Alcohol policyAlcohol policy

Dr Bruce RitsonDr Bruce Ritson

SHAAPSHAAP

Alcohol policies in a public Alcohol policies in a public health perspectivehealth perspective

Alcohol problems are not only prevalent Alcohol problems are not only prevalent throughout the world they are preventablethroughout the world they are preventable

Alcohol problems affect the whole spectrum of Alcohol problems affect the whole spectrum of drinkers not just alcoholicsdrinkers not just alcoholics

Average amount of alcohol consumed in a Average amount of alcohol consumed in a society affects the prevalence of problemssociety affects the prevalence of problems

One of the most effective ways to prevent One of the most effective ways to prevent alcohol related problems is through policies alcohol related problems is through policies that reduce average alcohol that reduce average alcohol consumption,especially limitations on physical consumption,especially limitations on physical and economic availability.and economic availability.

Bruun et al 1975Bruun et al 1975

What works?What works?

International Review of Policy Measures

Authored by Public Health Academics

Sponsored by WHO

Population Consumption and HarmPopulation Consumption and Harm

The more alcohol a nation consumes, the The more alcohol a nation consumes, the greater the burden of harm it will greater the burden of harm it will experience, and vice versa.experience, and vice versa.

Changes is per capita consumption are Changes is per capita consumption are reflected in changes in harm.reflected in changes in harm.

There is a statistically significant There is a statistically significant relationship between changes in per capita relationship between changes in per capita alcohol consumption and liver cirrhosis alcohol consumption and liver cirrhosis mortality.mortality.

(Calling Time: The nation’s drinking as a major (Calling Time: The nation’s drinking as a major health issue, Academy of Medical Sciences, March health issue, Academy of Medical Sciences, March 2004) 2004)

Population MeasuresPopulation Measures International evidence confirms that if overall alcohol International evidence confirms that if overall alcohol

consumption falls, reductions in alcohol-related harm can consumption falls, reductions in alcohol-related harm can follow within a relatively short time.follow within a relatively short time.

Efforts to reduce alcohol harm need to reach the majority of Efforts to reduce alcohol harm need to reach the majority of drinkers and not just high risk groups.drinkers and not just high risk groups.

It is the greater number of risky drinkers in a population It is the greater number of risky drinkers in a population who account for most of the alcohol-related harm.who account for most of the alcohol-related harm.

More harm associated with the acute effects (drinking to More harm associated with the acute effects (drinking to intoxication) rather than chronic effects (sustained drinking intoxication) rather than chronic effects (sustained drinking over a period of time).over a period of time).

A reduction in overall consumption can be expected to have A reduction in overall consumption can be expected to have a positive effect on the whole population as well as a positive effect on the whole population as well as reducing harm in high risk groups.reducing harm in high risk groups.

(Evidence-based strategies and Interventions to reduce alcohol-related harm, (Evidence-based strategies and Interventions to reduce alcohol-related harm, WHO A60/14 Add.1, 5 April 2007) WHO A60/14 Add.1, 5 April 2007)

““The only purpose for which power can be rightfully The only purpose for which power can be rightfully exercised over any member of a civilised community exercised over any member of a civilised community against his will is to prevent harm to others. His against his will is to prevent harm to others. His own good, either physical or moral is not a sufficient own good, either physical or moral is not a sufficient warrant. He cannot rightfully be compelled to do or warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so forbear because it will be better for him to do so because it will make him happier, because in the because it will make him happier, because in the opinion of others, to do so would be wise or even opinion of others, to do so would be wise or even right. The only part of the conduct of anyone for right. The only part of the conduct of anyone for which he is amenable to society is that which which he is amenable to society is that which concerns others. In the part which merely concerns concerns others. In the part which merely concerns himself this independence is of right absolute; over himself this independence is of right absolute; over himself, over his own body and mind the individual himself, over his own body and mind the individual is sovereign”. is sovereign”.

JS Mill (1859)JS Mill (1859)

No man is an island, intire No man is an island, intire of it selfe: every man is a of it selfe: every man is a peece of the Continent, peece of the Continent, apart of the maine.apart of the maine.

