POLICIES TO TACKLE HARMFUL ALCOHOL USE · The consequences of harmful alcohol use have not been thoroughly assessed The effects of harmful alcohol use have only been partially assessed

ENTITIES AND PUBLIC POLICIES

POLICIES TO TACKLE

HARMFUL ALCOHOLUSE

Thematic public report

Public policy evaluation

Summary

June 2016

� DISCLAIMER

This summary is intended to facilitate the understanding and useof the report produced by the Cour des Comptes.

Solely the original report is legally binding on the Cour descomptes.

Responses from government agencies and stakeholders areprovided at the end of the report.

Contents

Summary of the thematic public report by the Cour des comptes

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

1 No consensus on alcohol policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

2 Public measures are struggling to change behaviour . . . . . . . . . . .11

3 Insufficiently coordinated and evidence-based policies . . . . . . . . .15

4 Make preventing harmful alcohol use a public policy priority . . .17

Conclusion and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

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Drinking is a sensitive issue in France, where alcohol is associated with celebrations,lifestyle and culture. This social and cultural heritage is further strengthened byalcohol's economic clout, and results in a general tolerance towards drinking.This largely explains the challenges in designing and implementing a long-termintegrated public health and safety policy.

The French Monitoring Centre for Drugs and Drug Addiction (OFDT) estimatesthat of the country's 8.8 million regular drinkers, 3.4 million are at risk, only 10%of whom are in care. According to the only recent study available in France,which was published in 2013, approximately 49,000 deaths were attributable toalcohol in 2009, or 13% of deaths among men and 5% among women. A studyreleased in 2015 noted that alcohol was the primary cause of hospitalisation(580,000 patients, estimated cost of €2.6 billion) and that excessive drinking wasrelated to around 60 diseases.

Based on these findings, and pursuant to Article L. 111-3-1 of the Code ofFinancial Jurisdictions, the Cour des comptes decided to conduct an evaluation ofpublic policies aimed at tackling harmful alcohol use. Conducted in conjunctionwith the main stakeholders through a support committee, this evaluation soughtto assess the impact of these public policies on society, considering positive andnegative factors with reference to appropriate foreign examples. Based on theevaluation recommendations have been drawn up to address areas where roomfor improvement has been identified.

The evaluation consisted in examining data availability, in analysing patterns ofharmful alcohol use with regard to the most up-to-date clinical and epidemiologicalknowledge, in reviewing the main tools employed by relevant stakeholders in theareas of product distribution rules, price-setting, as well as public health and publicsafety, and in documenting the outcomes. Every effort has been made to ensurethat all findings were traceable and verifiable.

Introduction


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Introduction

Categories of alcohol use

The French Society for the Study of Alcohol identifies five categories of alcoholuse in France:

- non-consumption, i.e. non-drinkers; according to the OFDT (2.3 million peopleaged between 11 and 75 had never drunk alcohol in 2014);

- social or low-risk alcohol consumption, which covers 8.8 million regular drinkerso/w 4.8 million daily drinkers; intake in this category is below 21 units a week orthree units a day for men, 14 units a week or two a day for women, four unitsduring one session, with pregnant women abstaining completely;

- the misuse of alcohol, which comprises three sub-groups of regular drinkers:

1) at-risk use, defined as drinking that exceeds the abovementioned levels, resul-ting in an increased risk of developing cancer, liver disease (cirrhosis), cardiovascu-lar and digestive problems, and psychiatric problems such as depression oranxiety; people in this group are referred to as regular excessive drinkers of whomthere were an estimated 3.4 million in 2014;

2) use leading to somatic, psychological or social complications linked todrinking without alcohol dependence;

3) use with alcohol dependence, characterised by loss of control of consumptionand associated with a variety of complications.

Among the different types of at-risk use, heavy episodic drinking, commonly calledbinge drinking, is generally defined as the consumption of five or more units in onesession for men and four or more units for women, i.e. 50g or 40g of pure alcoholconsumed over a short period (two hours or more).


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1No consensuson alcohol policy


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Because of the special place occupiedby alcohol in France's history, culture,economy and social life, there iswidespread tolerance when it comesto the consumption of alcoholicbeverages, whose adverse effects areheavily underestimated.

