Health Committee - The Government's Alcohol StrategyWritten evidence from the British Medical Association (GAS 33)

About the BMA

The BMA is an independent trade union and voluntary professional association which represents doctors and medical students from all branches of medicine throughout the UK. With a membership of over 149,000 worldwide, we promote the medical and allied sciences, seek to maintain the honour and interests of the medical profession and promote the achievement of high quality healthcare.

Our members witness firsthand the devastating effects of alcohol on their patients, from disturbances in accident and emergency (A&E) departments to the acute and chronic harm caused to individual drinkers and those around them. The BMA has called for the implementation of wide-ranging measures that will reduce alcohol consumption across the population, rather than policies targeted at irresponsible drinkers alone.

Executive Summary

The scale of alcohol consumption in England represents a significant cause of medical, psychological and social harm, and is placing an unsustainable burden on the NHS. This is not caused by binge drinkers alone but is as a result of the high level of consumption across the population.

The BMA welcomes some aspects of the Government’s strategy, acknowledging positive aspects such as the recognition of the need to take action on price and availability. The BMA strongly believes that insufficient attention has been given to the management of harmful alcohol use or population-level measures to reduce chronic health harms and per capita consumption. A comprehensive strategy to tackle alcohol harm is required, and the BMA believes that this should give a voice to Government intervention and should not rely wholly on voluntary agreements with industry.

In order to reduce the affordability of alcohol, further increases in alcohol duty are needed, along with the rationalisation of the tax system to favour lower strength products. A minimum price for the sale of alcohol should be set at no less than 50p per unit.

While the new local licensing powers are welcome, stronger action is required through a national directive to reduce licensing hours for on- and off-licensed premises.

In light of the impact alcohol marketing has on young people’s drinking and the ineffectiveness of the existing regulatory framework, there should be a comprehensive ban on all alcohol marketing communications.

Alcohol education programmes should only be used to supplement policies that are effective at altering drinking behaviour, and to promote public support for comprehensive alcohol control measures. The continued reliance on the Drinkaware Trust to provide public health communications on alcohol is counterproductive, and should be replaced by information from a genuinely independent body.

With the lack of progress on voluntary agreements for product labelling, there should be a mandatory requirement to show unit information, alcohol guidelines, advice on alcohol-free days, and a health warning message on all product labels, printed and electronic marketing material, and at the point of sale.

The commitment to improve the identification of individuals at risk of harm is welcome, but there should be greater emphasis in the strategy on providing comprehensive treatment services for individuals who develop alcohol problems. Further assessments of the need for alcohol treatment services are required to ensure demand is matched by provision and funding.

As a consequence of reforms to the NHS, safeguards are needed to ensure public health expertise is retained at a local level to advise local authorities and licensing bodies on all aspects of alcohol policy.

Introduction

1. Alcohol is the nation’s favourite drug and its consumption in moderation can lead to feelings of relaxation and euphoria but it is also an addictive, powerful drug, capable of causing serious harm. Consumption in large doses manifests itself in aberrant behaviour as well as acute and chronic toxicity and doctors want an increased understanding of this. The BMA has repeatedly called for tough action to reduce alcohol-related harm and prevent generations of young people from growing up in a pro-alcohol society.

2. Alcohol consumption has increased steadily in the UK over the past 60 years.¹ Since 1990, the average amount drunk each year by adults (aged over 15) in the UK increased from 9.8 litres of pure alcohol per head to a peak of 11.5 litres in 2004, and subsequently declined to 10.2 litres in 2009.¹ It is difficult to assess the amount the average drinker consumes given that the proportion of the population abstaining from alcohol (predominantly for religious or cultural reasons) is increasing.² This suggests that average amount drunk per drinker may not have decreased.

3. Survey data have found that a significant proportion of the population consume alcohol above recommended amounts. In England in 2009, 37% of men and 29% of women drank more than the recommended daily amount in the last week, with 20% of men and 13% of women consuming double this level.³ Twenty-six per cent of men and 18% of women consumed more than recommended weekly amounts in an average week.³ For men this was highest in the 45–64 age group, followed by the 25–44 age group and the 16–24 age group.³ For women it was highest in the 16–24 age group, followed by the 45–64 age group and the 25–44 age group.³

4. These data illustrate that excessive alcohol consumption is not a problem restricted to young people binging to excess, but that the population as a whole is drinking in a way that is causing significant health and social harm (see Figure 1). The high levels of consumption are particularly significant given the dose-response relationship that exists with alcohol consumption, where increased consumption is directly related to an increased risk of premature death, cancer, and cerebrovascular disease.^{4, 5, 6}

Figure 1

OVERVIEW OF THE BURDEN OF ALCOHOL-RELATED HARM

Alcohol is causally related to over 60 different medical conditions.^{5, 6} The acute direct and indirect harms include intoxication, alcohol poisoning, unsafe sex, and accidents and injuries, while chronic consumption can cause dependence, liver cirrhosis, alcoholic psychoses, alcoholic cardiomyopathy, polyneuropathy and gastritis.^{5, 6, 7}

In 2009–10 there were over one million alcohol-related admissions to hospital, which is a 12% increase from 2008–09 and over double the number in 2002–03.³

Deaths directly attributable to alcohol have doubled in the UK in the last two decades, from 6.7 per 100,000 population in 1992 to 12.9 per 100,000 in 2010.⁸

