Health CommitteeWritten evidence from Alcohol Concern (GAS 62)

1. Summary

Drinking alcohol is a freedom that many enjoy, however this must be balanced with the need to avoid harm and improve health. Pricing is one of the most effective measures to address excessive consumption and alcohol-related harms.

A minimum unit price (MUP) of at least 50p would result in lower consumption levels and a significant reduction in alcohol-related harms, whilst ensuring that alcohol remains affordable for moderate drinkers.

In addition to price increases, the most effective strategies to reduce alcohol-related harm, include restrictions on the physical availability of alcohol, brief interventions with at-risk drinkers and treatment of drinkers with alcohol dependence.

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

Current health spending priorities need to be rebalanced, with much greater expenditure in areas such as alcohol treatment and advice services.

Central guidance and support for the development of cohesive and comprehensive services to tackle alcohol problems should be provided via a specialist team within Public Health England.

2. Alcohol Consumption and Public Health

2.1 There is overwhelming scientific evidence that excessive consumption significantly increases risk to long-term health. Alcohol is a factor in more than 40 serious medical conditions, including liver disease and mouth, food pipe, bowel and breast cancer,1 and one of the major preventable causes of death in England and Wales. Liver disease, in particular, to which alcohol is the key contributor, is the only major cause of death still increasing year-on-year.2 UK deaths from liver cirrhosis increased more than five-fold between 1970 and 2006.3 In contrast, in France, Italy and Spain, the number of deaths decreased by at least 50% and are now lower than those in the UK.4

2.2 As the Government’s alcohol strategy acknowledges, alcohol misuse also places a huge burden on the NHS. It is estimated to cost the NHS £2.7 billion every year. The number of hospital admissions due to alcohol misuse was 1.1 million in 2009–10, a 100% increase since 2002–03.5 If the rise continues unchecked, by the end of the current Parliament 1.5 million will be admitted to hospital very year as a result of drinking.6

3. Minimum Unit Price

3.1 Alcohol Concern has been campaigning for a MUP for a number of years, and we are strongly welcome the Government’s decision to commit to this measure.

3.2 A culture of alcohol overuse has developed. Recent qualitative research conducted on behalf of Alcohol Concern, found that heavy drinking is typically regarded by drinkers as an essential part of “a good night out”, with drunkenness seen by some as not only acceptable, but as something to look forward to, even though it often led to regrettable incidents.7 It is clear that changes to our drinking behaviour are needed, and an increasing body of evidence shows that the affordability of alcohol is a key driver in achieving this.8

3.3 A meta-analysis of the effects of alcohol prices and taxes on drinking, by Wagenaar et al, 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 numbers of studies and consistency of effects seen in the literature on alcohol taxes and prices”.9

3.4 There have been limited examples of minimum pricing policies which have been undertaken. 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.10 A recent study of MUP in British Columbia, Canada, which has been in place for 20 years, found that 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%.11

3.5 As part of a Sheffield University study in 2009, the potential effects of different minimum pricing levels were examined.12 The study found that the more intensive the pricing policy, the greater the harm reduction. Low minimum prices were found to have little impact, but the effectiveness accelerates rapidly from a MUP of 40p up to 70p. A MUP of 40p would result in a reduction in consumption of 2.7%, 3,600 fewer hospital admissions and 1,100 fewer crimes per year. A MUP of 50p would see a 7.2% reduction in consumption, 8,900 fewer hospital admissions and 4,200 less crimes per year. This impact would be even greater if the policy is combined with an off-licence discount ban.

3.6 Using the same data sources as the Sheffield study, which indicate that 80% of alcohol is consumed by 30% of the population and that the bottom 30% consumes only 2% of alcohol, it has been shown that, based on a 50p MUP, the bottom 30% of consumers would spend 10p per week more on alcohol, the middle 40% £1.09 and the top 30% £4.16 (if consumption remained the same).13 Alcohol Concern advocates at least 50p MUP, which would result in a significant reduction in alcohol-related harms whilst ensuring that alcohol remains affordable for moderate drinkers.

3.7 An effect of a MUP might also be to encourage alcohol producers to reduce the alcoholic content of their products.14 Wine usually has an alcohol content of 12%, meaning that a standard bottle contains nine units of alcohol. A bottle selling at a price for three bottles for £10 would cost £3.33 and a MUP of 50p would increase this to £4.50; however, by reducing the alcohol content to 9%, the price could still be £3.38, thus facilitating a reduction in alcohol content.