A long-standing traditionof production and consumption

The economic clout of the alcoholicbeverages sector explains the highlevel of sensitivity of stakeholderstowards any attempt to challengethe status of alcohol – especiallywine – on public health grounds.Wine and alcohol in general forman integral part of the French life-style, which makes it difficult toenforce an effective alcohol controlpolicy by drastically reducing theeffectiveness of crackdown actionand prevention measures.

Consumption is on the declinebut remains higher thanin other countries

Average alcohol consumption inFrance has fallen steadily by 1.7% ayear since 1960. In 2014, it stood atapproximately 12 litres of purealcohol per person per year, according

to the latest data provided by theOFDT. Even so, this is considerablyhigher than the average of Europeanmember countries of the Organisationfor Economic Cooperation andDevelopment (OECD).

The decline is essentially attributableto a reduction in wine consumption. Atthe same time, however, binge drinkinghas risen, as have cases of repeatedand regular drunkenness , particularlyamong women and young people.

Moreover, despite the overall decline inconsumption, persistent risky behaviouron the part of pregnant women, youngpeople and socially vulnerable peoplemust not be overlooked; nor shouldthe 8.8 million regular drinkers beunderestimated .

The consequences of harmfulalcohol use have not beenthoroughly assessed

The effects of harmful alcohol usehave only been partially assessed dueto the limited information available.

In the first place, alcohol consumptionhas short, medium and long-termhealth consequences.

No consensus on alcohol policy

Yet the data on alcohol-relateddeaths have only been the subject oftwo recent studies in France, makingrigorous epidemiological monitoringimpossible. When it comes to alcohol-related morbidity, it is only possible toidentify the number of people benefitingfrom 100% coverage by the Socialsecurity system(which is the case inFrance for a range of severe diseases)for every alcohol-related disease,either partially or entirely. The data aretherefore heavily underestimated.

In addition, the frontier between low-riskand dangerous drinking is hard to draw,and scientists increasingly question thenotion that no-risk consumption does


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not exist. For this reason, the question ofdrinking guidelines is highly controversialbut crucial when targeting preventionmessages. For example, many countriesrevised their recommended limitsfollowing the discovery that cancerrisks emerge at levels of consumptionbelow the guidelines.

Alcohol abuse can also lead to violence,particularly among relatives, be thecause of anti-social behaviour, crimesand offences, and considerably lessenroad safety. While the role of alcohol inroad traffic accidents is well measured,its role in personal injury is less clearlyidentified, since very few studies areavailable.

Change between 2000 and 2014 in levels of regular use of the main activeingredients, people aged 17, Metropolitan France (%)

Source: HBSC 2010, data employed by OFDT, ESPAD 2011 high school years, OFDT-INSERM-MEN

The challenge of striking abalance between economic,public health and safety issues

There is no consensus in Franceabout the need for a specific publicpolicy about alcohol. Producersstress their economic and social role,while health authorities point to therisks associated with harmful use.

In this respect, public players are at adisadvantage compared with thealcoholic beverages sector, which haseasy access to European andNational Institutions.

The lack of a comprehensive plan toaddress harmful alcohol use in Francehas brought about this imbalancebetween business and public playersand deprived health sector stakeholdersof an integrated roadmap involvingpublic authorities.


No consensus on alcohol policy

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A number of issues relating to harmfulalcohol use in France remain highlycontroversial. In particular:

- the overall economic appraisal ofharmful alcohol use is not frameddispassionately;

- there is no consensus on whatconstitutes moderate drinking;

- there is a lack of consensus aboutfields of investigation, guidelines andresults of clinical and epidemiologicalresearch, with each camp drawingdiffering conclusions.

The lack of consensus stands in theway of unified public action.

2Public measures are strugglingto change behaviour


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The evaluation by the Cour descomptes reveals that by inadequatelyharnessing the available tools – fromdistribution rules and taxation topenalties for driving under theinfluence of alcohol (DUI), preventionand provision of health care – CentralGovernment has failed to properlyuse tools aimed at changing riskybehaviour.

Distribution rules are out of stepwith changing consumption habits

Rules fail to take account of marketdevelopments

Access to alcoholic beverages is madeeasier nowadays by the increasednumber of temporary licensed premisesor locations offering takeaway sales,which the current rules do not capture.