In 2010, there were nearly 6,630 road traffic casualties as a result of drink driving, in which 250 people were estimated to be killed and 1,230 seriously injured.⁹

Alcohol consumption is a contributory factor in domestic violence incidents, child abuse and in criminal and disorderly behaviour.⁷

The total annual cost of alcohol-related harm in England has been estimated to range from £20 billion to £55 billion,^{10, 11} with the annual cost to the NHS (using 2006/7 prices) estimated at £2.7 billion.¹²

BMA View of the Government’s Alcohol Strategy and the Role of the Alcohol Industry

5. The BMA believes there are a number of positive aspects in the Government’s alcohol strategy, including recognition of the need to take action on the price and availability of alcohol. We are, however, concerned that the primary aim is to tackle irresponsible drinking, in particular bingeing to excess. This has resulted in a disproportionate focus on reducing acute social problems such as alcohol-related crime and disorder. Insufficient attention has been given to the need to reduce per capita alcohol consumption and the unmanageable burden alcohol is placing on the health and wellbeing of the population. Focusing on the binge pattern of drinking fails to recognise the strong relationship between total population alcohol consumption and the prevalence of harmful consumption.¹³ As a nation, we have a collective responsibility to reduce alcohol consumption, rather than targeting irresponsible drinkers alone. As set out elsewhere in this submission, there is a need for tougher population-level measures to reduce the affordability and accessibility of alcohol, as well as limiting alcohol marketing and promotion. More focus is needed on providing comprehensive treatment services for individuals who develop problems with alcohol.

6. The BMA is extremely concerned that a core component of the strategy is partnership working with the alcohol industry, as this has at its heart a fundamental conflict of interest that does not adequately address public health. The greater the emphasis on partnership with the industry, the more likely it is that policy makers will veer toward the use of ineffective policies. This is illustrated by the responsibility deal on alcohol where the public health organisations had not been given an equal voice compared to the industry in the formation of the network’s pledges. This led to a set of weak proposals that the BMA was not willing to endorse and therefore declined the invitation to sign up to the initiative. While the alcohol industry has a role to play, this should only be when a strategy is in place and regulations are being implemented.

The BMA recommends:

That greater attention needs to be given to the management of harmful alcohol use or population-level measures to reduce chronic health harms and per capita consumption.

That a comprehensive strategy to tackle alcohol harm is adopted, and believes that this should give a voice to Government intervention and should not rely wholly on voluntary agreements with industry.

Responsibility within Government for Alcohol Policy

7. Effectively reducing the high levels of alcohol-related harm requires a cross-government alcohol strategy that places the protection and promotion of public health at the heart of all policy decisions. The new strategy contains a number of robust measures to tackle crime, disorder and violence under the responsibility of the Home Office. Key areas where stronger measures are required are taxation and licensing—two of the most effective alcohol control measures. Despite strong and consistent evidence that increases in the price of alcohol are associated with reduced consumption and harm, the HM Treasury has made only limited changes to duty levels since the mid-1990s (see paragraph 10). In line with the evidence that increased opening hours are associated with higher levels of consumption and harm, the BMA believes a stronger stance is required from the Home Office at a national level to reduce licensing hours (see paragraph 14).

8. The strategy appears to lack significant input from the Department of Health as limited attention is given to the management of harmful alcohol use or population-level measures to reduce chronic health harms. We also note with concern that the strategy omits any action on drink driving.

9. With the development of different approaches to reducing alcohol-related harm in the devolved nations, cross-border partnership working is essential to ensure there is a coordinated approach throughout the UK. This will also facilitate learning from, and taking advantage of, policy developments between nations.

The BMA recommends:

That a cross governmental approach is taken to tackling alcohol related harm, and believes that more attention needs to be given to:

tackling the burden alcohol places on the health and wellbeing at a population level;

using taxation more effectively to reduce overall consumption; and

reducing licensing hours.

Specific Policy Interventions

Reducing the affordability of alcohol

10. There is strong and consistent evidence that increases in the price of alcohol are associated with reduced consumption and alcohol-related harm at a population level.^{6, 13–28} Heavy drinkers and young drinkers are known to be especially responsive to price.^{15, 17, 29–32}

11. The affordability of alcohol in the UK has increased significantly due to the widening gap between household disposable income and alcohol prices.^{3, 33, 34} At the same time, duty levels have remained relatively static: between 1997 and 2007, duty on beer and wine was only adjusted for inflation, and duty on spirits did not increase at all.³⁵ Although the BMA notes the commitment to increase alcohol duty at two% above inflation annually to 2014–15, further increases are needed to significantly reduce the affordability of alcohol and lower population-level consumption. This could be achieved by a significant increase in duty levels on all alcohol products (eg in the region of 10%), with continued annual increases above inflation.

12. There is also a need for further rationalisation of the duty system to reduce the comparative affordability of higher strength products. The commitment to support a change in EU regulations to tax wine proportional to its alcoholic content is welcome; similar changes are needed for cider. The narrowing of existing duty bands for beer, cider and wines, and the introduction of narrow duty bands for spirits, should also be used to favour lower strength products.

