Health Committee - The Government's Alcohol StrategyWritten evidence from the All Party Parliamentary Group on Alcohol Misuse (GAS 53)

1. The APPG

1. The Group comprises members from across both Houses, from all parties and none. Due to the timing of this enquiry, this submission has been approved by the Officers of the Group1 rather than the full membership, although it has been circulated to them to seek comments. It draws on the evidence of Alcohol Concern, the national agency on alcohol misuse, which provides the secretariat for the All Party Parliamentary Group. It also builds on previous discussions within the Group and can fairly be seen as a reflection of the approach of the parliamentarians who share a concern about Alcohol Misuse.

2. It has been acknowledged by members, and by expert advisors addressing our meetings, that pricing is one of the most effective measures to reduce excessive consumption with its associated health and other harms.

3. We therefore strongly welcome the commitment to a minimum unit price which would lower consumption and reduce alcohol-related harms.

4. We also welcome the government’s acknowledgement that price is only one part of an overall prevention strategy and that other action is needed, particularly to reduce the availability and promotion of alcohol.

5. Children and young people are especially vulnerable to the effects of alcohol marketing. Consequently, such marketing should be restricted to adult audiences.

6. Furthermore, in order to help those already either in difficulty with their drinking or at risk of harm, the availability of early interventions is essential, both to help people assess their drinking levels and identify the potential harm, and to receive information and assistance to cut back. For those already moving towards alcohol dependence and harm (either to themselves or others), the availability of appropriate treatment is an essential element of any strategy.

7. The NHS reorganisation offers the potential for a real impact on the provision of services (both brief interventions and more intensive treatment) especially given the role of GPs in commissioning and the new role of local government. However, such potential will only be realised if current health spending priorities are refocused, with much greater expenditure on cost-effective alcohol treatment and advice services.

8. The strategy will only be effective if there is an adequately resourced, expert and committed body to help drive, plan and implement the many recommendations and to assist GP commissioners, service providers, local government and all the other players to build the capacity and programmes to play their part. It is therefore vital that the one national agency set up with exactly this remit, Alcohol Concern, is provided with the wherewithal to fulfil this vital task.

2. Public Health

9. The enhanced role of public health provides the opportunity for effective interventions. We know (as set out by Alcohol Concern to the Committee) of the overwhelming scientific evidence that excessive consumption significantly increases risk to long-term health. Furthermore, alcohol-related illnesses are some of the major preventable causes of death.

10. Sadly, liver disease is the only major cause of death still increasing year-on-year2 with deaths from liver cirrhosis having increased more than five-fold between 1970 and 2006.3

11. Over 10 million adults drink more than recommended guidelines, with 2.6 million drinking more than twice their “safe” limits.4

12. Alcohol misuse places a huge burden on the NHS –as much as £2.7 billion a year. Hospital admissions due to alcohol misuse amounted to 1.1 million in 2009–10, a 100% increase from 2002–03.5

13. This is a public health burden which neither the country, nor the individuals concerned (and their families), can afford.

14. It is increasingly the case that the public has recognised, firstly, that excessive drinking has got out of hand and that, secondly, something should and can be done about this. People know that price and availability are key determinants of consumption and, in particular in relation to disturbances and low level violence, the number and size of outlets should be controlled. Hence the often vocal objections to the granting of licences. It is therefore important for local authorities to have greater freedom to set licensing fees to discourage the growth of off-licence sales, and to resist the continuous pressure for ever more outlets, including from post offices, near schools and in other inappropriate places.

3. Minimum Unit Price

15. The All Party Parliamentary Group welcomes the Government’s commitment to Minimum Unit Pricing as a step towards more appropriate alcohol pricing.