John Donne (1624)John Donne (1624)

Prevention; What measures Prevention; What measures work best?work best?

PricePrice Availability (licensing Act)Availability (licensing Act) Drink driving counter measuresDrink driving counter measures Community action (night time Community action (night time

economy)economy) Early recognition plus Brief Early recognition plus Brief

interventionsinterventions

The UK’s concentration on binge-drinking The UK’s concentration on binge-drinking youngsters and the antisocial or criminal youngsters and the antisocial or criminal consequences of heavy drinking has allowed consequences of heavy drinking has allowed politicians to project the problem onto a politicians to project the problem onto a small part of the population, which no doubt small part of the population, which no doubt suits the marketing strategies of the drinks suits the marketing strategies of the drinks industry. When the Chief Medical Officer in industry. When the Chief Medical Officer in England called for a minimum unit price for England called for a minimum unit price for alcohol, the proposal was instantly alcohol, the proposal was instantly dismissed by Prime Minister Gordon Brown dismissed by Prime Minister Gordon Brown in saying we “don’t want the responsible, in saying we “don’t want the responsible, sensible majority of moderate drinkers to sensible majority of moderate drinkers to have to pay more or suffer because of the have to pay more or suffer because of the excesses of a small minority”.excesses of a small minority”.

Sir Ian Gilmour, Lancet, 2009Sir Ian Gilmour, Lancet, 2009

““We have decided to reverse the We have decided to reverse the previous Government’s plan to previous Government’s plan to increase the duty on cider by 10 per increase the duty on cider by 10 per cent above inflation and the cent above inflation and the reduction will come intoeffect at the reduction will come intoeffect at the end of this month – just in time to end of this month – just in time to celebrate England’s progress to the celebrate England’s progress to the quarter finals, or else to drown our quarter finals, or else to drown our sorrows.”sorrows.”

George Osborne, Budget StatementGeorge Osborne, Budget Statement

The Big Society Can Solve The Big Society Can Solve Problems of Binge DrinkingProblems of Binge Drinking

““The truth is that problems associated with The truth is that problems associated with excessive irresponsible drinking requires excessive irresponsible drinking requires that the new government recognise it. The that the new government recognise it. The new government has rightly recognised that new government has rightly recognised that the solution lies not in heavy handed state the solution lies not in heavy handed state action but a more nuanced approach that action but a more nuanced approach that seeks to utilise the powerful influences that seeks to utilise the powerful influences that drive behavioural change.”drive behavioural change.”

Chris Sorek, Telegraph, 7/9/10Chris Sorek, Telegraph, 7/9/10

UK Alcohol ConsumptionUK Alcohol ConsumptionLitres of pure alcohol consumption per capita in the UK, Litres of pure alcohol consumption per capita in the UK,

1900-20061900-2006 [Tighe Brewer’s Statistical Handbook 2007][Tighe Brewer’s Statistical Handbook 2007]

Price & Consumption TrendsPrice & Consumption Trends

The Scottish Parliament

Established July 1999

Proportional representation

Reserved for Westminster : Foreign Policy, Defence, Social Security, most fiscal issues, Excise Duties, Drug Legislation

Devolved : Health, Education, Justice, Agriculture

Health Spend £10 Billion out of total £26 billion budget.

Scottish Strategy 2008

SCOTTISH PROPOSALS 2008

•No discount for multiple purchase

•Minimum retail price per unit

•No off sales to under 21s

•Social responsibility fee

•Separate alcohol retail areas

•Separate alcohol checkouts

•No under 18s to sell alcohol

• Lower driving limit and random testing

• Introduce widespread screening and brief Intervention in Primary Care

• Substantial investment in care and treatment services

Office National Statistics 2007

Liver Cirrhosis Death Rates 1950 - 2006

Updated for Scottish Alcohol Consultation. 2008

ALCOHOL RELATED DEATHS IN SCOTLAND 1990-2003

Mortality rates - Liver cirrhosis all ages per 100,000 per yearMortality rates - Liver cirrhosis all ages per 100,000 per year

