Health, Social and Economics Impact of alcohol ...ec.europa.eu/health/ph_determinants/life_style/alcohol/...A 100 page scientific report in English and French on the health, social

Health, Social and Economic Impact of Alcohol

Stakeholders’ workshop20 January 2005

A 100 page scientific report in English and French on the health, social and economic impact of alcohol, describing options for action at the Member State and European level

A 4 page summary in all languages of the EU25

To be delivered by end of March 2005

Contents:

1. Introduction

2. A history and economy of alcohol

3. The use of alcohol in Europe

4. The impact of alcohol on individuals

5. The impact of alcohol on Europe

Contents

6. The effectiveness of alcohol policy

7. European and global alcohol policy

8. Member State alcohol policy

9. Making alcohol policy in Europe

10. Conclusions and recommendations

Authors

Peter Anderson, MD, PhD, MPH

• Consultant in public health, Research Fellow, Oxford University, England and Radboud University, Nijmegen, Netherlands

Ben Baumberg, MA

• Scientist, Institute of Alcohol Studies, England

Andrew McNeill, BA

• Director, Institute of Alcohol Studies, England

Method of working

Official statistics, publications and reports of European Commission and World Health Organization

Reports and guidelines of governmental bodies

Systematic reviews and meta-analyses, including Cochrane reviews

1. Public health purpose of alcohol policy

The science and art of preventing disease, prolonging life and promoting health through the organized efforts of society (Acheson 1988)

The process of mobilizing local, state, national and international resources to ensure the conditions in which people can be healthy (Oxford Textbook of Public Health 2002)


The central purpose of alcohol policies is to serve the interests of public health and social well-being through their impact on health and social determinants, such as drinking patterns, the drinking environment, and the health services available to treat problem drinkers (Babor et al 2003)


Discussion point: How well does this describe the purpose of alcohol policy?

2. Terminology

The ICD 10 classification of mental and behavioural disorders of the World Health Organization (endorsed and accepted by the Member States) includes alcohol use disorders and defines them under the headings of intoxication, harmful use, and alcohol dependence.

2. Terminology

Acute intoxication A condition that follows the administration of alcohol resulting in disturbances in level of consciousness, cognition, perception, affect or behaviour, or other psycho-physiological functions and responses.

2. Terminology

Harmful use A pattern of alcohol use that is causing damage to health. The damage may be physical (as in cases of liver cirrhosis) or mental (e.g. episodes of depressive disorder secondary to heavy consumption of alcohol)

2. Terminology

Dependence syndrome A cluster of behavioural, cognitive, and physiological phenomena that develop after repeated alcohol use and that typically include a strong desire to take alcohol, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to alcohol use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state.

2. Terminology

Abuse The term "abuse" is sometimes used disapprovingly to refer to any use at all, particularly of illicit drugs. Because of its ambiguity, the term is not used in ICD-I0 (except in the case of non-dependence-producing substances) (WHO lexicon)

2. Terminology

Misuse Use of a substance for a purpose not consistent with legal or medical guidelines, as in the non-medical use of prescription medications (WHO lexicon)

2. Terminology

Discussion point: As ICD 10 is the standard accepted and recommended nomenclature, should this be the preferred terminology?

3. Economic cost of alcohol

The UK government’s costs:

Based on prevalence-based estimates of heavy drinking (500/360 g alcohol plus for men and women) and alcohol dependence

Follows the international guidelines for estimating the costs of the harm done by substances (Single et al, 2001) and utilises the “Cost-of-Illness” methodology

In this framework alcohol use disorders are treated as an illness that gives rise to costs and consumes resources, which in its absence would have been used in another way


Only external costs are considered. Individuals are assumed to take into account both the private benefits and costs of an activity when making decisions to undertake this activity.

From the point of view of public policy it is these external costs imposed by the user upon the rest of society that are relevant, not private benefits stemming from his or her activities. For example, when dealing with issues of environmental pollution, policy makers are concerned about external costs borne by society and not by the private benefits that the polluters may enjoy.


External benefits, such as alcohol’s perceived contribution to the development of social networks and social capital are not included

The output, income and employment generated by the alcohol industry are not measures of social benefits attributable to alcohol and are thus not included.


Estimates do not simply describe the budgetary impact of alcohol on government accounts.