4. The Effectiveness of Other Interventions

4.1 According to a recent review,15 the most effective strategies to reduce alcohol-related harm from a public health perspective include, in rank order, price increases, restrictions on the physical availability of alcohol, drink-driving counter measures, brief interventions with at-risk drinkers, and treatment of drinkers with alcohol dependence. Another review concludes that regulatory approaches (including those that manage price, availability and marketing of alcohol) reduce the risk and the experience of alcohol-related harm, whereas educational approaches (including school-based education and public education programs) do not.16

4.2 Educational programmes and persuasion strategies, typically favoured by the drinks industry, are expensive and compared with other interventions appear to have little long-term effect on alcohol consumption levels and drinking-related problems, especially compared with £800m spent on promoting alcohol through advertising. Studies have shown that although they can increase knowledge and change attitudes, actual alcohol use amongst participants largely remain unaffected.17 Other researchers argue that, even with adequate resources, strategies which try to use education to prevent alcohol-related harm are unlikely to deliver large or sustained benefits, and that “education alone is too weak a strategy to counteract other forces that pervade the environment”.18

4.3 Conversely, there is evidence that introducing restrictions on physical availability can have a positive effect in reducing harm. Several international studies have identified a link between outlet density and physical violence. Limiting outlet density within a community may be effective because this may increase the time and convenience that a typical drinker encounters in obtaining alcohol; limiting competition between retailers and thereby reducing the likelihood of cut-price promotions and under-age sales; and avoiding high crowd density that frequently accompanies the bunching of outlets that may exacerbate incidences of violence.19 We therefore welcome measures in the Government’s Alcohol Strategy to strengthen licensing arrangements.

4.4 A combination of law enforcement and sustained publicity campaigns has substantially reduced the number of drink-drive accidents in recent years. Despite this, 17% of all road fatalities in 2009 were a result of drink-driving.20 It is therefore surprising that there is no mention of specific measures to reduce drink-drive accidents in the new strategy. Alcohol Concern supports the recommendations of Sir Peter North,21 in particular the need to lower the legal blood alcohol limit to 50mg of alcohol in 100ml of blood, which would bring the country in line with many other European countries, including France, Spain, Germany, Italy and the Netherlands.

4.5 Evaluations of the effects of alcohol warning labels on drinks products are limited to the US, which have shown improved awareness of safe drinking, but only slight evidence of any effects in changing actual drinking behaviour.22 The tobacco labelling experience, however, offers strong evidence that warning labels can be effective in shifting behaviour. According to Ferrence et al,23 unlike cigarette warnings, alcohol warning labels are often “vague and equivocal” and are not presented “in a vivid manner that evokes emotional reactions”.

4.6 Plain packaging of cigarette products is gathering increasing support, with Australia set to become the first country to enforce this through legislation. To our knowledge, there are no studies of the potential effectiveness of plain packaging for alcohol products, and research in this area would be welcome. Labelling is clearly part of the alcohol marketing mix, illustrated by a leading drinks company’s recent decision to include images of James Bond on packaging as part of its sponsorship deal with the movie franchise.24

5. Alcohol Marketing and the Drinks Industry

5.1 Children and young people are particularly vulnerable to the effects of alcohol marketing, especially those who are already showing signs of alcohol-related problems. Such marketing manipulates this vulnerability by shaping their attitudes, perceptions and expectancies about alcohol, which then influence their decision to drink.25

5.2 A number of recent studies have shown a clear association between alcohol marketing and youth drinking behaviour, and which conclude that the alcohol industry should not be involved in making alcohol policy.26 , 27 , 28 , 29 This is a position endorsed by the World Health Organisation, which chooses not collaborate with any of the sectors of the alcohol industry.30

5.3 Alcohol Concern’s own research has highlighted the frequency and volume of exposure by children and young people to alcohol advertising. In the UK over £800 million is spent on alcohol advertising. Over one million children were exposed to alcohol advertising during the televised England games of the World Cup in June 2010.31 In a study of more than 400 children aged 10 and 11, the number of these able to identify alcohol branding and advertising was found to be comparable to, and in some cases, greater than those who recognised brand and advertising for products known to appeal to and often aimed at children, such as ice cream and cake.32

5.4 It is therefore disappointing that the Government’s new strategy fails to provide firm action to strengthen regulations on alcohol marketing, especially given that many young people feel that current regulations do not provide adequate protection to their peers. A survey of over 2,300 under-18s suggests that people from this age group are highly aware of alcohol promotion and that existing rules are insufficiently robust to protect them from unnecessary exposure. Similarly, Alcohol Concern’s Youth Alcohol Advertising Council, a group of 10 under-18s from across the country that meet quarterly to review selected alcohol advertising against key principles of the Advertising Standards Code, have identified what they regard as frequent breaches of compliance with both the wording and spirit of the Code.33 The group has a made a number of complaints about alcohol advertising and very few have been upheld.

