Alcohol - Health Committee Contents


Memorandum by Dr Peter Anderson (AL 58)

AN OVERVIEW OF ALCOHOL AND ALCOHOL POLICIES

  This overview is based on three publications:

    1. Anderson, P., Chisholm, D., & Fuhr, D.C. Reducing the harm done by alcohol. Lancet. 2009. In press.

    2. Anderson P, Baumberg B. Alcohol in Europe. Report for the European Commission. London: Institute of Alcohol Studies, 2006.

    http://ec.europa.eu/health/ph_determinants/life_style/alcohol/documents/alcohol_europe.pdf

    3. Anderson, P. Evidence for the effectiveness and cost-effectiveness of interventions to reduce alcohol-related harm. Copenhagen: World Health Organization Regional Office for Europe. 2009. In press.

HARM DONE BY ALCOHOL

Intoxicant

  Alcohol is an intoxicating drug that affects a wide range of structures and processes in the brain, which, when interacting with personalities and expectations, is a cause of intentional and unintentional injuries and harm to people other than the drinker, including reduced job performance and absenteeism, family deprivation, interpersonal violence, suicide, homicide, crime, and drink driving accidents, and a contributory factor for risky sexual behaviour, sexually transmitted diseases and HIV infection. Estimates vary, but it is suggested that alcohol is a cause of one in three of all injury deaths amongst men aged 20-64 years and one in five of all such deaths in women.

Teratogen

  Alcohol is a potent teratogen with a range of negative outcomes to the foetus, including low birth weight, cognitive deficiencies and foetal alcohol disorders. Although it is difficult to prove whether or not occasional drinking is detrimental during pregnancy, most public health authorities assume no safe level of consumption.

Neurotoxin

  Alcohol is toxic to the brain, leading, in adolescence, to structural changes in parts of the brain that deal with memory, and, in middle age, to shrinkage of the brain.

Dependence producing drug

  Alcohol is a dependence producing drug, similar to other substances under international control, through its reinforcing properties, and subsequent to adaptation by structures in the brain.

Immunosuppressant

  Alcohol suppresses the immune system, increasing the risk of infectious diseases, including tuberculosis and pneumonia.

Carcinogen

  Alcoholic beverages are classified as cancer causing by the International Agency for Research on Cancer, being a cause of cancers of the oral cavity and pharynx, oesophagus, stomach, colon, rectum and breast, with no safe level of consumption.

Coronary heart disease

  Alcohol has a double relation with coronary heart disease. In low, and apparently regular doses (as little as one drink every other day), alcohol reduces the risk of heart disease, although scientific doubt remains about how big this reduction might be, and, at high doses, particularly when consumed in a binge fashion, increases the risk of heart disease and of sudden death from irregularities in the heart rhythm.

Risk of death

  The risk of dying from a chronic alcohol-related condition (such as high blood pressure or cancers) throughout life increases from zero consumption with the amount of alcohol consumed, and from an acute alcohol-related condition (such as accidents) increases from zero consumption with both the frequency of drinking and with the amount drunk on an occasion. The lifetime risk of death rises above one in 100 for both men and women when more than two drinks are drunk on average each day. This level compares with an arbitrary limit often used for environmental toxins of a risk of death of one in 1,000,000, and the lifetime risk of dying in a traffic accident associated with driving 10,000 miles a year in the US of one in 60.

Community impact

  At the level of the community, there is a very close relationship between a community's overall alcohol and its level of alcohol-related harm and alcohol dependence. Deprived communities have an increased risk of harm, even when taking into account individual differences in drinking behaviour.

ALCOHOL POLICIES

  Alcohol policies can be considered as sets of measures aimed at minimizing the health and social harms from the use of alcohol. There are also a variety of other policies which can reduce or increase alcohol-related problems, but which are not normally described as alcohol policies, since they are not implemented specifically to reduce alcohol-related harm as a primary aim, such as general road safety measures.

Information and education

  Providing information and education is important to raise awareness and impart knowledge, but, particularly in a living environment in which many competing messages are received in the form of marketing and social norms supporting drinking, and in which alcohol is readily accessible, do not lead to changes in behaviour. Reviews of hundreds of studies of school-based education have concluded that classroom-based education is not effective in reducing alcohol-related harm. Although there is evidence of positive effects on increased knowledge about alcohol and on improved alcohol related attitudes, there is no evidence for a sustained effect on behaviour.

  The limited available research has shown that industry funded educational programmes tend to lead to more positive views about alcohol and the alcohol industry.

  There have been no rigorous scientific evaluations of whether or not public information campaigns based on drinking guidelines as used in the UK have any impact on alcohol-related harm.