It cannot be argued that if the net impact of alcohol on the government’s budget were positive then harmful alcohol use would be in the public interest. Budgetary studies of this type totally ignore the costs of loss of life and the pain and suffering caused by alcohol, which should be used in cost estimates.


Crime60%

Lost productivity32%

Health care8%Alcohol

costs England €30billion per year

Source: UK Cabinet Office 2003


Discussion point: Is the England methodology an acceptable methodology to adopt?

4. Alcohol consumption in Europe

Alcohol consumption (l per person aged 15+) for EU15, EU25 and EU10

10

11

12

13

14

15

16

17

1970 1975 1980 1985 1990 1995 2000

Con

sum

ptio

n (l

per

cap

15+

)

EU25EU15EU10


It seems more sensible to interpret this as part of a larger changing attitude in Southern European populations, whereby people have become more concerned about drinking alcohol and its possible harmful effects. (European Comparative Alcohol Study)


However, the growing role of wage labour did have some effect, since too much wine or alcohol consumption is thought to reduce the capacity to meet the more and more exacting demands of daily work. (European Comparative Alcohol Study)


Change in consumption = 2.1 - 0.6 (change in policy)

-10

-8

-6

-4

-2

0

2

4

6

8

10

-5 0 5 10 15

Change in alcohol policy 1950-2000

Chan

ge in

alc

ohol

con

sum

ptio

n 19

70-2

000

Changes in alcohol consumption by changes in alcohol policy; 14 EU countries. ECAS study


Discussion point: What are the explanations for the decline since the mid 1970s, and the plateau during the late 1990s?

5. What determines young people's drinking

Systematic reviews (for example Australia’s Ministerial Council on Drug Strategy’s review of the prevention of substance use, risk and harm in Australia) consistently find that it is parental and community role models that are of the utmost importance in encouraging alcohol use and alcohol-related harm among children and adolescents.


The report of the Ministerial Council on Drug Strategy thus suggested the need for whole-population strategies to address overall levels of use and to break intergenerational patterns.


Discussion point: What whole population strategies could be adopted?

6. The individual harm done by alcohol

1

2

3

4

5

6

7

0 10 20 30 40 50 60 70 80 90 100 110 120

grams alcohol per day

Rel

ativ

e ris

k Cancer oral cavity

Cancer of breast

Hypertension

Haemorrhagic stroke

Pancreatitis

Risk of harm by alcohol consumption (g/day); Source: Corrao et al 2004


Grammes of alcohol per day

160140120100806040200

Rel

ativ

e ris

k

1.6

1.4

1.2

1.0

.8

.6

Risk of heart disease by alcohol consumption (g/day); Source: Corrao et al 2004


0

10

20

30

40

16-34 35-64 65+

Age (years)

Gra

mm

es a

lcoh

ol/d

ay

WomenMen

Level of alcohol consumption with lowest risk of mortality by gender and age; Source: White et al 2002


Discussion point: What are the policy implications of this?

7. Disability adjusted life years

The Disability adjusted life year (DALY) is a summary measure of population health that combines information on mortality and non-fatal health outcomes.

It measures a gap in health between the current position and what could be achieved.

It is additive across causes to give the total health gap for a population.


Mortality by sex and age is based on the 10th Revision of the International Classification of Diseases, Injuries and Causes of Death (WHO 1992)

Non-fatal health outcomes are based on surveys containing both self-reported and measured health status levels.

Health status is adjusted on a scale that ranges from zero (for a state equivalent to death) to unity (for a state of ideal health), based on surveys on health in more than 60 Member States.


DALYs are discounted at 3% a year, giving greater weight to the near future as opposed to the distant future.

DALYs include non-uniform age weights in order to reflect the dependency of children and older people on young adults.


The contribution of risk factors is based on age and gender specific incidence, remission and case-fatality rates derived from epidemiological surveys in different populations (Comparative Risk Assessment).


Alcohol7.4%

61 million DALYs

Proportion of total EU25 DALYs caused by alcohol; source: Rehm et al in press


Discussion point: Although there are other summary measures of population health, since DALYs are the most frequently used, is it reasonable to use them?

8. A population’s level of drinking

There is a relationship between the levels of alcohol consumed by a population and the proportion of heavy drinkers.


Relationship between mean alcohol consumption and prevalence of heavy drinking. 32 countries. Rose 1992.


