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Alcohol policy:research and practice
Professor Colin Drummond
Institute of Psychiatry
King’s College LondonMSc AddictionJanuary 2011
Topics
• What are the drivers?
• What are the policy options?
• What is happening in England?
• What about Europe?
• Conclusions
“Rising consumption over the last 25 years have been accompanied by an increase in
availability”
• 68% increase in licensed hotels and restaurants
• 100% increase in off licences
• 145% increase in on licence applications
• Increased capacity of on licenses:
“Super pubs” are now 20 times bigger than typical pubs
The Licensing Act 2003
explained:
Flexible opening hours for
premises, with the potential for
up to 24 hour opening, seven days a week.
This will help to minimise public
disorder resulting from fixed closing
times.
What the experts said…..• Bruun et al., 1975
• Royal College of Psychiatrists, 1986
• British Medical Association, 1989
• Faculty of Public Health Medicine, 1991
• Edwards et al., 1994
• Royal College of Physicians and the British Pediatric Association, 1995
• Babor et al., 2003
• Academy of Medical Sciences, 2004
• WHO expert committee, 2007
• NICE, 2010
DISCLAIMER:DISCLAIMER:NO EFFECTIVE STRATEGIES HAVE BEEN NO EFFECTIVE STRATEGIES HAVE BEEN
USED IN THE MAKING OF THIS DOCUMENTUSED IN THE MAKING OF THIS DOCUMENT
AHRSE, 2004• The two main supply-side levers that are commonly cited as influencing
harm are price and availability:– price is controlled by Government through levels of taxation; it is also governed
by the laws of supply and demand – for example, price promotions; and– availability is controlled through restrictions on suppliers (planning and licensing
law) and individuals.
• There is a clear association between price, availability and consumption. But there is less sound evidence for the impact of introducing specific policies in a particular social and political context: – our analysis showed that the drivers of consumption are much more complex
than merely price and availability;– evidence suggested that using price as a key lever risked major unintended side
effects;– the majority of those who drink do so sensibly the majority of the time.– Policies need to be publicly acceptable if they are to succeed; and measures to
control price and availability are already built into the system.
Alcohol strategy optionsBabor et al. (2003) Alcohol: No ordinary commodity
• High impact– Taxation & pricing– Restricting availability– Limiting density of outlets– Lower BAC limits– Graduated driving licences
• Medium impact– Brief interventions– Treatment– Safer drinking environment– Heavier enforcement
• Low impact– Unit labelling– “Sensible” drinking
campaigns– Public education– School based education– Voluntary advertising
restrictions
ALCOHOL HARM REDUCTION STRATEGY FOR ENGLAND (AHRSE)2004
Some major problems
• No money• No targets• No high impact strategies• Licensing relaxation• Voluntary codes for alcohol industry• Less effective controls on alcohol
consumption• Increased criminalisation
University of Sheffield report on pricing and promotion (Nov 2008)
• Commissioned by DH• High impact of tax increase• Increases across the board have more impact• High impact of minimum price• Greater impact on heavy drinkers and under-age• Impact on harm (40p min price->41,000 less
hospital admissions; £500M health cost savings, also reduced crime, unemployment)
• Smaller impact of banning promotions
Impact of minimum price per unit of alcohol on consumption
minimum price (p)
Change in consumption (%)
What the government said• March 2009: Donaldson: minimum price of 50p per unit of
alcohol to reduce consumption, idea of passive drinking• March 2009: Brown: “But . . . it’s also right that we do not want
the responsible sensible majority of moderate drinkers to have to pay more or suffer as a result of the excesses of a small minority”
• March 2009: Lansley: "There is clearly a need for action. But it is very important to recognise that to deal with this problem we need to deal with people's attitudes and not just the supply and price of alcohol. Higher taxes on high-alcohol drinks aimed at young people
• March 2009: Donaldson: “I take a different view as to whether heavy drinking is a minor and insignificant problem.”
• April 2009: Darling Budget: Retains plan for 2% above inflation increase in alcohol tax
The growing influence of industry, UK• 2004, AHRSE proposes industry levy,
threatens legislation• 2004, Diageo hosts meeting with PM• 2004, CEO of Portman Group joins AERC,
and is member of Better Regulation Commission, Scottish Ministerial Advisory Committee on Alcohol Problems, Director, Advertising Standards Agency, Trustee, Drinkaware Trust.