1957-19611957-1961 1987-19911987-1991 1997-20011997-2001

MenMen WomenWomen MenMen WomenWomen MenMen WomenWomen

England England & Wales& Wales

3.43.4 2.22.2 8.38.3 5.45.4 14.114.1 7.77.7

FinlandFinland 9.99.9 5.55.5 23.823.8 8.18.1 28.728.7 9.99.9

FranceFrance 48.448.4 19.919.9 31.931.9 14.114.1 28.128.1 10.810.8

IrelandIreland 5.45.4 3.93.9 7.87.8 5.35.3 11.111.1 6.56.5

ScotlandScotland 8.28.2 6.16.1 16.916.9 11.111.1 34.434.4 16.116.1

SwedenSweden 9.29.2 4.74.7 13.713.7 6.26.2 13.513.5 5.65.6

Source: Leon & McCambridge

Sales Data Neilsen analysis Sales Data Neilsen analysis 20082008

PopulatioPopulation 16 +n 16 +

ScotlandScotland

20052005 20062006 20072007

Litres Litres pure pure alcoholalcohol

11.911.9 11.611.6 11.811.8

EnglandEngland

10.110.1 10.010.0 9.99.9

What is SHAAP?What is SHAAP?

An independent medical advocacy bodyAn independent medical advocacy body

Set up in November 2006 by the Scottish Set up in November 2006 by the Scottish Medical Royal Colleges and Faculties with Medical Royal Colleges and Faculties with start-up funding provided by the Scottish start-up funding provided by the Scottish Executive Executive

To provide authoritative medical opinion To provide authoritative medical opinion on the impact of alcohol on health.on the impact of alcohol on health.

SHAAP Advocacy SHAAP Advocacy Influencing policy for whole population Influencing policy for whole population

approaches including regulatory policies such as approaches including regulatory policies such as controls on price and availability.controls on price and availability.

Promoting the public health case for protecting Promoting the public health case for protecting young people from experiencing alcohol-related young people from experiencing alcohol-related harm.harm.

Highlighting third party damage caused by Highlighting third party damage caused by alcohol.alcohol.

Advocating for effective treatment for people with Advocating for effective treatment for people with alcohol-related problems and appropriate training alcohol-related problems and appropriate training for clinicians.for clinicians.

Collaborating with UK, European and international Collaborating with UK, European and international colleagues to advocate for the public health colleagues to advocate for the public health interest in alcohol policy. interest in alcohol policy.

Tackling the IssueTackling the Issue - Price and Availability- Price and Availability

Alcohol 62% more affordable in 2005 than in 1980. Alcohol 62% more affordable in 2005 than in 1980.

Large increase in the amount of alcohol bought in shops, Large increase in the amount of alcohol bought in shops, supermarkets and off-licences. supermarkets and off-licences.

SHAAP would like to see:SHAAP would like to see:

New Licensing (Scotland) Act, restricting the ability of pubs and New Licensing (Scotland) Act, restricting the ability of pubs and clubs to run cheap drinks promotions, extended to cover clubs to run cheap drinks promotions, extended to cover supermarkets, off-licences and corner shopssupermarkets, off-licences and corner shops

The discretionary code in the Act requiring alcohol to be displayed The discretionary code in the Act requiring alcohol to be displayed separately from other goods made a mandatory conditionseparately from other goods made a mandatory condition

Stricter enforcement of laws relating to alcohol sales.Stricter enforcement of laws relating to alcohol sales.

Who drinks the cheap booze?Who drinks the cheap booze?

64% of all cheap off-trade alcohol is consumed by 64% of all cheap off-trade alcohol is consumed by harmful drinkers (only 9% by moderate drinkers). harmful drinkers (only 9% by moderate drinkers).

26% of harmful drinkers’ alcohol is “cheap”, 17% of 26% of harmful drinkers’ alcohol is “cheap”, 17% of moderate drinkers’.moderate drinkers’.