13. The BMA welcomes the commitment to introduce a minimum price per unit as a way of tackling the deep discounting of alcohol in the off-trade, which is known to encourage consumption and undermine the effectiveness of tax-based approaches. It will also encourage alcohol to be consumed in the on-trade (where there are stronger controls on its use) rather than the off-trade, by reducing the price differentials for the sale of alcohol between these two settings. A minimum price per unit strategy is preferable to other pricing policies because it targets cheap drinks, has a disproportionate effect on heavier drinkers, and is unlikely to be significantly regressive when the effects are considered for the whole population.^{14, 15, 36–40} Modelling has found that increasing the level of a minimum price per unit leads to steep reductions in alcohol consumption and harm (see Figures 2 and 3).^{38, 41–44} In reviewing available research, the BMA Board of Science concluded that a minimum price for the sale of alcohol should be set at no less than 50p per unit.

14. The BMA welcomes the commitment to introduce a ban on multi-buy promotions as a way of reducing irresponsible retailing in the off-trade. This could be expanded to include multi-buy discounts in the on-trade.

Figure 2

INCREASES IN MINIMUM PRICE PER UNIT AND PERCENTAGE CHANGE IN CONSUMPTION⁴¹

Minimum price per unit	Percentage change in consumption
20p	0.0
25p	−0.1
30p	−0.4
35p	−1.1
40p	−2.4
45p	−4.3
50p	−6.7
60p	−11.9
70p	−17.7

Figure 3

COMPARISON OF THE IMPACT OF A MINIMUM PRICE PER UNIT AT 40P AND 50P ON VARIOUS OUTCOMES AFTER 10 YEARS⁴¹

Outcome	Minimum price per unit level
	40p	50p
Alcohol-related hospital admissions	39,400 fewer admissions per annum	97,700 fewer admissions per annum
Alcohol-related crimes	10,100 fewer offences per annum	42,500 fewer offences per annum
Alcohol-related absenteeism from work	133,600 fewer days absent per annum	442,300 fewer days absent per annum
Unemployment due to alcohol problems	11,500 avoided cases of unemployment per annum	25,900 avoided cases of unemployment per annum

The BMA recommends:

Duty levels on alcohol need to increase significantly in order to reduce the affordability of alcohol and lower population-level consumption.

That the tax system is rationalised so the excise duty levied on alcohol is proportionate to the amount of alcohol in the product.

A minimum price per unit of no less than 50p should be set.

That a ban on multi-buy promotions be introduced to reduce irresponsible retailing in the on- and off-trade.

Restricting access to alcohol

15. There is strong evidence that increased opening hours and a high density of outlets are associated with increased alcohol consumption and alcohol-related problems.^{6, 13, 19, 45–55} The BMA welcomes the new powers to allow local authorities to control the density of licensed premises, make health a licensing objective, review licenses, and restrict alcohol sales. We believe that the liberalisation of licensing legislation in recent years (including the introduction of the Licensing Act 2003 which permits 24-hour sales) requires stronger action through a national directive to reduce licensing hours for on- and off-licensed premises.

16. There is also a need to assess the impact of the emergence of “pubcos” on alcohol consumption and harm. These companies buy up and let pubs to prospective landlords, charging them high rents and tying them in to expensive supply contracts. The resulting high costs and narrow margins result in increased pressure on landlords to maximise sales. There is concern that this may be encouraging excessive consumption, and lowering the commitment to important measures such as not serving those who are intoxicated.

The BMA recommends:

That an assessment of the impact the commercial practices of companies that own pubs has on alcohol consumption and harm is made.

Marketing, promotion and product development

17. A substantial body of research has found that alcohol advertising and promotion influences the onset, continuance and amount of alcohol consumption among young people.^{14, 26, 56–58} This includes all major forms of mass media advertising—press, television and billboards—as well as broader marketing communications such as sponsorship, merchandising and product placement. These all have a cumulative effect of generating a pro-alcohol social norm and limiting the effectiveness of public health messages—the more common and acceptable young people think drinking is, the more likely they are to drink and to consume alcohol in greater quantities.^59–65

18. The BMA is disappointed that the new strategy has not strengthened existing controls on alcohol advertising. The use of co-regulation and self-regulation is an entirely inadequate response to the impact alcohol marketing communications has on young people’s drinking. This system of regulation has a number of major weaknesses:

With the exception of the pre-vetting of television advertisements, regulatory controls are only applied after an advertisement has been run and a complaint has been made.

The penalties for transgressions are minimal and do not act as an effective deterrent.

The reliance on public complaint is of limited effectiveness in an increasingly fragmented media market place where the target audience is unlikely to be a critical audience.

The focus on content cannot adequately address promotion in the form of associations (eg sports sponsorship clearly draws connections between alcohol and sporting success).

Objections can be made on the style, language or design of a particular advertisement, but not on the volume of advertising.

19. Given the link between alcohol marketing, social norms and young people’s drinking, as well as the ineffectiveness of co-regulation and self-regulation, the BMA believes there should be a comprehensive ban on all alcohol marketing communications.

20. There has been an unprecedented increase in the number of new alcohol products and associated marketing and promotional activities in recent years. This has made it difficult to maintain a clear indication of the range of available products. Numerous studies have examined how new alcoholic drinks have directly met the needs of various segments of the youth market, are very popular with them, and can contribute to heavier drinking and to lowering the age of onset of drinking.^66–72 The BMA believes that a full audit of the market should be conducted, and consideration given to how any drinks that either appeal to young people more than adults, or are particularly associated with problematic drinking, are removed.

