Session 2021-22
Health and Care Bill
Written evidence submitted by Alcohol Health Alliance UK, Collective Voice, and NHS Addiction Providers Alliance (HCB48)
Written Evidence to be submitted to the Health and Care Bill Committee
Executive Summary
We welcome the chance to submit written evidence to the Health and Care Bill Committee. Our primary concern is that there is little reference to alcohol harm in a Bill that represents one of the most comprehensive pieces of health legislation in almost a decade.
We recommend that:
· Alcohol should be clearly and explicitly included within the definition of "less healthy food and drink" in the Bill ; this would mean alcohol is subject to the proposed advertising regulations due to cover ‘high in fat, sugar and salt’ (HFSS) products.
· Clause 127 should be amended to ensure all alcoholic drinks will be required to display the Chief Medical Officers’ (CMOs) low risk drinking guidelines; health warnings; ingredients; and nutritional information. This should come into force on 1 January 2023 in line with the commencement of Section 125 and Schedule 16, as outlined in the Bill.
· The Bill currently does not do enough to address alcohol as a major cause of ill-health across the population and the leading cause of ill-health, disability, and death in the 15-49 age group. This could be rectified through the inclusion of evidence-based measures to reduce alcohol harm such as:
o The introduction of m inimum unit pricing (MUP) in England to tackle cheap high-strength drinks.
o A commitment to full access to high quality alcohol treatment and recovery services for those who need it, backed by appropriate funding.
Introduction
The Alcohol Health Alliance UK (AHA) is an alliance of more than 60 non-governmental organisations who work together to promote evidence-based policies to reduce the harm caused by alcohol. Members of the AHA include medical royal colleges, charities, and treatment providers (see appendix).
Collective Voice is the national alliance of drug and alcohol treatment and recovery charities.
The NHS Addiction Providers Alliance works collaboratively with service users, carers and other organisations who are committed to making a positive difference to the on-going development of the addictions field, including within drug, alcohol, gambling and gaming treatment and support. It provides drug and alcohol services in 35 local authority areas and in 43 prisons nationally.
Reason for Submission
We are submitting evidence to the Committee because we believe this Bill has scope to address alcohol harm in the UK. Alcohol harm is a major risk to the health of the individual, but also to public health. For the individual, regular drinking risks a future burdened by illnesses such as cancer, liver and heart disease. For some, it can also manifest itself as an addiction. For families, alcohol problems might lead to relationship breakdowns, can be linked to domestic violence, and can further impoverishment.
Not addressing alcohol harm in a Bill designed to implement the NHS Long Term Plan, which itself covers areas from prevention to treating diseases, is a missed opportunity to improve the UK’s health service. We hope that the below evidence will help the Public Bill Committee improve the legislation in its current form, so that it sufficiently addresses alcohol harm. This will enable the Bill to deliver on its aim for the Bill to implement the NHS Long Term Plan and for the Government’s Obesity Strategy to be addressed in Part 5 of the Bill (see explanatory notes [1] and the delegated memorandum [2] ).
For more information about the AHA or this submission, please contact its Policy and Advocacy Manager, Enya Evans, on enya.evans@ahauk.org.
Alcohol is an unhealthy product: Clause 125
1. Alcohol is the leading risk factor for death, ill-health, and disability among 15-49-year-olds. [3] It is linked to more than 200 health conditions, including seven types of cancer, liver disease and cardiovascular disease. [4] Every day, 33 people are diagnosed with alcohol-related cancer. [5]
2. The coronavirus pandemic has further exacerbated the alcohol harm crisis, with deaths from alcohol increasing by 20% to the highest levels since records began . [6] There was also a rapid increase in the number of alcoholic liver deaths, rising by 20.8% between 2019 and 2020, compared to a rise of 2.9% between 2018 and 2019 . [7] It is critical that the increasing levels of drinking seen during the pandemic are addressed urgently.