The so-called "quota" rule of one licensedpremises per 450 people does not applyto takeaway sales (by supermarkets andconvenience stores) or to online sales.Furthermore, takeaway sales, particularlyby late-night grocery stores, and salesto minors are not covered by checks.

Successive challenges to the Évin Act

In 1991, France passed the Évin Act,which introduced rules governing theadvertising of alcoholic beverages anda ban on the sale of alcoholic beveragesto minors aged 16 or under. Thesearrangements have been held up as anexample in Europe.

Successive amendments have dilutedthe law's effectiveness. The authorisation

given to sporting groups to sell alcoholwas lifted in 1999. Stricter conditionsof sale introduced by the HPST Actof 21 July 2009 were accompaniedby rules for online advertising.Article 13 of the Health SystemModernisation Act of 26 January2016 introduced measures to relaxthese requirements, in the name ofsupporting local produce and winetourism. Despite the restrictivelegislative framework, alcoholbrands employ a wide range ofchannels, including social networks,to deliver their advertising, tailoringtheir messages to different targetgroups. An INPES study in 2015found that French people feel thatadvertising is everywhere andrepresents a threat to young people.

Lobby groups are lightly regulated

Alcohol lobbying is not sufficientlyregulated in France. The current rules,which apply only to members ofParliament, need to be expanded andbolstered.

Unclear taxation goals

Taxation of alcoholic beverages isclosely regulated by Europeandirectives. Indirect taxes includeVAT and excise duties. Social leviesare also applied to some highlyalcoholic beverages. Revenues fromthese taxes, which amount toaround €6.6 billion including VAT,are partially earmarked for farmerwelfare.

Public measures are struggling to change

behaviour

There is no link between consumption,revenues and the level of taxation perbeverage category. Accordingly, wineaccounts for 58% of consumption,71% of non-export revenues but just3.6% of excise duties.

Furthermore, excise duty rates are notstrictly proportionate to alcoholcontent or to the specific harmfuleffects of different alcoholic beverages,except in the case of spirits and andpremix drinks. Public health objectivestherefore seem to have had littleinfluence on the goals of the taxregime.

Systems of checks and penalties do apoor job of containing risky behaviour

This is particularly true for drink drivingand drunk and public drunkenness.

Testing for drink drivingI has beendeclining for a number of years

because of policing issues and thecumbersome nature of the procedure.Meanwhile, penalties either do notoffer a sufficient deterrent (fines) orare hard to implement (suspension oflicense).

Police action agains public drunkennessalso runs into several difficulties: asidefrom the fact that law enforcementrepresentatives are exposed toaggressive and violent behaviour,these activities are a heavy drain onhuman resources, and follow-upmeasures are not in place to assistpeople in finding primary careassistance once they sober up.

Insufficient evaluationof health and road safetyeducation initiatives

Health and road safety educationinitiatives play an important role,but not enough is known about theiroutcomes.


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Spirits are most heavily taxed

Source: Cour des comptes


behaviour


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Insufficient assessment of healtheducation initiatives

While INPES is responsible for mostpreventive activities, other entitiesare also involved, especially thoseworking in specific environments,such as school and workplace health.Non-profit associations also have arole to play.

INPES, the main public organisationoperating in the field of prevention, hassought to adapt, despite decliningfinancial resources.

There is no overarching vision of thedifferent initiatives in place forschools, synergies between health andeducation personnel are struggling toemerge, and interventions by lawenforcement representatives are notevaluated.

In post-secondary education, there is ashortage of resources for preventivemedicine and health promotion services.In the workplace, the dearth of data onharmful alcohol use, workplacepractices and alcohol-related accidentsmakes it impossible to design anappropriate strategy.

Insufficient evaluation of road safetyeducation

Preventive road safety measures arenow chiefly divided between nationalcommunication campaigns conductedby the central government road safetyand traffic control Delegation(DSCR) and measures undertaken aspart of département-level roadsafety action plans (PDASRs).However the effectiveness of thesemeasures is not evaluated sufficiently.

Moreover, self-test solutions, such asmandatory alcohol sensors andalcolocks, though useful, are notwidely used.

Primary care physicians do not playenough of a role

Patients who drink to excess or sufferfrom alcohol-related diseases may becared for at several different levels,without necessarily having a formaltreatment pathway. This situation suffersfrom a lack of involvement by primarycare physicians, particularly generalpractitioners, but also from thefragmented approach to specialisedtreatments and the lack of interactionin many cases among medical andsocio-medical services.