The BMA recommends:

That a comprehensive ban on all alcohol marketing communications is introduced.

Education and information

21. Alcohol education programmes can have an effect on raising awareness, increasing knowledge and modifying attitudes. They are not effective in changing drinking behaviour.^{6, 13, 17, 18, 21, 73–84} The BMA believes it is essential that the disproportionate focus on educational programmes in the strategy is redressed. Educational strategies should only be used to supplement other policies that are effective at altering drinking behaviour, and to promote public support for comprehensive alcohol control measures.

22. The involvement of the Drinkaware Trust in providing public health communications is a significant area of concern. This form of industry social marketing is counterproductive because industry responsibility campaigns are less effective than ones from other sources, keep messages in a commercial comfort zone, and distract attention away from more effective measures to regulate alcohol use.^{85, 86} Industry-related messages about alcohol have been found to subtly enhance sales and company reputations.^{87, 88} This is despite the fact that the public is cynical about the motives of corporate sponsors, and that non-governmental organisations make a more effective and credible source.^{89, 90} There is also evidence that alcohol companies avoid the use of messages focusing on the harmful consequences of irresponsible drinking,⁹¹ and set their messages within a “drinking as normal” context.⁹² The Drinkaware Trust, for example, states that “We promote responsible drinking and find innovative ways to challenge the national drinking culture to help reduce alcohol misuse and minimise alcohol-related harm”.⁹³ This overlooks the possibility that abstinence may be the best option for some people all the time, and for all people some of the time. It also reinforces the idea of safe limits rather than relative risks, and maintains that problems only arise when people use the product in certain ways. The BMA believes that health promotion, such as guidance and advice on responsible drinking, should only be provided by a genuinely independent public health body, and not through industry-sponsored social marketing, or by individual drinks companies. This should be funded by a compulsory levy on the alcohol industry, set as a proportion of current expenditure on alcohol marketing.

The BMA recommends:

Health promotion guidance, including information on responsible drinking, should only be provided by a genuinely independent public health body.

Labelling and drinking guidelines

23. The BMA welcomes the decision to review the alcohol guidelines as this will provide a useful opportunity to ensure there is clear and consistent messaging regarding the health harms of alcohol consumption and the importance of alcohol-free days.

24. While most people are aware of the existence of alcohol guidelines, few can accurately recall them, understand them, or appreciate the relationship between units, glass sizes and drink strengths.^{21, 94–96} Labelling of alcoholic products provides a useful method for raising awareness about and understanding of alcohol guidelines.^{13, 97, 98} As insufficient progress has been made on product labelling through voluntary agreements,⁹⁹ the BMA believes that it should be a mandatory requirement to label all products to show unit information, alcohol guidelines, advice on alcohol-free days, and a health warning message. This information should also be readily available at the point of sale (through the use of standardised posters), and in all printed and electronic material.

The BMA recommends:

That it should be a mandatory requirement to label all alcoholic products to show unit information, alcohol guidelines, advice on alcohol-free days, and a health warning message. This information should also be readily available at the point of sale and in all printed and electronic material.

Reducing the strength of alcoholic beverages

25. In principle the BMA supports the commitment to reduce the strength of alcoholic beverages through reformation and smaller product sizes. As noted in paragraph 14, this should be supported by tax incentives that favour lower strength products. Controls will be required to ensure this leads to the substitution of high strength products by lower strength versions (rather than the development of an additional market), and that it is not used as a marketing opportunity to promote lower strength products (eg as “a healthier option”).

Raising the legal drinking age

26. Research from North America has found that regulating access to alcohol through restrictions on the legal age of consumption and purchase is an effective strategy for preventing alcohol-related health and social problems among young people.^{13, 19, 100–106} While it is illegal for anyone under 18 to buy alcohol, attempt to buy alcohol, or to be sold alcohol in the UK,1 the legal age for consumption is five, provided it is on private premises and parental consent is given. In light of the evidence from America and the disparity in the legal drinking age for the purchase and consumption of alcohol, consideration could be given to reviewing the legal age of consumption.

Drink driving

27. The BMA has repeatedly highlighted the need for further measures to reduce the number of people killed or seriously injured as a result of drink driving. This includes a reduction in the legal alcohol limit from 80mg/100ml to 50mg/100ml, with consideration for further reductions for newly qualified drivers.

Early intervention and treatment

28. The BMA welcomes the commitment to improve the identification of individuals at risk of harm from alcohol through the use of evidence-based screening tests and brief advice¹⁰⁷ where this is clinically appropriate. This will require adequate funding and resources, and comprehensive training and guidance for all healthcare professionals. The BMA has previously objected to alcohol being an indicator in the Quality and Outcomes (QOF) framework, and supported the implementation of a directed enhanced service (DES) or locally enhanced service (LES), which can achieve the same goal, and has the advantage of ensuring equal service provision.

29. The BMA believes there is insufficient focus in the strategy on the referral, management and treatment of individuals with alcohol problems or who are alcohol dependent. Further emphasis is needed on the recommendations from the National Institute of Health and Clinical Excellence (NICE) on the assessment of, and interventions for, harmful drinking and alcohol dependence, as well as alcohol-related physical complications.^108–111 We also urge the Government to publish its National Liver Disease Strategy that has been subject to continued delays since it was first announced in October 2010.