5.5 It is also concerning to find in the new strategy the wish 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)”. Current rules rightly prohibit advertising that implies that alcohol can enhance the social success of an individual or event, although a study of the industry’s internal marketing documents by Hastings et al34 concluded that, in practice, this a theme frequently incorporated into alcohol advertising. Young people in the UK have by far the most positive expectations of alcohol in Europe and are least likely to feel that it might cause them harm;35 implying that alcohol is an aid to socialising is unlikely to be helpful in this context.

5.6 Alcohol Concern believes the Government should seriously review the role performed by the Advertising Standards Authority and the Portman Group in relation to the regulation of advertising. More should be done to pre-vet advertising. There is also more that can be learned by France who have stricter controls over advertising in place such as the restriction only to advertise “factual” information (eg ABV strength, ingredients, point of origin) rather than emotional or social associations and also their controls over sponsorship of events which appeal to young people.

6. Investing in Treatment Services

6.1 Around half of the £2 billion spent on public health and treatment currently goes on drugs initiatives meanwhile, latest available figures show that local PCTs spend an average of £600k a year on alcohol treatment and counselling services, representing just 0.1% of a typical PCT’s yearly spending.36 Yet nationally 13–20% of all hospital admissions are alcohol-related and this figure is widely considered to be an underestimate, as coding of alcohol-related disorders is “notoriously inaccurate” and evidence of alcohol-related problems can easily be missed or ignored.37 There is an urgent need to provide care for a large and growing group of patients with alcohol-related health problems. Presently a lack of coordinated action means that “care is imperfect and spending is poorly targeted and ineffective”, very few hospitals have dedicated alcohol services and only 5.6% of dependent or harmful drinkers access treatment, compared to 67% of dependent or harmful drug users.38

6.2 Historically, there has been a lack of high-level support for alcohol services, which has resulted in a piecemeal approach to planning and development. With 1.6 million people in England experiencing alcohol dependency support for this group must be made a greater priority than indicated in the strategy.

6.3 The Strategy does propose interventions for some specific groups, including offenders and young people who binge drink, but fails to address the significant proportion of the population who, although not dependent, regularly drink at or above published guidelines over a long period of time, which can lead to or contribute to a range of health conditions. We believe that there should be full implementation of the NICE guidelines relating to alcohol treatment, which provide an excellent, evidenced-based guide to effective intervention and referral systems.

6.4 Changes to the public health system that are due to take place in 2013 offer real opportunities to develop a more cohesive and cost-effective approach to preventing and treating alcohol problems. However there is also a serious risk that a lack of appropriate expertise and guidance will lead to these opportunities being lost, or to an unacceptable disparity in the level and quality of services across the country. Local authorities and their colleagues in clinical commissioning groups will require support in the form, perhaps, of a national service framework that could be adapted to local needs, backed up by the opportunity to share best practice. Such a framework could be led by a dedicated alcohol team within Public Health England, with established experts setting out, and supporting the implementation of, principles for action, rather than prescriptive plans.

6.5 Similarly, the NHS Commissioning Board should provide local commissioning groups with guidance on the best practice for commissioning comprehensive alcohol treatment services, based on the NICE guidance and the forthcoming quality standard on alcohol dependence. They must hold commissioning consortia to account on their performance against a set of indicators relating to alcohol treatment services, linking to the shared mortality improvement area to reduce the under 75 mortality rate for liver disease in the NHS Outcomes Framework.

May 2012

1 Cancer Research UK (2008) Alcohol and cancer, online, available from
http://www.cancerresearch.org.uk [Accessed 23/02/10].

2 Office for National Statistics (2008) Health statistics quarterly, Winter 2008, No 40, Newport, ONS.

3 House of Commons Health Select Committee (2010) Alcohol: First report of session 2009-10, Volume 1, London, The Stationery Office.

4 ibid.

5 North West Public Health Observatory (2009) Alcohol-Related Hospital Admissions, North West Public Health Observatory and Centre for Public Health.

6 Department of Health (2010) Alcohol Ready Reckoner V.5.1, London, Department of Health.

7 Alcohol Concern (2010) A drinking nation? Wales and alcohol, London, Alcohol Concern.

8 Bailey, J et al (2011) Achieving Positive Change in the Drinking Culture of Wales, Glyndŵr University Wrexham and Bangor University, London, Alcohol Concern.

9 Wagenaar, A C, Salois, M J and Komro, K A (2008) Effects of beverage alcohol price and tax levels on drinking: A meta-analysis of 1003 estimates from 112 studies, p187, Presented at the 34th Annual Alcohol Epidemiology Symposium of the Kettil Bruun Society for Social and Epidemiological Research on Alcohol, Vicotir, British Columbia, June 2–6, 2008.