  Evaluation of the impact of health warnings on alcohol product containers do not demonstrate that exposure produces a change in drinking behaviour. These results contrast with evidence from tobacco, where there is evidence of an impact on quitting smoking. Nevertheless, warning labels are important in helping to establish a social understanding that alcohol is a special and hazardous commodity.

Health sector response

  There is extensive evidence for the effectiveness of early identification and brief advice for persons with a risky level of alcohol use in the absence of severe dependence, with evidence that less intensive advice is just as good as more intensive advice. It is difficult to get primary care staff to deliver brief advice, but there is much more evidence and experience of how to do this: one option to consider is at least to get all GPs and practice nurses to run screening and advice programmes in high blood pressure clinics, and reimburse GPs as part of quality paid programmes.

  For individuals with severe alcohol dependence and related problems, a wide variety of specialized treatment approaches have been evaluated, with evidence of good effect for behavioural therapies and pharmacological therapies.

  One of the main problems is that there is an enormous mismatch between need and availability of help (for example, in general practice, it has been estimated that, commonly, less than 10% of the population who drink riskily are identified and less than 5% of those who could benefit are offered brief advice. In England, only one in 18 of alcohol dependent drinkers actually access treatment).

Community programmes

  Community based programmes can include education and information campaigns, controls on selling and other regulations reducing access to alcohol, enhanced law enforcement and surveillance, and community organization and coalition development. Interventions which have controlled access, and which have involved enforcement have been found to be effective in reducing alcohol related traffic fatalities and assault injuries.

Work place programmes

  There is some evidence of a limited impact of work place programmes in changing drinking norms and reducing harmful drinking. A lot more needs to be done to structure work settings to minimize the risk of exacerbating alcohol-related harm, particularly in the current time of the economic crisis.

Drink-driving policies

  There is powerful evidence that lowering the legal blood alcohol concentration (BAC) is effective in reducing drink-driving casualties, provided it is supported by intensive breath testing. There is no evidence that designated driver schemes (where one person is designated as a non-drinking driver) reduce road traffic accidents.

The availability of alcohol

  Government monopolies for the sale of alcohol reduce alcohol-related harm; such systems tend to have fewer stores, which are open for shorter hours than systems of private sellers. Implementation of laws which set a minimum age for the purchase of alcohol show clear reductions in drinking-driving casualties and other alcohol-related harms; the most effective means of enforcement is on sellers, who have a vested interest in retaining the right to sell alcohol. Urban settings, particularly those that promote the night time economy, can be risk factors for harmful alcohol use and harmful patterns of drinking. An increased density of alcohol outlets is associated with increased levels of alcohol consumption amongst young people, with increased levels of assault, and with other harms such as homicide, child abuse and neglect, self-inflicted injury, and, with less consistent evidence, road traffic accidents. While extending times of sale can redistribute the times when many alcohol-related incidents occur, such extensions generally do not reduce rates of violent incidents and often lead to an overall increase in consumption and problems. Following the 2003 Licensing Act in the United Kingdom, which recommended in general that shops, stores and supermarkets be allowed to sell alcohol at any time which they choose to open (24 hours opening), pubs stayed open on average only an extra 27 minutes. No real change in alcohol-related crimes was found up until 3am, but a 22% increase in crimes occurred between 3am and 6am. In other words, alcohol-related crimes were shifted until later in the night. In some studies, changes in the licensing act appeared to have little impact on the numbers of people treated for injuries sustained through assault, although in other studies, there were large increases in the number of night time alcohol-related attendances in accident and emergency departments.

Advertising alcohol

  Alcohol is marketed through increasingly sophisticated advertising in mainstream media, as well as through linking alcohol brands to sports and cultural activities, through sponsorships and product placements, and through direct marketing such as the Internet, podcasting and mobile telephones. The Science Group of the European Commission's Alcohol and Health Forum recently concluded that alcohol marketing increased the likelihood that non-drinking young people will start to drink, and the likelihood that existing young drinkers will drink in a more risky fashion. The effects of advertising exposure seem cumulative: young people who are more exposed are more likely to continue to increase their drinking as they move into their mid-twenties, while drinking declines at an earlier age in those who are less exposed. The international evidence and experience do not suggest that self-regulation implemented by advertising, media and alcohol producers prevents the types and content of marketing that impact on younger people.