3. Alcohol also has a high calorie and sugar content. For context:
a. A pint of beer has the same calories as a Mars Bar and a glass of wine has the same calories as three Jaffa Cakes. [8]
b. 100ml of a 40% spirit contains 244 kcal. By comparison, 100ml of Coke contains 42 kcal. [9]
c. Some alcohol products contain more than 100% of the daily recommended sugar intake. [10]
4. The Bill’s explanatory notes make clear that the Bill aims to deliver upon the Government’s Long-Term Plan for the NHS and its Obesity Strategy. [11] The Plan itself recognises that addressing alcohol harm must be part of its effort to focus on prevention and address health inequalities, stating that it:
"contributes to conditions including cardiovascular disease, cancer and liver disease, harm from accidents, violence and self-harm, and puts substantial pressure on the NHS". [12]
5. Similarly, the Obesity Strategy recognises that:
"alcohol is highly calorific... It has been estimated that for those that drink alcohol it accounts for nearly 10% of the calories they consume. We know that each year around 3.4 million adults consume an additional day’s worth of calories each week from alcohol, that is nearly an additional 2 months of food each year". [13]
6. Despite the recognition of alcohol’s risk to health, as evidenced in the Long-Term Plan and the Obesity Strategy, alcohol is not included in the definition of "less healthy food and drink". Alcohol is therefore excluded from the regulations introduced by Clause 125 and Schedule 16. The fact that the Government recognises that alcohol is highly calorific is evidence that they recognise that it is ‘less healthy’. There is also a precedent for alcohol to be included in the Bill, since the Government is already consulting on calorie labelling to apply to alcohol, something which is done for the other HFSS products which are included in the Bill’s definition of ‘less healthy’.
7. The Bill states that the ‘less healthy’ products within the Bill’s scope are drawn from the 2011 Nutrient Profiling Technical Guidance [14] , which does not cover "non-nutrient substances" like alcohol or caffeine. [15] The fact alcohol is a non-nutrient substance underlines the fact it is an unhealthy product. Schedule 16 (part 1, section 1, subsection 6) of the Bill enables the Secretary of State for Health to amend the meaning of ‘relevant guidance’ and revise what products fall under the scope of the Bill. However, it is our understanding that the Government is not planning on amending the scope to include alcohol.
8. We believe it is vital that the Bill is amended to explicitly recognise alcohol as an unhealthy product that falls within the Bill’s scope. Such an amendment would help the Government to deliver on its Obesity Strategy and NHS Long Term Plan. Furthermore, such an amendment would enable the Government to address the many risks related with alcohol consumption.
9. One such risk is underage drinking, which negatively impacts upon the health and development of children and young people. There is an established evidence base that alcohol marketing causes underage drinking. [16] Exposure to alcohol marketing reduces the age at which young people start to drink, increases the likelihood that they will drink, and increases the amount of alcohol that they consume if they already drink. [17] Early age of drinking onset is associated with an increased likelihood of developing alcohol dependence in adolescence and adulthood, and also with dependence at a younger age. [18]
10. Children are exposed to excessive amounts of alcohol marketing. Research shows:
a. Four in five 11-19-year-olds had noticed alcohol marketing in the past month, with half of those aged under 18 being exposed to 28 or more instances of marketing every month. [19]
b. 10-15-year-olds in the UK are exposed to more televised alcohol marketing than adults. [20]
c. Nine out of ten primary school children recognised the beer brand ‘Foster’s’, a higher recognition rate than for leading brands of crisps, biscuits and ice-cream. [21]
11. Despite alcohol being an age restricted product and a demonstrable health risk to children, this Bill intends to prevent children from seeing an advert for a sugary soft drink, but not an alcoholic drink. Recognising that alcohol is unhealthy will enable this Bill to remedy that inconsistency.
12. That is why we strongly support a consistent approach to ensure effective advertising restrictions across HFSS products include alcohol , b ased on the evidence that alcohol is an unhealthy product and that children’s exposure to alcohol advertising is especially harmful . Restricting alcohol marketing is recommended by the World Health Organisation (WHO) as one of the most effective policies to reduce alcohol related harm, particularly for young people, children, and adolescents. [22]
Labelling: Clause 127
13. We welcome the Government’s commitment to bringing forth a consultation on introducing calorie labelling on alcohol products. As it stands, there are no legal requirements for alcohol products to include health warnings, calorie information, or even basic information such as ingredients.