30. The BMA is concerned about the inadequate provision of specialised alcohol treatment services highlighted by the 2004 Alcohol Needs Assessment Research Project (ANARP).¹¹² It is essential that further assessments of the need for alcohol treatment services are undertaken, to ensure there is adequate provision of, and funding for, services to support individuals who have severe alcohol problems or who are alcohol dependent.

The BMA recommends:

That greater provision for the referral, management and treatment of individuals with alcohol problems or who are alcohol dependent is offered as part of a comprehensive strategy.

Impact of the NHS Reforms

31. The reforms to the public health service are the largest in a generation and are occurring as the entire NHS is being reformed. The relationship between the reforms to public health and the wider NHS has been complicated by the overlapping timescales of the reforms. Many important aspects of the changes to the delivery of public health form an integral part of the Health and Social Care Act. The Government’s plan to place Public Health England within the Department of Health causes several interrelated and unnecessary problems. With other elements of public health being transferred to local authorities, and possibly other bodies such as the NHS Commissioning Board or clinical commissioning groups, such a move risks fragmentation of public health.

32. As yet it is not possible to make a full assessment on whether the reforms will support an integrated approach to future planning of services for people who experience alcohol-related harm. However, the BMA believes that it is essential that public health expertise is retained at a local level to advice local authorities and licensing bodies on the impact of decisions on public health, as well as to inform the development of local alcohol prevention programmes, needs assessments and the commissioning of treatment services.

References

1. British Beer and Pub Association (2010). Statistical handbook 2010. London: Brewing Publications Limited.

2. Office for National Statistics (2011). Smoking and drinking among adults, 2009. A report on the 2009 General Lifestyle Survey. Newport: Office for National Statistics.

3. The Health and Social Care Information Centre (2011). Statistics on alcohol: England, 2011. London: The Health and Social Care Information Centre.

4. Boffetta P & Garfinkel L (1990). Alcohol drinking and mortality among men enrolled in an American Cancer Society prospective study. Epidemiology 1: 342–8.

5. Rehm J, Room R, Graham K et al (2003). The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview. Addiction 98: 1209–28.

6. Room R, Babor T & Rehm J (2005). Alcohol and public health. The Lancet 365: 519–30.

7. British Medical Association (2008). Alcohol misuse: tackling the UK epidemic. London: British Medical Association.

8. Office for National Statistics (2012). Alcohol-related deaths in the United Kingdom, 2010. Newport: Office for National Statistics.

9. Department for Transport (2011). Reported Road Casualties in Great Britain: 2010 provisional estimates for accidents involving illegal alcohol levels. London: Department for Transport.

10. Prime Minister’s Strategy Unit (2004). Alcohol harm reduction strategy for England. London: Prime Minister’s Strategy Unit.

11. Lister G (2007). Evaluating social marketing for health—the need for consensus. Proceedings of the National Social Marketing Centre, 24–25 September, Oxford.

12. Department of Health (2008). The cost of alcohol harm to the NHS in England. London: Department of Health.

13. Babor T, Caetano R, Casswell S et al (2010). Alcohol: no ordinary commodity (Second edition). New York: Oxford University Press.

14. Booth A, Meier P, Stockwel T et al (2008). Independent review of the effects of alcohol pricing and promotion. Part A: Systematic Reviews. Sheffield: School of Health and Related Research, University of Sheffield.

15. Brennan A, Purshouse R, Taylor K et al (2008). Independent review of the effects of alcohol pricing and promotion. Part B: modelling the potential impact of pricing and promotion policies for alcohol in England. Sheffield: School of Health Related Research, University of Sheffield.

16. Heeb J, Gmel G, Zurbrugg C et al (2003) Changes in alcohol consumption following a reduction in the price of spirits: a natural experiment in Switzerland. Addiction 98: 1433–46.

17. Edward G, Anderson P, Babor TF et al (1994). Alcohol policy and the public good. Oxford: Oxford University Press.

18. Plant M, Single E & Stockwell T (1997). Alcohol: minimising the harm. What works? London: Free Association Books.

19. Raistrick D, Hodgeson R & Ritson B (1999). Tackling alcohol together: The evidence base for UK alcohol policy. London: Free Association Books.

20. Elder R W, Lawrence B, Ferguson A et al (2010). The effectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms. American Journal of Preventive Medicine 38: 217–229.

21. Plant M A & Plant M L (2006). Binge Britain: alcohol and the national response. Oxford: Oxford University Press.

22. Cooke P J & Tauchen E (1982). The effect of liquor taxes on heavy drinking. Bell Journal of Economics 13: 379–90.

23. Saffer H & Grossman M (1987). Beer taxes, the legal drinking age, and youth motor vehicle fatalities. Journal of Legal Studies 16: 351–74.

24. Koski A, Sirén R & Vuori E (2007). Alcohol tax cuts and increase in alcohol-positive sudden deaths—a time-series intervention analysis. Addiction 102: 362–8.

25. Matthews K, Jonathan Shepherd J & Sivarajasingham V (2006) Violence-related injury and the price of beer in England and Wales. Applied Economics 38: 661–70.