For example, a survey by IFOPcommissioned by the Cour descomptes found that two-thirds ofgeneral practitioners surveyedwere unfamiliar with the alcoholscreening and. brief interventionmechanism, and that just 2% ofthem used it in a formal manner.

Efforts made to structure hospital-based care, care overly fragmented inthe socio-medical and non-profit sector

While hospital-based care is nowfairly well organised, other types ofcare are overly fragmented. Care isshared between the medical andhospital sector, the specialisedsocio-medical sector, which includesaddiction treatment, support andprevention centres (CSAPAs) anddrug user risk reduction drop-in andsupport centres (CAARUDs), andthe non-profit sector.


behaviourSummary of the thematic public report by the Cour des comptes

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Testing and penalties for DUI


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3Insufficiently coordinatedand evidence-based policies

Not enough is known about thehealth, economic and social costsarising from harmful alcohol use. InFrance, there is no comprehensivepolicy but merely a series of measuresplaced side by side with a view topreventing harmful alcohol use.Without the necessary coordinationto address conflicts between measures,outcomes are broadly disappointingand inadequately evaluated.

Costs have still to be measured

Unlike some countries, France doesnot adequately measure alcohol'shealth and social costs.

Health costs are broadly underestimated,given that estimates by the nationalhealth insurance fund for salariedworkers (CNAMTS) include just threesets of diseases that are entirelyattributable to alcohol (alcoholiccirrhosis, aerodigestive tract cancersand alcohol-related mental illnesses).

Prevention costs, meanwhile, are hardto isolate, since they are spreadacross a wide array of participants,including interministerial structures,central government directorates,health agencies, social security, devolvedand decentralised departments, andsubsidised non-profit associations.

Finally, the economic and socialcosts of harmful alcohol use are notmeasured by the public authoritiesbut by researchers, such as ProfessorPierre Kopp, an economist, whoestimated in 2015 that the social costsof alcohol abuse in 2010 amounted to€120 billion.

The Cour des comptes notes thatother countries, such as Sweden,Norway, the UK and Italy, have equippedthemselves better, setting up tools thatmonitor data on harmful alcohol usemore effectively, more routinely andon a more centralised basis than thesolutions employed in France.

A lack of investment in trainingand research

In France, instruction and research inthe field of alcohol have not beengiven priority in recent years.

Instruction on alcohol addiction inmedical and paramedical trainingcourses varies from region to regionbut is broadly inadequate.

Compared with what is going on abroad,research is unambitious, whether in themedical field or in public health.


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Insufficiently coordinated

and evidence-based policies

Incomplete coordinationof participants

Interministerial steering arrangementsremain unclear

In France, an interministerial unit, theMILDECA, was given responsibilityfor designing and implementingthe 2013-2017 drug and addictionprevention plan, which covers alladdictions, although alcohol, unliketobacco, does not have its own specificprogramme. However, the HealthDirectorate (DGS) is responsible foralcohol-related public health policyand plans.

There is no national strategy fordrink-related delinquency and violence,but rather public action plans containingvarying measures to prevent harmfulalcohol use.

Local steering arrangementsare shared between prefectsand regional health agencies (ARS)

Ever since HPST law was passed in2009, the ARS have been responsible

for designing and implementing theirown strategic health priorities in theirregion based on the national framework.The prefects of the département,meanwhile, are responsible for applyingother national policies, particularly interms of road safety, by coordinating thevarious territorial bodies tasked withputting these policies into practice.This dual governance arrangement,combined with the non-alignment ofdecision-making levels, has manydisadvantages, especially since otherlocal participants, including municipalauthorities and département andregional councils, also act within thescope of their own responsibilities. Thissituation undermines the clarity oflocal policies aimed at addressingharmful alcohol use.

Compounding this complexity, fundingfor local initiatives is heavily restrictedand insufficiently targeted.


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4Make preventing harmfulalcohol use a publicpolicy priority

The evaluation by the Cour descomptes makes it clear that harmfulalcohol use has highly detrimentaleffects on public health and publicsafety and that the health and socialcosts far exceed alcohol-related taxrevenues. Similarly, the fragmentednature of previous policies and the lackof targeted objectives and instrumentstomeasure the effectiveness of initiativeson the ground mean that France fallsshort of the best practices recommendedby the World Health Organisation(WHO) and the OECD.