14. Consumers have a right to know what they are consuming and the associated risks with drinking alcohol. However, many people are unaware of the calorie content in alcohol. For example, 80% of people are unable to identify the number of calories in a large glass of wine. [23]
15. Furthermore, many people are unaware of alcohol’s risk to health. For example, only a quarter of people are aware of alcohol’s link to breast cancer. [24] Similarly, despite alcohol’s link to worse pregnancy outcomes and serious lifelong impacts for the baby, one in three people are unaware it is safest not to drink whilst pregnant; it is estimated that 41% of people consume alcohol during pregnancy. [25]
16. Not only do the public have a right to know what is in their drink and make informed choices in the interest of their health, they also want to know this information. A recent survey conducted by YouGov found that 75% of people want the number of units in a product on alcohol labels, 61% want calorie information, and 53% want the amount of sugar. [26]
17. Without legal information requirements, voluntary inclusion of information on alcohol labels has been low. Our review of 424 alcohol product labels in London, the South East and North East of England, Wales, and Scotland revealed:
a. 71% of labels did not include the Chief Medical Officers’ (CMOs) low-risk drinking guidelines;
b. More than a quarter of labels included incorrect or misleading information that was either outdated or from other countries;
c. 72% of labels did not list their ingredients;
d. A majority had no nutritional information and just 7% of labels displayed full nutritional information including calories.
18. Clause 127 of the Bill provides the legal framework for labelling requirements to be introduced through regulations at a later date. Whilst waiting for the consultation on calorie labelling on alcohol products to be introduced, we believe Clause 127 should be amended to ensure that alcohol products display the CMOs’ low-risk drinking guidelines, health warnings, ingredients and nutritional information.
19. As evidenced earlier, the urgent alcohol harm crisis requires swift action. It is our view that any opportunity to enable people to make informed choices about their health, and the impact of alcohol upon it, should not be missed. By amending the Bill in this way, a proper debate can be ensured rather than it being left to future regulation, which may not benefit from the same scrutiny.
Minimum Unit Pricing: Suggested n ew c lause in Part 5
20. There is no mention of Minimum Unit Pricing (MUP) in the Bill. We believe MUP should be included as a tool to tackle cheap high-strength alcoholic drinks in England .
21. Consumption is closely linked to the price of alcohol: the more affordable alcohol is, the more is consumed, and thus the more harm is caused. The WHO recommends reducing the affordability of alcohol as one of the most effective policies to reduce alcohol harm. [27]
22. For instance, the affordability of off-licence beer has more than tripled over the last three decades. [28] It is possible to drink the low-risk weekly guideline of 14 units for just £2.68 – about the price of a cup of coffee in many high street chains. [29]
23. Both Scotland and Wales have already introduced MUP. Evidence from Scotland shows that MUP is effective: MUP has led to an 7.7% fall in household alcohol purchases in Scotland compared to Northern England. [30] In the first full year of data following the introduction of MUP, alcohol-specific deaths in Scotland decreased by 10%. [31] It is estimated that a 50p MUP in England would save 525 lives and prevent over 22,000 hospital admissions annually. [32]
24. One of the aims of the Health and Care Bill is to address health inequalities. The introduction of MUP would help the Bill to achieve this aim because people in our poorest communities suffer the most from the effects of cheap, high strength alcohol. They are six times more likely to die and eight times more likely to be hospitalised due to alcohol than people in the most affluent communities. [33] Evidence suggests that 90% of the lives that will be saved by minimum unit pricing will be amongst people living in poverty. [34]
25. In summary, we suggest the Committee should consider the inclusion of MUP in this Bill because there is clear evidence that this would improve health and help address health inequalities in England.
Alcohol Treatment
26. Alcohol treatment is essential to support those with alcohol dependence towards recovery. It is also vital to reduce emergency service call outs, unnecessary hospital admissions and avoidable deaths. However, there is a concerning lack of reference to alcohol treatment in the Bill.
27. There are two key ways in which the Bill could improve the delivery of alcohol treatment services: recognition and funding. This is especially important given the history of real term funding cuts suffered by alcohol treatment services . These have amounted to over £100 million – an average of 30% per service in England. [35] Between 2016 and 2018 alone, more than two-thirds of local authorities cut their alcohol treatment budgets. [36] These cuts are part of the reason that many dependent drinkers are not getting treatment.