Relationship between mean blood pressure and prevalence of hypertension. 32 countries. Rose 1992.


Relationship between mean mental ill-health and prevalence of mental ill health. 11 regions, UK. Rose 1992.


14

16

18

20

22

24

26

28

140 150 160 170 180 190 200 210 220

Mean population alcohol consumption (g/week)

% d

rink

ing

>280

g/w

eek

Relationship between mean alcohol consumption and proportion of heavy drinkers; 8 English regions Source: Primatesta et al 2002


9.8

10.7

9.4

0

2

4

6

8

10

12

14

16

1980 1990 2001

Year

% a

bsta

iner

s

8.5

9

9.5

10

10.5

11

Per c

apita

con

sum

ptio

n

% female abstainers % male abstainers Per capita consumption

Abstinence rates in the UK and population alcohol consumption; Source: Academy of Medical Sciences


0

50

100

150

200

250

300

350C

hang

e in

alc

ohol

co

nsum

ptio

n (c

l pur

e al

coho

l)

0 50 100 150 200 250 300 350 400Initial alcohol consumption (cl pure alcohol per

year)

Mean change, total population

Change in alcohol consumption between 1968 and 1969 by initial level of consumption, following alcohol policy liberalization in Finland; Mäkelä 2002


An increase in consumption produces an increase in harmful effects on the health of the population.


% reduction in male death rate when per capita alcohol consumption reduced 1L per year. Medium consuming European countries Source: Norström & Skog 2001 *Both men and women

-12

-10

-8

-6

-4

-2

0

AccidentsCirrhosisHomicideIHDSuicidePancreatitis*All causes


Sir Richard Doll, the founding father of modern epidemiology has summed the evidence as such: “every scientific committee I have ever sat on has concluded that reduction in harm caused by drinking can only be achieved by reducing our overall consumption. It just doesn't work to target a minority”.


Discussion point: How can the message that to deal with the harm done by alcohol one needs a mix of targeted and overall strategies best be conveyed to civil society and its governments?

9. Violence to families, women and children

Alcohol is involved in about 50 percent of cases of domestic physical and sexual violence, although its role in precipitating or exacerbating violence varies. It is estimated to cause 16% of child abuse.


5.6

50%

9.3

55%

10.4

61%

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Homicide per 100,000 population

Northern Europe Central Europe Southern Europe

Alcohol consumption L/capita

Homicide Attributable to alcohol

Proportion of homicides attributable to alcohol; ECAS study


Training programs for bar staff and managers have demonstrated reductions in high risk drinking and drinking problems, although the effects, which are modest, have not been found in all evaluations.(Babor et al 2003)


The most effective options have involved enhanced enforcement of regulations around serving and legal liability of bar staff and owners for the actions of those they serve. (Babor et al 2003)


Discussion point: What are the best policy options to reduce alcohol related family violence from occurring?

10.The impact of school based education

56 studies of psychosocial and educational interventions were selected for inclusion in the systematic review. 20 of the 56 studies showed evidence of ineffectiveness. (Foxcroftet al 2003)


No conclusions could be made about whether or not preventive interventions were effective in the short and medium term. (Foxcroft et al 2003)


0

510

1520

25

3035

40

Baseline 8 months 20 months 32 months

Pro

por

tion

(%

)

Control Intervention

The impact of 2 education sessions [ ] on binge drinking in 13-15 year olds; McBride et al 2004


3 out of 8 studies showed some evidence of effectiveness in the long term (over 3 years), particularly a family based intervention and a culturally focused skills training. (Foxcroft et al 2003)


Discussion point: Where would the released resources be better invested to reduce the harm done by alcohol?

11.Brief interventions for harmful alcohol use

Numbers needed to treat (NNT) for alcohol and smoking

10

20

88

0

5

10

15

20

25

Al c ohol A l c ohol -r e l a t e d ha r m

Ni c ot i ner e pl a c e me nt

t he r a py

Ce ssa t i ona dv i c e


3 0 0 0 0

18 0 02 0 0 0

0

5 0 0 0

10 0 0 0

15 0 0 0

2 0 0 0 0

2 5 0 0 0

3 0 0 0 0

3 5 0 0 0

A lcoho lad vice

N ico t inerep lacement

t herap y

A verag e o fmed ical

t reat ment s

Cost per year of ill health or premature death prevented (€)