10 Gray, D et al (2000) Beating the grog: An evaluation of the Tennant Creek liquor licensing restrictions, Australian and New Zealand Journal of Public Health, 24(1), pp 39–44.

11 Stockwell, T et al (2012) Does minimum pricing reduce alcohol consumption? The experience of a Canadian province, Addiction, online, available from
http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2011.03763.x/full [Accessed 04/04/2012].

12 School of Health and Related Research (2009) Model-Based Appraisal of Alcohol Minimum Pricing and Off-Licensed Trade Discount Bans in Scotland: An Scottish Adaptation of the Sheffield Alcohol Policy Model version 2, online, available from http://www.scotland.gov.uk/Publications/2009/09/24131201/0 [Accessed 04/04/2012].

13 Record, C and Day, C (2009) Britain’s alcohol market: How minimum alcohol prices could stop moderate drinkers subsidising those drinking at hazardous and harmful levels, Clinical Medicine, 9(5), pp421–425.

14 ibid.

15 ibid.

16 Anderson, P (2009) Global alcohol policy and the alcohol industry, Current Opinion in Psychiatry, 22(3), pp 253–257.

17 op cit Babor, T et al (2010).

18 op cit Bailey, J et al, p 31 (2011).

19 Alcohol Concern (forthcoming) Full to the brim? Explaining the relationship between outlet-density and alcohol-related harm, London, Alcohol Concern.

20 Department for Transport, online,
http://webarchive.nationalarchives.gov.uk/20110503151558/http://dft.gov.uk/pgr/statistics/datatablespublications/accidents/casualtiesgbar/rrcgb2009 [Accessed 23/04/2012].

21 Sir Peter North (2010) Report of the Review of the Drink and Drug Driving Law, online, available from
http://webarchive.nationalarchives.gov.uk/20100921035225/http://northreview.independent.gov.uk/docs/NorthReview-Report.pdf [Accessed 23/04/2012].

22 Wilkinson, C and Room, R (2009) Warnings on alcohol containers and advertisements: International experience and evidence of effects, Drug & Alcohol Review, 28(4), pp 426–435.

23 Ferrence R, Hammond D, Fong G T Warning labels and packaging, in Bonnie R J, Stratton K, Wallace R B, eds (2007) Ending the tobacco problem: blueprint for the nation, Committee on Reducing Tobacco Use: strategies, barriers, and consequences, Washington: National Academy Press, pp 435–448.

24 Crummy, M (2012) James Bond swaps Martini for Heineken, the drinks business, 3 April 2012, online, available from http://www.thedrinksbusiness.com/2012/04/james-bond-swaps-martini-for-heineken [Accessed 05/04/2012].

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

26 Jones, S C et al (2008) How effective is the revised regulatory code for alcohol advertising in Australia?, Drug and Alcohol Review, 27(1), pp 29–38.

27 op cit Anderson, P (2009).

28 Hastings, G et al (2010) Failure of self-regulation of UK alcohol advertising, BMJ, 340, b5650.

29 Gordon, R et al (2011) Assessing the cumulative impact of alcohol marketing on young people’s drinking: Cross-sectional data findings, Addiction Research & Theory, 19(1).

30 World Health Organisation (2007) WHO Expert Committee on problems related to alcohol consumption, WHO Technical Report Series (2nd report), Geneva, WHO.

31 Alcohol Concern (2010) Overexposed: Alcohol marketing during the World Cup 2010, London, Alcohol Concern.

32 Alcohol Concern (2012) Making an impression: Recognition of alcohol brands by primary school children, London, Alcohol Concern.

33 Alcohol Concern (2011) Youth Advertising Standards Advisors: Autumn 2011 Report and Youth Advertising Standards Advisors: Winter 2011 Report, London, Alcohol Concern.

34 Hastings et al (2010) “They’ll drink bucket loads of the stuff”: An analysis of internal alcohol industry advertising documents, Stirling, Institute for Social Marketing, University of Stirling &the Open University, Memorandum to the House of Commons Health Committee Report on Alcohol, Session 2009–10.

35 The European School Survey Project on Alcohol and Other Drugs (ESPAD) (2007) The 2007 ESPAD Report Substance Use among Students in 35 European Countries, online, available from:
www.espad.org/documents/Espad/ESPAD_reports/2007/The_2007 _ESPAD_Report-FULL_091006.pdf [accessed 2 June 2011].

36 National Audit Office (2008) Reducing Alcohol Harm: Health services in England for alcohol misuse, London, NAO.

37 The British Society of Gastroenterology and the Royal Bolton Hospital NHS Foundation Trust, 2011.

38 Department of Health, 2004.

Prepared 19th July 2012