28. For example, pre-pandemic, only one in five dependent drinkers were believed to be in treatment, leaving 80% lacking help. [37] The Covid pandemic has been found to have worsened the situation, leading to "significant and sustained increases in the rate of unplanned admissions for alcoholic liver disease". [38]
29. In an era of hugely diminished resource many alcohol treatment providers have been forced to reduce their offer. A lack of outreach services leads to some people with most complex needs missing out on support, while the reduction in capacity means many of those at lower levels of drinking are missing out too. The ‘dual diagnosis’ issue which has bedevilled the field for decades sadly persists. This means that many dependent drinkers are not receiving specialised treatment for alcohol harm, or, worse, not receiving treatment of any kind at all.
30. Furthermore, a commitment to secure funding would allow for future planning and reduce the amount of short commissioning and tendering cycles which disrupt service provision and quality when funding is only announced for one or two years at a time.
31. The Government has not published an Alcohol Strategy since 2012, but even then it recognised that "increasing effective treatment for dependent drinkers will offer the most immediate opportunity to reduce alcohol related admissions and to reduce NHS costs". [39] For every £1 invested in alcohol treatment, £3 is yielded in return, rising to £26 over 10 years. [40]
32. Recovery also yields powerful dividends for families and communities affected by addition. Again, returning to the Bill’s aim to address health inequalities, it is "many of the most deprived areas facing the highest levels of need, most acute gaps in provision, and poorest treatment outcomes". [41] That is why we suggest that the Bill should include a commitment to full access to high quality alcohol treatment and recovery services for those who need it, backed by appropriate funding.
Appendix
List of AHA Members
Academy of Medical Royal Colleges
Association of Directors of Public Health
British Association for the Study of the Liver
British Society of Gastroenterology
Faculty of Occupational Medicine
Look Around
National Organisation for Foetal Alcohol Syndrome UK
Northern Ireland Alcohol and Drug Alliance
Royal College of Anaesthetists
Royal College of Emergency Medicine
Royal College of General Practitioners
Royal College of Physicians of Ireland
Royal College of Physicians of Edinburgh
Royal College of Physicians of London
Royal College of Physicians and Surgeons, Glasgow
Royal College of Psychiatrists
Royal College of Surgeons of Edinburgh
Royal College of Surgeons of England
Royal Society for Public Health
Scottish Families Affected by Alcohol and Drugs
Scottish Health Action on Alcohol Problems (SHAAP)
Society for the Study of Addiction
Tower Hamlets GP Group
Violence and Society Research Group
Welsh Association for Gastroenterology and Endoscopy (WAGE)
Yorkshire and Humber Public Health Network
Joint authors
NHS Addiction Providers Alliance
September 2021
[1] Department of Health and Social Care (2021). Health and Social Care Bill Explanatory Notes, p.40.
[2] Department of Health and Social Care (2021). Memorandum from DHSC to the Delegated Powers and Regulatory Reform Committee, p.142.
[3] Public Health Engalnd (2018). The Public Health Burden of Alcohol and the Effectiveness and Cost-Effectiveness of Alcohol Control Policies An evidence review.
[4] World Health Organisation (September 2018). Fact sheets: alcohol.
[5] Brown, KF. et al. (2018). The fraction of cancer attributable to modifiable risk factors in England, Wales, Scotland, Northern Ireland, and the United Kingdom in 2015. The British Journal of Cancer.
[6] Public Health Engalnd (2021). Monitoring alcohol consumption and harm during the COVID-19 pandemic.
[7] Ibid, p.69.
[8] NHS Live Well (2020), Calories in Alcohol.
[9] NHS Health Scotland (2018). Hospital admissions, deaths and overall burden of disease attributable to alcohol consumption in Scotland.
[10] Action on Sugar (2020). Sugar content of ready to drink alcoholic beverages.
[11] Department of Health and Social Care (2021). Health and Social Care Bill Explanatory Notes, p.40.
[12] NHS Long Term Plan (2019). Long Term Plan, p.38.
[13] Department of Health and Social Care (2020). Tackling Obesity: Empowering adults and children to live healthier lives.
[14] Department of Health (2011). Nutrient Profiling Technical Guidance.