• 2004, Advertising industry threats to sue Academy of Medical Sciences over Calling Time report
The growing influence of industry, UK• Nov 2004, Portman group named as agency
responsible for delivering public health messages on alcohol in England, in Choosing Health White Paper
• 2005, DCMS sides with alcohol industry (BBPA) on implementation of Licensing Act
• 2006, Drinkaware trust, new incarnation of Portman Group, £5M p.a. budget, supported by a national producers fund, “independent” steering group
• 2005-6, EU alcohol policy roundtable for DG Sanco. Hosted by European Policy Centre. UK companies active in attempting to rubbish public health research.
Improving health and treatment services
• Improve staff training on early identification
• Pilot early identification and treatment
• National Needs Assessment
• MOCAM, evidence review
• Better help for vulnerable groups (e.g. homeless, drug addicts, mentally ill, young people)
Treatment: a spectrum of need
Harmful
Hazardous
Dependence
Increasing consumption
Brief interventions
Specialist interventions
Residential interventions
Assisted withdrawal
The potential of ‘stepped care’
• Caters for a range of needs
• Intensive interventions delivered only to those who do not respond to brief interventions
• Practical clinical algorithm (care pathway)
• Already accepted in a range of conditions
• New method of shared care with specialists supporting GPs
Alcohol Screening and Brief Intervention Research Programme
national brief intervention research consortium
A&E St. Mary’s 'Scientia Vincit
Timorem'
Safe, Sensible, SocialSafe, Sensible, Social– No specific funding commitmentNo specific funding commitment– Local needs assessmentLocal needs assessment– Redefinition of target groups: young binge Redefinition of target groups: young binge
drinkers & older adults drinking over 50/35 unitsdrinkers & older adults drinking over 50/35 units– New PSA targets: alcohol-related hospital New PSA targets: alcohol-related hospital
admissionsadmissions– National Audit Office studyNational Audit Office study– Roll out of units campaign, social marketing, Roll out of units campaign, social marketing,
brief interventionsbrief interventions– NTA role: NATMSNTA role: NATMS
Safe, Sensible, Social & young people
• Young people<18 and 18-24 binge drinkers• Sharpened criminal justice for drunken behaviour• Toughened enforcement of underage sales• Trusted guidance for parents and young people• Public information campaign to promote sensible
drinking• Public consultation on alcohol pricing and promotion• Local alcohol strategies and partnerships: universal
education, targeted support, specialist drug and alcohol treatment (£62M Young People’s Substance Misuse Grant)
PSA 25
• To reduce the rate of alcohol related hospital admissions by 2011
• Alcohol related admissions rising by 73,000 pa
• Aim to reduce the rate from 25% to 11% pa• NHS contribution to this of 6%• Through the Alcohol Improvement
Programme
Early Implementor PCTs
NHSPlanned delivery on RA-RHAs
Impl
emen
tatio
nSu
ppor
t
Prio
rity
acce
ss
lear
ning
learning
Evid
ence
Trailblazers (SIPS), ANARPEffectiveness review, HES data,etc
Trailblazers (SIPS), ANARPEffectiveness review, HES data,etc
PCTs (Unplanned) delivery on targets through implementation of elements of the high
impact actions
learningAlcohol Interventions Improvement Centre
Enabling changePriority support to early implementor PCTs.Tools: Learning sets, collaboratives, etc
Learning CentreCollects, co-ordinates and disseminates learning and good practice. Tools: SIPS toolkits, HuBCAPP, e-learning resource
NST(DH)Supports 18 struggling PCTs P.A.Strategic reports & follow-up
visits
Revi
ew
Supp
ort
Regional co-ordinators (DH/SHA)
Responsibility to ensure delivery
of targets
learning
National Alcohol Improvement Programme
DH Policy TeamRole: Work with outside bodies to facilitate frontline delivery. Develop policy, Develop Guidance, Commission, co-ordinate and contract manage support projects, channel expertise,
DH brandedle
arni
ng
NWPHO
Provide local data on need and key evidence
Start delivering RA-RHAs
Receive priority support from AIIC
Implement high impact actions
Supp
ort
Influ
ence
£600k
£2.7m
£250k
£750k
£4m
£1.2m
£60k
Total £9.66m for 2009/10
£100k