Pricing policies

  Drinkers respond to changes in the price of alcohol as they do to changes in the price of other consumer products. When other factors are held constant, such as income and the price of other goods, a rise in alcohol prices leads to less alcohol consumption and less alcohol-related harm and vice versa. The increase in price results in a drop in consumption that is relatively smaller than the price increase; thus, increasing alcohol taxes not only reduces alcohol consumption and related harm, but increases government revenue at the same time, noting that, in general, alcohol taxes are well below their maximum revenue producing potential and that collected revenue is usually well below the social costs of alcohol. If prices are raised, consumers reduce overall consumption and tend to shift to cheaper beverages, with heavier drinkers tending to buy the cheaper products within their preferred beverage category. Policies that increase alcohol prices delay initiation of drinking, slow young people's progression towards drinking larger amounts, and reduce young people's heavy drinking and the volume of per occasion drinking. Price increases reduce the harms caused by alcohol, as well as alcohol dependence. Setting a minimum price per unit of alcohol is modelled to reduce consumption and alcohol-related harm. Both price increases and setting a minimum price will have a much greater impact on heavier rather than lighter drinkers, with modest or only minimal extra financial cost to lighter drinkers.

Drinking environments

  The relationship between drinking and alcohol-related harm can be both affected and mediated by the physical and social context of drinking and by the succeeding contexts while the drinker is intoxicated. There is some evidence that safety-oriented design of bar and club premises and the employment of security staff, in part to reduce potential violence, can reduce alcohol-related harm. Whilst interventions modifying the behaviour of those serving alcohol and of door and security staff are rather limited on their own, there is some evidence for effectiveness when backed up by enforcement by the police.

Reducing the public health impact of illegally and informally produced alcohol

  Unrecorded alcohol, defined as homemade alcohols, illegally produced or smuggled alcohol products as well as surrogate alcohol that is not officially intended for human consumption (mouthwash, perfumes and eau-de-colognes) can have health consequences due to an higher alcohol content and chemical contamination, for which many poisoning outbreaks and fatalities have been recorded internationally, and possibly from some other contaminants which have been attributed to higher rates of liver disease. Illegally traded alcohol can bring a health risk due to either contamination during the trading process or due to a lower cost than legal alcohol, and thus higher consumption. The experience with tobacco smuggling would suggest that the widespread introduction of tax stamps which record that duty has been paid, coupled with electronic movement and surveillance systems to track the trade of alcohol, could reduce illegal trade.

Implications for policy development

  A main goal of alcohol policy is to promote public health and social well-being. In addition, policy can address market failures by deterring children from using alcohol, protecting people other than drinkers from the harm done by alcohol, and providing all consumers with information about the effects of alcohol. Further, the concept of "stewardship" implies that the state has a duty to look after important needs of people individually and collectively. It emphasises the obligation of states to provide conditions that allow people to be healthy and, in particular, to take measures to reduce health inequalities. The stewardship-guided state recognises that a primary asset of a nation is its health: higher levels of health are associated with greater overall well-being and productivity. In the UK, with a long tradition of government regulation of the sale of alcohol, full adoption of evidence-based alcohol policies would be a matter of recovering a lost policy tradition that has been abandoned relatively recently in the face of the deregulatory phase of the past three or so decades.

  Since there are significant commercial interests involved in promoting alcohol's manufacture, distribution, pricing and sale, the alcohol industry has become increasingly involved in the policy arena in order to protect its commercial interests, leading to a common claim among public health professionals that the industry is influential in setting the policy agenda, shaping the perspectives of legislators on policy issues, and determining the outcome of policy debates towards self-regulation. It has been argued that the responsibilities of the alcohol industry in reducing the harm done by alcohol should be related to its product, through, for example, commitments to a minimum pricing structure, and commitments to support reductions in illegally traded alcohol.

  And, finally, effective alcohol policies can be eroded by international trade, trade agreements and cross-border issues. For example, there is substantive evidence that the introduction of a single market for alcohol in the European Union in 2003 resulted in significant tax competition between countries, and thus lower tax rates than would have occurred without a single market.

ABOUT THE AUTHOR

  Dr Anderson is trained as a general practitioner and a specialist in public health medicine at the University of Oxford and the London School of Hygiene and Tropical Medicine. His PhD thesis was on the risk of alcohol. From 1992 to 2000, he worked as the regional advisor for both alcohol and tobacco with the European Office of the World Health Organization. Since 2001, he has worked as a consultant in public health and has been an adviser in the field of addictions to the European Commission, the World Health Organization and several Ministries of Health around the world, including the UK Department of Health. He is the European Editor of the journal Drug and Alcohol Review, President of the international scientific society on brief interventions for hazardous and harmful alcohol consumption, INEBRIA, member of the European Commission's science group on alcohol and health, and advisor to the World Health Organization's expert Committee on alcohol. He is an honorary associate professor at the University of Maastricht in the Netherlands. He has over 120 publications in international peer reviewed journals and is the author or editor of some 15 books.

April 2009





 
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