26. Anderson P, de Bruijn A, Angus K et al (2009). Impact of alcohol advertising and media exposure on adolescent alcohol use: a systematic review of longitudinal studies. Alcohol and Alcoholism, 44: 229–43.

27. Wagenaar A C, Salois M J & Komro, K A (2008). Effects of beverage alcohol taxes and prices on consumption—a systematic review and meta-analysis of 1003 estimates from 112 Studies. Presented at the 34th Annual Alcohol Epidemiology Symposium of the Kettil Bruun Society for Social and Epidemiological Research on Alcohol, Victoria, British Columbia, June 2–6, 2008.

28. Wagenaar A C, Salois M J & Komro K A (2009). Effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies. Addiction 104: 179–90.

29. Sutton M & Godfrey C (1995). A grouped data regression approach to estimating economic and social influences on individual drinking behaviour. Health Economics 4: 237–47.

30. Grossman M, Coate D & Arluck G M (1987). Price sensitivity of alcoholic beverages in the United States: youth alcohol consumption. In: Holder H (ed) Advances in substance abuse: behavioural and biological research. Control issues in alcohol abuse prevention: strategies for states and communities. Connecticut: JAI Press.

31. Kuo M, Heeb J L, Gmel G et al (2003). Does price matter? The effect of decreased price on spirits consumption in Switzerland. Alcoholism: Clinical and Experimental Research 27: 720–5.

32. Chaloupka F J, Grossman M, Bickel WK et al (1999). The economic analysis of substance use and abuse: an integration of econometric and behavioural economic research. Chicago: University of Chicago Press.

33. Österberg E & Karlsson T (2003). Alcohol policies in EU member states and Norway: a collection of country reports. Helsinki: STAKES.

34. Rabinovich L, Brutscher P B, de Vries H et al (2009). The affordability of alcoholic beverages in the European Union: Understanding the link between alcohol affordability, consumption and harms. Cambridge: Rand Europe.

35. Robinson S & Lader D (2009). Smoking and drinking among adults, 2007 General Household Survey 2007. Newport: Office for National Statistics

36. Black H, Gill J & Chick J (2011). The price of a drink: levels of consumption and price paid per unit of alcohol by Edinburgh’s ill drinkers with a comparison to wider alcohol sales in Scotland. Addiction 106: 729–36.

37. Ludbrook A, Petrie D, McKenzie L et al (2012). Tackling alcohol misuse: purchasing patterns affected by minimum pricing for alcohol. Applied Health Economics and Health Policy 10: 51–63.

38. Purshouse R, Meier P, Brennan A et al (2010). Estimated effect of alcohol pricing policies on health and health economic outcomes in England: an epidemiological model. Lancet 375: 1355–64.

39. Anderson P, Chisholm D & Fuhr D C (2009). Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol. Lancet 373: 2234–46.

40. National Institute for Health and Clinical Excellence (2010). Alcohol use disorders—preventing harmful drinking: guidance. London: National Institute for Health and Clinical Excellence.

41. Purshouse R, Brennan A, Latimer N et al (2009). Modelling to assess the effectiveness and cost-effectiveness of public health related strategies and intervention to reduce alcohol attributable harm in England using the Sheffield Alcohol Policy Model version 2.0. Sheffield: School of Health and Related Research, University of Sheffield.

42. Purshouse R, Meng Y, Rafia R et al (2009). Model-based appraisal of alcohol minimum pricing and off-licensed trade discount bans in Scotland: a Scottish adaptation of the Sheffield Alcohol Policy Model version 2. Sheffield: School of Health and Related Research, University of Sheffield.

43. Meng Y, Purshouse R & Brennan A (2010). Model-based appraisal of alcohol minimum pricing and off-licensed trade discount bans in Scotland using the Sheffield Alcohol Policy Model (v.2): an update based on newly available data. Sheffield: School of Health and Related Research, University of Sheffield.

44. Meng Y, Hill-McManus D, & Brennan A (2012). Model-based appraisal of alcohol minimum pricing and off-licensed trade discount bans in Scotland using the Sheffield Alcohol Policy Model (v.2): second update based on newly available data. Sheffield: School of Health and Related Research, University of Sheffield.

45. Scottish Executive Social Research (2003). Liquor licensing and public disorder: Review of literature on the impact of licensing and other controls/audit of local initiatives. Edinburgh: The Stationery Office.

46. Sewel K (2002). International alcohol policies: a selected literature review. Edinburgh: Scottish Executive.

47. Chikritzhs T & Stockwell T (2002). The impact of later trading hours for Australian public houses (hotels) on levels of violence. Journal of Studies on Alcohol 63: 591–9.

48. Ogilvie D, Gruer L & Haw S (2005). Young people’s access to tobacco, alcohol and other drugs. BMJ 331: 393–96.

49. Ragnarsdottir T, Kjartansdottir A & Davidsdottir S (2002). The effect of extended alcohol serving-hours in Reykjavik. In: Room R (ed) The effects of Nordic alcohol policies—what happens to drinking and harm when alcohol controls change? Helsinki: Nordic Council for Alcohol and Drug Research.

50. McGuinness T (1980). An econometric analysis of total demand for alcoholic beverages in the UK, 1956–75. Journal of Industrial Economics 24: 85–109.

51. Huckle T, Huakau J, Sweetsur P et al (2008). Density of alcohol outlets and teenage drinking: living in an alcogenic environment is associated with higher consumption in a metropolitan setting. Addiction 103: 1614–21.