16. Any such increase will reduce consumption. But equally important is the message it sends out to all drinkers and to society in general. Over the past quarter century, a culture of alcohol overuse has developed, with heavy drinking frequently regarded by drinkers as an essential part of “a good night out” and drunkenness seen by some as acceptable (even desirably) despite its contribution to regrettable incidents.6 Changes to our drinking culture and behaviour are needed, with the affordability of alcohol being a key driver in achieving this.7

17. Wagenaar’s meta-analysis concluded that: “price affects drinking of all types of beverages, and across the population of drinkers from light drinkers to heavy drinkers. We know of no other preventative intervention to reduce drinking that has the .... consistency of effects”.8

18. A locally imposed minimum pricing restriction in Australia resulted in a 19.4% reduction in alcohol consumption, fewer hospital admissions for alcohol-related illnesses and fewer arrests.9

19. In British Columbia, with Minimum Unit Pricing in place for 20 years, a 10% increase in minimum prices reduced consumption of spirits and liqueurs by 6.8%, wine by 8.9%, alcoholic sodas and ciders by 13.9%, beer by 1.5%, and all alcoholic drinks by 3.4%.10

20. A 2009 study found that the more intensive the pricing policy, the greater the harm reduction.11 Low minimum prices had little impact, but the effectiveness accelerated rapidly from a Minimum Unit Price of 40p up to 70p. Whilst 40p would result in a reduction in consumption of 2.7% (with 3,600 fewer hospital admissions and 1,100 fewer crimes pa), 50p would see a 7.2% reduction in consumption (8,900 fewer hospital admissions and 4,200 fewer crimes).

21. A Minimum Unit Price might encourage producers to reduce the alcoholic content of their products.12 Wine usually has an alcohol content of 12% (nine units per bottle). At the cheapest end of the market, where three bottles sell for £10, a MUP of 50p would increase the price of one bottle from £3.33 to £4.50. However, if the producers reduced the alcohol content to 9%, the price could remain at £3.38.

22. Producing and promoting such lower strength drinks can be an effective way to reduce consumption, with its associated intoxication and impairment.13

4. The Effectiveness of other Interventions

23. The most effective interventions in reducing alcohol-related harm have been ranked as: price, restrictions on the availability of alcohol, drink-driving measures, brief interventions with at-risk drinkers, and treatment of drinkers with alcohol dependence.14

24. In particular, we emphasise that this list does NOT include educational approaches—the normal “tool” recommended or adopted by the industry, and often supported by government. It can make people feel they are doing something and, in particular, it provides resources or events to showcase to emphasis one’s concerns. But these have little lasting effect compared with price, availability and treatment interventions.

25. Regulatory approaches (such as price, availability, marketing) reduce the incidence of alcohol-related harm, whereas educational approaches (including school-based education and public education programs) do not.15

26. Educational programmes, typically favoured by the drinks industry, are expensive yet have little long-term effect on consumption or alcohol-related problems. Although they can increase knowledge and change attitudes, actual alcohol use remain largely unaffected.16 Indeed, “education alone is too weak a strategy to counteract other forces that pervade the environment”.17

Alcohol Labelling

27. The recent implementation of the EU Food Information for Consumers Regulation (FIR) contains a provision allowing energy-only labelling for alcoholic drinks. This facilitates the disclosure of calorific content. Such calorific content of alcohol will assist consumers in deciding what and how much to drink. It would therefore benefit public health if consumers can easily understand the calorific content of the alcohol and therefore limit energy intake accordingly. This might be of particular assistance to diabetics, the obese and regular drinkers wishing to limit their calorie intake to recommended levels. Similarly, those with weight problems would be more easily able to manage their condition if the calorific content of drinks were on the labels. It should be noted that whilst alcohol can be highly calorific and linked to obesity, there is low awareness of this. Thus some drinkers might reduce their intake if they realised the high calorific content of the alcohol. There should be a level playing field for manufacturers of soft drinks and alcoholic drinks. At present there is a risk that someone comparing a soft drink product displaying calorific content with alcoholic with no calorific disclosure might think the latter contains fewer calories.

28. We therefore recommend that all alcoholic drinks should carry standardised calorie content information on the label.

29. This should be acceptable to producers, especially as the one intervention generally accepted by the industry is about Unit labelling on drinks products. However, we should also note in regard to the latter, that evaluations of the effects of alcohol warning labels in the US, shown improved awareness of safe drinking, but only slight evidence of any effects in changing actual drinking behaviour.18 So whilst any such information is to be warmly welcomed, like education it cannot be relied on to impact harmful behaviour.

Availability and drink/driving

30. Restrictions on availability, by contrast, does reduce harm, including violence.

31. Similarly, law enforcement alongside sustained publicity campaigns has reduced the number of drink-drive accidents. Despite this, 17% of all road fatalities in 2009 resulted from drink-driving.19 It is therefore extremely regrettable that there are no measures to reduce drinking and driving in the strategy.