Meier 2008

The Licensing Objectives

- Prevention of Crime and Disorder- Securing Public Safety- Preventing Public Nuisance- Protecting and Improving Public Health- Protecting Children from Harm.

Tackling the IssueTackling the Issue-Treating People with Alcohol Problems-Treating People with Alcohol Problems

SHAAP would like to see:SHAAP would like to see:

Effective treatments from brief interventions to Effective treatments from brief interventions to residential programmes available to people with residential programmes available to people with alcohol problemsalcohol problems

Staff trained and supported to deliver evidence-Staff trained and supported to deliver evidence-based interventionsbased interventions

Services of sufficient capacity to meet the needs Services of sufficient capacity to meet the needs of the populations theyof the populations they serve.serve.

Increased screening for alcohol misuse will have a knock-on effect on the volume of downstream services required. As a consequence the overall package delivers a considerableuplift in funding for early intervention and treatment (including support for newly identified dependent drinkers), and for prevention activities.

Where appropriate, services should comply with guidance contained in the Health Technology Assessment Report 3 on Prevention and Relapse in Alcohol Dependence.

SCOTTISH GOVERNMENT PUBLIC HEALTH ALLOCATIONS 08/09

Tackling the IssueTackling the Issue

- Educating Doctors about alcohol- Educating Doctors about alcoholDoctors of tomorrow need to be educated about alcohol Doctors of tomorrow need to be educated about alcohol

problems to be able to detect problems and treat patients.problems to be able to detect problems and treat patients.

SHAAP would like to see: SHAAP would like to see:

A core curriculum on alcohol for both undergraduate and A core curriculum on alcohol for both undergraduate and postgraduate medical educationpostgraduate medical education

The five Scottish Medical Schools, the Deaneries, the Royal The five Scottish Medical Schools, the Deaneries, the Royal Colleges and NHS Education Scotland collaborating to Colleges and NHS Education Scotland collaborating to deliver a core curriculum on alcohol across the career span deliver a core curriculum on alcohol across the career span

Training for medical students and doctors on the potential Training for medical students and doctors on the potential for alcohol-related impairment in themselves and accessing for alcohol-related impairment in themselves and accessing help for a medical student or doctor.help for a medical student or doctor.

MINIMUM PRICING – WHO WINS?

- The public’s health

- Deprived communities

- Heavy drinkers or their families

- Moderate drinkers

- Pubs and restaurants

- Premium Brands

- Small retailers

ALL OF THE ABOVE

SCOTTISH GOVERNMENT PROPOSALS 2009

- A Minimum Price for Alcohol (Example of 40p per unit.)

- No discounts for multiple purchase. (3 for 2, 20 for 12)

Age limit of 21 in off sales.

Social responsibility fee to pay for city centre management.

More support and treatment.

Trends in Drinking VenueTrends in Drinking Venue

Scot Gov / Nielsen 2010

The 1990s The 2000s

35p per unit 30p per unit 20p per unit

Perception of Alcohol as a Perception of Alcohol as a ProblemProblem

60% Adults (16+) viewed alcohol as 60% Adults (16+) viewed alcohol as a serious issue in Scotlanda serious issue in Scotland

46% reported that people being 46% reported that people being drunk or rowdy in public places had drunk or rowdy in public places had an effect on their own quality of lifean effect on their own quality of life

People living in the most deprived People living in the most deprived areas were more likely to be affected areas were more likely to be affected by alcohol useby alcohol use

(SCVS)(SCVS)

What do you need for a public health strategy ?

-InvolvementNHS public health, Local authority health Improvement, Police, retailers and producers.

-InformationNational and local. Health, crime, sales data

-MonitoringKey performance indicators. (Improved health,Less crime, child welfare, reduced consumption.)

Inequalities and Mortality in Scotland

Leyland et al, Medical Research Council 2007

Death Rate per100,000 population2001

SHAAPSHAAP

www.shaap.org.ukwww.shaap.org.uk

Tel 01312473667Tel 01312473667

Tom RobertsTom Roberts

12 Queen Street, 12 Queen Street,

Edinburgh. EH2 1JQEdinburgh. EH2 1JQ