0

200

400

600

800

1000

1200

1400

1600

Euro A

DA

LYs

prev

ente

d pe

r milli

on p

eopl

e pe

r yea

rBrief interventions

Random breath testing

Taxation (40%)

Restricted sales

Advertising ban

Impact of different policy options in preventing DALYs per million people per year in sub-region A of EU25; Adapted from Chisholm et al 2004


0

10

2 0

3 0

4 0

50

Control Treatment Control Treatment

Screening rates Advice giving rates

Impact of educational and office based programmes in increasing proportion screened and advised (%); Anderson et al 2004


Discussion point: How important is it for the health care sector to take up these interventions, and how can they best be widely implemented?

12.Choosing different policy options

0

200

400

600

800

1000

1200

1400

1600

Euro A

DA

LYs

prev

ente

d pe

r milli

on p

eopl

e pe

r yea

r

Brief interventions


Taxation (40%)

Restricted sales

Advertising ban

Impact of different policy options in preventing DALYs per million people per year in sub-region A of EU25; Adapted from Chisholm et al 2004


0

50

100

150

200

250

Euro A

Cos

t per

100

peo

ple

per y

ear(

€)Brief interventions


Taxation (40%)

Restricted sales

Advertising ban

Cost of implementing same policy options per 100 people per year(€) in sub-region A of EU25; Adapted from Chisholm et al 2004

10

100

1000

10000

10 100 1000 10000DALYs prevented per million people per year

Cos

t per

100

peo

ple

per y

ear(

€)A. Brief physician advice (25% coverage)

B. Random Breath Testing

C1. Taxation (40%)

C2. Taxation (75%)

D. Restricted access (sales)

E. Advertising ban

F1. Brief advice+RBT

F2. Tax(75%)+Ad Ban

F3. Tax(75%)+RBT

F4. Brief advice+Tax(75%)

F5. Tax(75%)+Ad Ban+Restrict access

F6. Brief advice+Tax(75%)+RBT

F7. Brief advice+Tax(75%)+Ad Ban

F8. Brief advice+Tax(75%)+Ad Ban+RestrictaccessF9. Brief advice+Tax(75%)+Ad Ban+RBT

F10. Tax(75%)+Ad ban+Restrictaccess+RBTF11. Brief advice+Tax(75%)+Adban+RBT+Restrict access

€10,0

00 pe

r DALY

€1,00

0 per

DALY

€100

per D

ALY


Cost, impact and cost effectiveness of implementing policy options in sub-region A of EU25; Adapted from Chisholm et al 2004


Reasons for taxation:

1. Incomplete information about health risks2. Incomplete information about dependence,

particularly for younger drinkers (about one half of the reason for heavy drinking young adults not to reduce their consumption is due to the difficulty (costs) of dependence)

3. Costs imposed on others


Protection of children might be the most compelling economic argument for higher taxes:

1. Childhood drinking is predictive of future harm and dependence

2. Children are not yet sovereign adults making informed choices

3. Impact of marketing4. Alcohol is generally affordable and accessible, thus

the market does not spontaneously protect children


If alcohol taxes are to be used mainly to deter children and adolescents from harmful drinking, then the tax on children should be higher than the tax on adults. Such differential tax is difficult to implement. A uniform rate for children and adults would impose a burden on adults; societies may consider this is justifiable to protect children. If adults drink less, children drink less


Alcohol taxes have a greater impact on:Younger drinkersHeavier drinkersPoorer drinkers

Thus, it is a targeted tax


0%

5%

10%

15%

20%

25%

30%

35%

Tax - beer Tax - wine Tax - spirits

World EU25

Prevalence of tax >30% of price (beer and wine) and 50% (spirits) in EU25 and rest of world; WHO 2004


Discussion point: If countries are to be serious about reducing the harm done by alcohol, is there not a compelling case for increasing taxes (which also increase government revenue)?

This paper was produced for a meeting organized by Health & Consumer Protection DG and represents the views of its author on the subject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumer Protection DG's views. The European Commission does not guarantee the accuracy of the data included in this paper, nor does it accept responsibility for any use made thereof.

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Health, Social and Economics Impact of alcohol ...ec.europa.eu/health/ph_determinants/life_style/alcohol/...A 100 page scientific report in English and French on the health, social