[15] Public Health England (2018). 2018 review of the UK Nutrient profiling model.
[16] Sargent, J. D., Cukier, S., & Babor, T. F. (2020). Alcohol marketing and youth drinking: is there a causal relationship, and why does it matter?. Journal of Studies on Alcohol and Drugs, Supplement, (s19), 5-12
[17] Anderson et al. (2009). Impact of Alcohol Advertising and Media Exposure on Adolescent Alcohol Use: A Systematic Review of Longitudinal Studies. Alcohol and Alcoholism, 44(3):229-43; Smith, L. & Foxcroft, D. (2009). The Effect of Alcohol Advertising, Marketing and Portrayal of Drinking Behaviour in Young People: A Systematic Review of Prospective Cohort Studies. BMC Public Health, 9:51; Jernigan, D. et al. (2016). Alcohol Marketing and Youth Consumption: A Systematic Review of Longitudinal Studies Published Since 2008. Addiction, 112: 7–20
[18] Donaldson, L. (2009). Guidance on the Consumption of Alcohol by Children and Young People. Department of Health. http://www.cph.org.uk/wp-content/uploads/2013/09/Guidance-on-the-consumption-of-alcohol-by-children-and-young-people.pdf
[19] Critchlow, N., MacKintosh, AM., and Thomas, C. (2019). Awareness of alcohol marketing, ownership of alcohol branded merchandise, and the association with alcohol consumption, higher-risk drinking, and drinking susceptibility in adolescents and young adults: a cross-sectional survey in the UK .
[20] Winpenny, E., Patil, S., Elliott, M., van Dijk, L., Hinrichs, S., Marteau, T., Nolte, E. (2012). Assessment of young people’s exposure to alcohol marketing in audiovisual and online media.
[21] Alcohol Focus Scotland (n.d). Children’s Recognition of Alcohol Marketing.
[22] The World Health Organisation (2019).The Safer Technical Package.
[23] Royal Society for Public Health (2014) Increasing awareness of‘ invisible‘ calrories from alcohol.
[24] Alcohol Health Alliance (2018). How we drink, what we think: Public views on alcohol and alcohol policies in the UK.
[25] Popova, S., Lange, S., Probst, C., Gmel G., and Rehm, J. (2017). Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis.
[26] Alcohol Health Alliance (May 2021). Great British Public and leading health experts back changes to alcohol labelling.
[27] The World Health Organisation (2017). Tackling NCDs.
[28] The Institute of Alcohol Studies (2020). Budget 2020 analysis.
[29] Alcohol Health Alliance (2020). Small Change: Alcohol at pocket saving prices.
[30] Anderson, P., O'Donnell, A., Kaner, E., Llopis, E. J., Manthey, J., & Rehm, J. (2021). Impact of minimum unit pricing on alcohol purchases in Scotland and Wales: controlled interrupted time series analyses. The Lancet Public Health. https://doi.org/10.1016/S2468-2667(21)00052-9
[31] National Records of Scotland (2020). Alcohol-specific deaths: main points.
[32] Angus, C. et al. (2016). Alcohol and cancer trends: Intervention Studies. University of Sheffield and Cancer Research UK
[33] Giles, L., & Robinson, M. (2017). Monitoring and Evaluating Scotland’s Alcohol Strategy: Monitoring Report. Edinburgh: NHS Health Scotland.
[34] Meier, P., Holmes, J., Angus, C., Ally, A., Meng, Y., and Brennan, A. (2016). Estimated Effects of Different Alcohol Taxation and Price Policies on Health Inequalities: A Mathematical Modelling Study.
[35] Drummond, C. (2017). Cuts in addiction services are a false economy.
[36] Health and Social Care Committee (2016). Public health post-2013 inquiry. p.2.
[37] Public Health Engalnd (n.d). Public Health Dashboard.
[38] Public Health England (2021). Monitoring alcohol consumption and harm during the COVID-19 pandemic.
[39] HM Government (2012). The Government’s Alcohol Strategy, p.25.
[40] Public Health England (2018). Alcohol and drug prevention, treatment and recovery: why invest?
[41] Alcohol Concern and Alcohol Research UK (2018). The hardest hit: addressing the crisis in alcohol treatment services, p.5.