32. The All Party Parliamentary Group therefore calls on the Committee to endorse the recommendations of Sir Peter North to lower the legal blood-alcohol limit to 50mg of alcohol in 100ml of blood, 20 and bring the country in line with virtually every other European country.

5. Investing in Treatment

33. Around half of the £2 billion spent on public health and treatment goes on drugs interventions, whilst PCTs spend an average only £600,000 a year on alcohol treatment and counselling, just 0.1% of a typical PCT’s expenditure.21

34. The lack of high-level support for alcohol services has resulted in a piecemeal approach to provision. The 1.6 million people in England experiencing alcohol dependency22 are entitled to far greater priority than is indicated in the strategy. Only one in every 18 dependent drinkers currently receives treatment23 despite the fact that support for such people drinkers makes good economic sense: for every £1 spent on treating dependent drinkers, £5 is saved on health, welfare and crime.24

35. We know that hospital A&E departments can be overwhelmed by problem drinkers (or their victims) though there are other, less visible, impacts on the NHS with chronic health and trauma injuries in GP surgeries and on medical wards. Without serious investment in interventions to help those misusing alcohol with their drinking, such impacts on the health service will continue to grow.

36. The Government outlined a number of important high-impact interventions in the Alcohol Strategy, including Brief Intervention and Advice, and alcohol liaison nurses in the A&E. As the new arrangements for commissioning alcohol services are embedded, it is vital that these services are funded by local authorities and the NHS.

37. The APPG welcomes the Government’s commitment to look at how GPs can be supported to screen for alcohol misuse, through the Quality and Outcomes Framework. In the reformed NHS, GPs will continue to be at the frontline of diagnosing and treating people with alcohol problems and they will have a crucial role to play in identifying, assessing and referring people with alcohol use disorders. However, GPs have tended to under-identify alcohol misuse, with GPs identifying only one in 67 males and one in 82 female hazardous and harmful drinkers. Furthermore, less than a third of GPs used an alcohol screening questionnaire; and of those third, they only used them for an average of 33 patients a year.

38. The lack of incentives for GPs actively to seek to minimise alcohol harm were specifically raised by Group Members in the Lords during the Health and Social Care Bill debates; we hope that QOF points can be developed to address this.25

6. Alcohol Marketing and the Drinks Industry

39. Not only are children and young people particularly vulnerable to alcohol marketing, but it establishes early on in their minds: (a) that this is a desirable/glamorous commodity; and (b) that it is socially acceptable to see it infuse normal life. By shaping their attitudes, perceptions and expectancies about alcohol, this is bound to influence later drinking habits.26

40. Given the association between marketing and youth drinking, many have concluded that the alcohol industry should not be involved in alcohol policy, a position endorsed by the World Health Organisation, which does not collaborate with the alcohol industry.27

41. Alcohol Concern has highlighted the frequency and volume of exposure by young people to advertising. Over one million children were exposed to alcohol advertising during the televised England games of the World Cup in 2010.28 10 and 11 year olds were as able to identify branding and advertising for alcohol as for products aimed at them (such as ice cream and cake).29

42. The Group therefore regrets that the Government’s strategy does not strengthen regulations on alcohol marketing. Perhaps as alarming is the desire to encourage “advertising which builds more positive associations (for example, between alcohol and positive socialising) instead of negative ones (for example, between alcohol and wild, disinhibited behaviour)”. This runs contrary to the current ASA rules which rightly prohibit advertising that implies that alcohol can enhance the social success of an individual or event.

7. A National Agency

43. Without a specialised, non-governmental agency able to provide the expertise, guidance, support and know-how to GP commissioners, local government, service providers and the range of professionals involved in alcohol misuse, it is difficult to see how the government’s strategy can be delivered on the ground. The Department itself cannot act with the speed, flexibility and range of resources and advice needed; it does not link naturally with the network of alcohol agencies and specialists (across the whole of local government as well as police, probation, transport and education) and does not reflect local community and other interests. Alcohol Concern, with its long record in these areas, its broad based executive and range of expertise and with a single focus on alcohol misuse, is a necessary part of a successful strategy. As an independent body, and as part of the voluntary sector, it is also far more effective, and better value for money, than any statutory equivalent. It can work alongside the whole field of service providers, AA as well as the health service, and develop best practice across the range of interventions.