52. Scribner R A, Cohen D A & Fisher W (2000). Evidence of a structural effect for alcohol outlet density: a multilevel analysis. Alcoholism: Clinical and Experimental Research 24: 188–95.

53. Scribner R A, Mason K, Theall K et al (2008). The contextual role of alcohol outlet density in college drinking. Journal of Studies on Alcohol and Drugs 69: 112–20.

54. Weitzman E R, Folkman A, Folkman M P H K L et al (2003). The relationship of alcohol outlet density to heavy and frequent drinking and drinking-related problems among college students at eight universities. Science & Place 9: 1–6.

55. Kypri K, Bell M L, Hay G C et al (2008). Alcohol outlet density and university student drinking: a national study. Addiction 103: 1131–8.

56. Smith L A & Foxcroft D R (2009). The effect of alcohol advertising, marketing and portrayal on drinking behaviour in young people: systematic review of prospective cohort studies. BMC Public Health 9: 51.

57. Science Group of the European Alcohol and Health Forum (2009). Does marketing communication impact on the volume and patterns of consumption of alcoholic beverages, especially by young people?—a review of longitudinal studies. Scientific Opinion of the Science Group of the European Alcohol and Health Forum.

58. Gordon R, MacKintosh A M & Moodie C (2010). The impact of alcohol marketing on youth drinking behaviour: A two-stage cohort study. Alcohol and Alcoholism 45: 470–80.

59. LaBrie J W, Cail J, Hummer J F et al (2009), What men want: the role of reflective opposite-sex normative preferences in alcohol use among college women. Psychology of Addictive Behaviors 23: 157–62.

60. LaBrie J W, Hummer J F, Neighbors et al (2008). Live interactive group-specific normative feedback reduces misperceptions and drinking in college students: A randomized cluster trial. Psychology of Addictive Behaviors 22: 141–8.

61. Doumas D M & Hannah E (2008). Preventing high-risk drinking in youth in the workplace: a web-based normative feedback program. Journal of Substance Abuse Treatment 34: 263–71.

62. Neighbors C, Lee C M, Lewis M A et al (2007). Are social norms the best predictor of outcomes among heavy-drinking college students? Journal of Studies on Alcohol and Drugs 68: 556–65.

63. Perkins H W (2007). Misperceptions of peer drinking norms in Canada: Another look at the “reign of error” and its consequences among college students. Addictive Behaviors 32: 2645–56.

64. Walters S T, Vader A M & Harris T R (2007). A controlled trial of web-based feedback for heavy drinking college students. Preventive Science 8: 83–8.

65. Scottish Government, The (2008) Changing Scotland’s relationship with alcohol: a discussion paper on our strategic approach. Edinburgh: The Scottish Government.

66. Goldberg M E, Gorn G J & Lavack A M (1994). Product innovation and teenage alcohol consumption: the case of wine coolers. J Public Policy and Marketing 13: 218–27.

67. McKeganey N, Forsyth A, Barnard M et al (1996). Designer drinks and drunkenness amongst a sample of Scottish schoolchildren. British Medical Journal 313: 401.

68. Hughes K, MacKintosh A M, Hastings G et al (1997). Young people, alcohol, and designer drinks: quantitative and qualitative study. British Medical Journal 314: 414.

69. Barnard M & Forsyth A J M (1998). Alcopops and under-age drinking: changing trends in drink preference. Health Education 6: 208–12.

70. Romanus G (2000). Alcopops in Sweden—a supply side initiative. Addiction 95: s609–19.

71. Measham F & Brain K (2005). “Binge” drinking, British alcohol policy and the new culture of intoxication. Crime Media Culture 1: 262–83.

72. Jackson M, Hastings G B, Wheeler C et al (2000). Marketing alcohol to young people: implications for industry regulation and research policy. Addiction 95: s597–608.

73. Crombie I, Irvine L, Elliot L et al (2005). Public health policy on alcohol. Dundee: University of Dundee.

74. Casswell S, Gilmore L, Maguire V et al (1989). Changes in public support for alcohol policies following a community based campaign. Addiction 84: 515–22.

75. White D & Pitts M (1998). Educating young people about drugs: a systematic review. Addiction 93: 1475–87.

76. Tobler N & Stratton H (1997). Effectiveness of school-based drug prevention programs: a meta-analysis of the research. Journal of Primary Prevention 18: 71–128.

77. Gorman D (1995). Are school-based resistance skills training programs effective in preventing alcohol misuse? Journal of Alcohol and Drug Education 41: 74–98.

78. Ennett S, Tobler N, Ringwalt C et al (1994). How effective is drug abuse resistance education? A meta-analysis of project DARE outcome evaluations. American Journal of Public Health 84: 1394–401.

79. Bruvold W (1990). A meta-analysis of the California school-based risk reduction programme. Journal of Drug Education 20: 139–52.

80. Gorman D (1996). Do school-based social skills training programs prevent alcohol use among young people? Addiction Research 4: 191–210.

81. Foxcroft D, Lister-Sharp D J & Lowe G (1997). Alcohol misuse prevention for young people: a systematic review reveals methodological concerns and lack of reliable evidence of effectiveness. Addiction 92: 531–7.