“High Impact Changes”1. Work in partnership2. Develop activities to control alcohol misuse 3. Influence change through advocacy 4. Improve the effectiveness and capacity of
specialist treatment • 100 extra people treated can save 28 admissions
5. Appoint an Alcohol Health Worker• Can save 15 admissions per month = 180 per year
6. IBA - Provide more help to encourage people to drink less
• IBA in A&E can save 40 admissions per year
7. Amplify national social marketing priorities
NICE Guidance 2010-11
• Alcohol use disorders– Preventing harmful drinking (PH24)
– Diagnosis and clinical management of alcohol related physical complications (CG100)
– Diagnosis, assessment and management of harmful drinking and alcohol dependence (CG)
• Related guidance– Psychiatric comorbidity (CG)
– Complex pregnancies (CG)
Government’s Alcohol Strategy 2013
• Minimum unit price
• Revision of licensing act
• Responsibility deal for industry
• Drinkaware
• Review drinking guidelines
• NHS health check
• Under 18 A&E pathway
• Payment by results
AMPHORA• EU research programme grant• 4m Euros, 4 years• 9 Workpackages, including
– Price consumption and harm– Availability– Cultural determinants– Marketing and advertising– Brief interventions and treatment– Drinking environments– Illegal production
1.1. EU adults drink 27g alcohol (nearly three drinks) a day, more than twice the world's average.
2. About 138,000 EU citizens, aged 15-64 years, die prematurely from alcohol in any one year.
3. EU drinkers consume more than 600 times the exposure level set by the European Food Safety Authority for genotoxic carcinogens, of which ethanol is one.
4. Countries with stricter and more comprehensive alcohol policies generally have lower levels of alcohol consumption, and policies are tending to get stricter in recent years.
5. Alcohol policies impact on alcohol consumption, even when talking into account broader socio-demographic changes, such as increased urbanization which is associated with increased consumption and increased maternal age at all childbirths which is associated with decreases in consumption.
6. Online alcohol marketing and alcohol branded sports sponsorship increase the likelihood of 14 year olds to drink alcohol.
7. Brief interventions for risky drinking and pharmacological treatments for alcohol use disorders are effective.
8. The proportion of people who actually access treatment out of those who need it ranges from only 1 in 25 to 1 in 7.
9. Young people are often already drunk by the time they go out, fuelled by cheap alcohol from shops and supermarkets, with drinking venues exacerbating problems further.
10. 10. Monitoring alcohol policy and its impact needs much improvement.
European Alcohol Strategy
• WHO Global alcohol strategy 2010
• WHO Implementation plan 2013
• WHO European Alcohol Action Plan 2012
• EU Alcohol Strategy?
Conclusions
• Effective strategies are available
• Implementation variable across Europe
• Influence of the alcohol industry
• Lack of political will
• Lack of public support?
References• Bruun et al. (1975) Alcohol control policies in public health
perspective. Finnish Foundation for Alcohol Studies. New Brunswick, New Jersey.
• Prime Ministers Strategy Unit (2003) Interim Analysis. Cabinet Office.
• Prime Ministers Strategy Unit (2004) Alcohol Harm Reduction Strategy for England. Cabinet Office, London
• Drummond et al. (2005) Alcohol Needs Assessment Research Project. Department of Health
• Anderson and Baumberg (2006) Alcohol in Europe. Institute of Alcohol Studies
• NTA (2006) Models of Care for Alcohol Misusers• Raistrick et al (2007) Review of the effectiveness of treatment
for alcohol problems. Department of Health• National Audit Office (2008) Reducing alcohol harm. NAO
References contd
• Oforei-Adjei, Casswell, Drummond et al (2007) World Health Organisation Expert Committee on Alcohol Problems, Second Report. WHO, Geneva.
• Babor et al (2003) Alcohol, no ordinary commodity. OUP, Oxford
• Room et al., (2005) Alcohol and publi health. Lancet, 365, 519
• Lancet series 2009:• http://www.thelancet.com/series/alcohol-and-global-health• http://amphoraproject.net/w2box/data/e-book/AM_E-
BOOK_2nd%20edition%20-%20final%20Sept%202013_c.pdf
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