. The Government has
made some improvements in the Policing and Crime Act 2009, but
must take additional measures. (Paragraph 252)
28. In Scotland legislation
gives licensing authorities the objective of promoting public
health. Unfortunately, public health has not been a priority for
DCMS. We recommend that the Government closely monitor the operation
of the Scottish licensing act with a view to amending the Licensing
Act 2003 to include a public health objective. (Paragraph 253)
Supermarkets and off-licence sales
29. Over
recent decades an ever increasing percentage of alcohol has been
bought in supermarkets and other off-licence premises. Such purchases
exceed those made in pubs and clubs by a large margin. The increase
in off-licence purchases has been associated with the increasing
availability of, promotions of, and discounting of alcohol. Heavily
discounted and readily available alcohol has fuelled underage
drinking, led to the phenomenon of pre-loading where young people
drink at home before they go out and encouraged harmful drinking
by older people. (Paragraph 279)
30. Some areas have
very large numbers of off-licences open for long hours. There
are also too many irresponsible off-licences. Addressing this
problem will require both better enforcement and improvements
to the licensing regime. A public health objective in the licensing
legislation would apply to off-licences as well as pubs and clubs
and could be used to place limits on the number of outlets in
an area. This aspect of the Scottish licensing legislation should
be closely monitored with a view to its implementation in England.
(Paragraph 280)
31. Although they
acknowledged that alcohol was a dangerous commodity, supermarkets
told us that they used discounts and alcohol promotions because
they were engaged in fierce competition with each other. In some
cases, it is possible to buy alcohol for as little as 10p per
unit. At this price, the maximum weekly recommended 15 units for
a woman can be bought for £1.50p. This is not a responsible
approach to the sale of alcohol. Retail outlets should make greater
efforts to inform the public of the dangers of alcohol at the
point of sale. (Paragraph 281)
32. The Scottish Government
has introduced controls on promotions including restricting alcohol
to one aisle. These measures should be instituted in England.
(Paragraph 282)
Prices: taxes and minimum prices
33. The
consumption of alcohol, like that of almost all other commodities,
is sensitive to changes in price as all studies have shown. Because
some countries with high alcohol prices have high levels of per
capita consumption and vice versa some countries with low levels
of consumption have low prices, it is sometimes implied that alcohol
sales do not respond to price changes. This is economic illiteracy.
Different countries, like different people and groups, respond
differently to price, but they all respond. Studies have shown
varying elasticities of demand. The increase in alcohol consumption
over the last 50 years is very strongly correlated with its increasing
affordability. (Paragraph 325)
34. Increasing the
price of alcohol is thus the most powerful tool at the disposal
of a Government. The key argument made by the drinks industry
and others opposed to a rise in price is that it would be unfair
on moderate drinkers. We do not think this is a serious argument.
The Sheffield study found that for the moderate drinker consuming
6 units per week a minimum price of 40p per unit would increase
the cost by about 11p per week. At 40p per unit a woman drinking
the recommended maximum of 15 units could buy her weekly total
of alcohol for £6. (Paragraph 326)
35. Opponents also
claim that heavier drinkers are insensitive to price changes,
but these drinkers will be most affected by price rises since
they consume so much of the alcohol purchased in the country (10%
of the population drink 44% of the alcohol consumed; 75% of alcohol
is drunk by people who exceed the recommended limits). (Paragraph
327)
36. We believe that
the Government should introduce minimum pricing for the following
reasons:
- It would affect most of all
those who drink cheap alcohol, in particular young binge-drinkers
and heavy low income drinkers who suffer most from liver disease.
- It is estimated that a minimum price of 50p per
unit would save over 3,000 lives per year, of 40p 1,100 lives
per year.
- Unlike rises in duty (which could be absorbed
by the supermarkets' suppliers and which affect all sellers of
alcohol) it would benefit traditional pubs and discourage pre-loading.
For this reason it is supported by CAMRA.
- It would encourage a switch to weaker wines and
beers. (Paragraph 328)
37. However,
without an increase in duty minimum pricing will lead to an increase
in the profits of supermarkets and the drinks industry and an
increase in marketing, promotions and non-price competition. The
Treasury must take into account public health when determining
levels of taxation on alcohol as it does with tobacco. Alcohol
duty should continue to rise year on year above incomes, but unlike
in recent years duty increases should predominantly be on stronger
alcoholic drinks notably on spirits. (Paragraph 329)
38. The duty on spirits
per litre of pure alcohol was 60% of male average manual weekly
earnings in 1947; in 1973 (when VAT was imposed in addition to
duty) duty was 16% of earnings; by 1983 it was 11% and by 2002
it had fallen to 5%. We recommend that in stages the duty on spirits
be returned in stages to the same percentage of average earnings
as in the 1980s. Cider is an extraordinary anomaly; the duty on
industrial cider should be increased. To protect small real cider
producers, their product should be subject to a lower duty. Beer
under 2.8% can be taxed at a different rate: we recommend that
duty be reduced on these weak beers; although at present there
a few producers of beers of this strength, the cut should encourage
substitution. (Paragraph 330)
39. In the longer
run the Government should seek to change EU rules to allow higher
and more logical levels of duty on stronger wines and beers; it
should also seek to raise the strength of beer which can be subject
to a lower duty rate from 2.8 to slightly higher levels. (Paragraph
331)
40. The introduction
of minimum pricing would encourage producers to intensify their
marketing. This will make it all the more important to control
marketing. (Paragraph 332)
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