82. Foxcroft D, Ireland D, Lister-Sharp D J et al (2003). Longer-term primary prevention for alcohol misuse in young people: a systematic review. Addiction 98: 397–411.

83. Bangert-Drowns R (1988). The effects of school-based substance abuse education—a meta-analysis. Journal of Drug Education. 18: 243–64.

84. Paglia A & Room R (1999). Preventing substance use problems among youth: a literature review and recommendations. Journal of Primary Prevention 20: 3–50.

85. American Medical Association (2002). Partner or foe? The alcohol industry, youth alcohol problems, and alcohol policy strategies. Chicago, IL: American Medical Association.

86. Yoast R A & Williams J (2004). Alcohol industry 101. Its structure & organization. Chicago, IL: American Medical Association.

87. Christie J, Fisher D, Kozup J C et al (2001). The effects of bar-sponsored alcohol beverage promotions across binge and nonbinge drinkers. Journal of Public Policy Marketing 20: 240–53.

88. Smith S W, Atkin C K & Roznowski J (2006). Are “Drink Responsibly” alcohol campaigns strategically ambiguous? Health Communication 20: 1–11.

89. Szykman L R, Bloom P N & Blazing J (2004). Does corporate sponsorship of a socially-oriented message make a difference? An investigation of the effects of sponsorship identity on responses to an anti-drinking and driving message. Journal of Consumer Psychology 14: 13–20.

90. Ringold D J (2008). Responsibility and brand advertising in the alcohol beverage market: the modeling of normative drinking behavior. Journal of Advertising 37: 127–41.

91. Lavack A M (1999). Message content of alcohol moderation TV commercials: impact of corporate versus nonprofit sponsorship. Health Marketing Quarterly 16: 15–31.

92. DeJong W, Atkin C K & Wallack L (1992). A critical analysis of “moderation” advertising sponsored by the beer industry: are “responsible drinking” commercials done responsibly? The Milbank Quarterly 70: 661–78.

93. Drinkaware Trust, The (2012) About us. Accessed online: www.drinkaware.co.uk 23 April 2012

94. Hasking P, Shortell C & Machalek M (2005). University students’ knowledge of alcoholic drinks and their perception of alcohol-related harm. Journal of Drug Education 35: 95–109.

95. Gill F & O’May F (2006). How “sensible” is the UK sensible drinking message? Preliminary findings amongst newly matriculated female university students in Scotland. Journal of Public Health 29: 13–6.

96. Office for National Statistics (2010) Drinking: adults’ behaviour and knowledge in 2009. London: Office for National Statistics.

97. Greenfield T K, Giesbrecht N, Johnson S P et al (1999). US federal alcohol control policy development: a manual. Berkeley: Alcohol Research Group.

98. Agostinelli G & Grube J (2002). Alcohol counter-advertising and the media: a review of recent research. Alcohol Research and Health 26: 15–21.

99. Department of Health (2010). Consultation on options for improving information on the labels of alcoholic drinks to support consumers to make healthier choices in the UK—response to consultation. London: The Stationery Office.

100. Saffer H & Grossman M (1987). Beer taxes, the legal drinking age, and youth motor vehicle fatalities. Journal of Legal Studies 16: 351–74.

101. Kelp K I, Schmid L A & Murray D M (1996). Effects of increased minimum drinking age law on drinking and driving behaviour among adolescents. Addiction Research 4: 237–44.

102. O’Malley P M & Wagenaar A C (1981). Effects of minimum drinking age laws on alcohol user, related behaviours and traffic crash involvement among American youth: 1976–1987. Journal of Studies of Alcohol 52: 478–91.

103. Wagenaar A C & Maybee R G (1986). Legal minimum drinking age in Texas: effects of an increase from 18 to 19. Journal of Safety Research 17: 165–78.

104. Shults R, Elder R, Sleet D et al (2001). Reviews of evidence regarding interventions to reduce injuries to motor vehicle occupants. American Journal of Preventive Medicine 21: 23–30.

105. US General Accounting Office (1987). Drinking-age laws: an evaluation synthesis of their impact on highway safety. Washington: US General Accounting Office.

106. Smart R & Goodstadt M (1977). Effects of reducing the legal alcohol-purchasing age on drinking and drinking problems: a review of empirical studies. Journal of Studies on Alcohol 38: 1313–23.

107. National Institute for Health and Clinical Excellence (2010). Alcohol-use disorders: preventing the development of hazardous and harmful drinking. London: National Institute for Health and Clinical Excellence.

108. National Institute for Health and Clinical Excellence (2010). Alcohol-use disorders: diagnosis and clinical management of alcohol-related physical complications. London: National Institute for Health and Clinical Excellence.

109. National Institute for Health and Clinical Excellence (2011). Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. London: National Institute for Health and Clinical Excellence.

110. National Institute for Health and Clinical Excellence (2011). Alcohol dependence and harmful alcohol use quality standard. London: National Institute for Health and Clinical Excellence.

111. National Institute for Health and Clinical Excellence (2011). Services for the identification and treatment of hazardous drinking, harmful drinking and alcohol dependence in children, young people and adults. London: National Institute for Health and Clinical Excellence.

112. Department of Health (2005). Alcohol Needs Assessment Research Project (ANARP): the 2004 national alcohol needs assessment for England. London: Department of Health.

May 2012