44. We therefore also call on the Committee to ensure that this body is now properly funded to help drive and deliver the commendable objectives set out in the government’s strategy.

May 2012

1 Baroness Hayter; Lord Brooke of Alvethorpe; Tracey Crouch MP; Baroness Finlay; Russell Brown MP

2 Office for National Statistics, Health statistics quarterly, Winter 2008.

3 House of Commons Health Select Committee, Alcohol: First report of session 2009-10, Volume 1.

4 House of Commons Public Accounts Committee, Reducing Alcohol Harm: health services in England for alcohol misuse, 2010.

5 North West Public Health Observatory, Alcohol-Related Hospital Admissions, 2009.

6 Alcohol Concern, A drinking nation? Wales and alcohol, 2010

7 Bailey, J, et al, Achieving Positive Change in the Drinking Culture of Wales, Glyndŵr University Wrexham and Bangor University, 2011.

8 Wagenaar, A C, Salois, M J and Komro, K A, Effects of beverage alcohol price and tax levels on drinking: A meta-analysis of 1,003 estimates from 112 studies, 34th Annual Alcohol Epidemiology Symposium of the Kettil Bruun Society for Social & Epidemiological Research on Alcohol, Vicotir, British Columbia, June 2008.

9 Gray, D, et al, “Beating the grog: An evaluation of the Tennant Creek liquor licensing restrictions”, Australian and New Zealand Journal of Public Health, 24(1), 2000.

10 Stockwell, T, et al, “Does minimum pricing reduce alcohol consumption? The experience of a Canadian province”, Addiction, 2012

11 School of Health and Related Research, Model-Based Appraisal of Alcohol Minimum Pricing and Off-Licensed Trade Discount Bans in Scotland: An Scottish Adaptation of the Sheffield Alcohol Policy Model, 2009.

12 ibid.

13 Babor, T, et al, Alcohol: No Ordinary Commodity, 2010, OUP.

14 ibid.

15 Anderson, P, “Global alcohol policy and the alcohol industry”, Current Opinion in Psychiatry, 22(3), 2009.

16 Babor, T, et al, op. cit, 2010.

17 Bailey, J, et al, op. cit, 2011

18 Wilkinson, C & Room, R. Warnings on alcohol containers and advertisements: International experience and evidence of effects, Drug & Alcohol Review, 28(4), 2009

19 Department for Transport

20 Sir Peter North, Report of the Review of the Drink and Drug Driving Law, 2010

21 National Audit Office, Reducing Alcohol Harm: Health services in England for alcohol misuse, 2008.

22 McManus, S, et al (eds), Adult psychiatric morbidity in England, 2007, 2009

23 Alcohol Needs Assessment Research, The 2004 national needs assessment for England, Department of Health, 2005.

24 Godfrey, C, et al, “Effectiveness of treatment for alcohol problems: findings of the randomised UK alcohol treatment trial (UKATT)”, British Medical Journal, 2005, 331

25 House of Commons Health Committee, Alcohol: First Report Session of 2009–10.

26 Anderson, P, The impact of alcohol advertising: ELSA project on the evidence to strengthen regulation to protect young people, Utrecht, National Foundation for Alcohol Prevention, 2007.

27 Jones, S C, et al., “How effective is the revised regulatory code for alcohol advertising in Australia?”, Drug and Alcohol Review, 27(1), 2008. Anderson, P, op cit, 2009. Hastings, G, et al, “Failure of self-regulation of UK alcohol advertising, BMJ, 2010, 340. Gordon, R, et al, “Assessing the cumulative impact of alcohol marketing on young people’s drinking: Cross-sectional data findings”, Addiction Research & Theory, 2011, 19(1). WHO Expert Committee on problems related to alcohol consumption, WHO Technical Report Series, 2007.

28 Alcohol Concern, Overexposed: Alcohol marketing during the World Cup 2010, 2010.

29 Alcohol Concern, Making an impression: Recognition of alcohol brands by primary school children, 2012.

Prepared 21st July 2012