A unified policy to address harmfulalcohol use would help to raiseawareness among consumers aboutthe damaging effects of alcohol onhealth and social life, and make peoplemore personally accountable in termsof their relationship to alcohol. Thiskind of awareness is a pre-requisite foreffective public policy.

Given the existing fragmentedgovernance arrangements, stepsshould be taken to implement aconsistent long-term plan at thehighest level of government.

Draw up a programme to reduceharmful alcohol use

To address the urgent need forpublic action, an interministerialaction programme needs to bedrawn up and led at the very highestlevel, i.e. by the Prime Minister, as isthe case, for example, in the UK. Thisprogramme should be backed by thenecessary resources and regularlyevaluated.

A comprehensive and regularlyevaluated programme

The strategy to prevent harmfulalcohol use prepared as part of thisnationwide programme should bebased on objectives derived fromepidemiological and socio-economicdata and identify the most appropriatetools for each action area.

Action taken under the programmeshould be followed up using pre-deter-mined indicators, rounded out by spe-cific monitoring for certain measures.An assessment every three or fouryears would be used to measure pro-gress, taking account of the latestscientific advances, and make anynecessary adjustments. An undeniableidentification of the health and socio-economic costs due to harmful alcoholuse would support this assessment.


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Make preventing harmful alcohol use a public

policy priority

A programme based on scientificevidence

To be effective over the long run, ahealth policy for alcohol will requireefforts to continue to advancingknowldege through an evidence-based medicine approach. This willentail examining the scientific literaturewith a view to identifying the mostappropriate level of intervention foreach patient.

Ensure that the programmeis steered effectively

Programme implementation will requireclear governance. The programme willbe steered at the national level.Interministerial coordination will be vital,with the Health Minister occupying a keyrole, supported by the Interior Ministeron questions of public safety. Localimplementation of the programmeshould be entrusted to regional anddépartement prefects, with ARShandling the health component,supported by the MILDECA projectleader. Regional and département

councils and the most involvedmunicipal authorities would also beinvited to participate.

Earmark the necessary resources

Implementing a programme to reduceharmful alcohol use will requirehuman and financial resources toprovide for prevention, other priorityareas, research and training.

Use every tool available

Every available tool must be used,including information, prevention andsupport. Action should also be takenon pricing, which would entail raising

taxes. Introduction of a minimumprice – a good solution because of itscomparative effectiveness – would haveto include steps ensure compliancewith the Treaty on the Functioning ofthe European Union.

Meanwhile, the use of alcohol is subject toa wide array of rules, chiefly concerningadvertising, product information,lobbying, product availability and DUI.These rules need to be strengthenedand improved to combat harmful use,which remains too widely tolerated inFrance.

Come up with more effectiveinformation and preventive measures

An effective strategy needs to bebased both on measures that addressthe general population and measuresaimed at clearly identified targetgroups. If regular excessive drinkersare targeted too closely, there is adanger of overlooking other at-riskregular drinkers.

It is equally vital to conduct specificmeasures particularly for youngpeople, pregnant women and peoplein specific or vulnerable situations.

The preventive message for pregnantwomen should be to recommendcomplete abstinence, given that it isnot possible to set a level of use thatwould be acceptable for the foetus.

In addition to schools, three otherparts of the population deserve specialattention: post-secondary institutions,the workplace and offenders.


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policy priority

For the workplace, the Labour Codeshould be amended to place a totalban on bringing alcohol to work, as isthe case in Italy. A limited number oftemporary exemptions could beauthorised over the course of the year.Two action areas could be usefullyexpanded: first, implementation ofthe alcohol screening and briefintervention process by medical staffat the workplace; second, measuresto provide guidance to people withdrinking problems.

Step up training and involvementof health professionals to moreeffectively identify risky behaviour

First, a target needs to be set foralcohol-related training in medicaland paramedical courses of study,followed up by mandatory knowledgetesting.

Also, health professionals, whetherthey work in oncology, emergencyunits, surgery or maternity wards,need better training in preciselyidentifying alcohol use. Increasedtraining hours in study courses andthe opening of addiction specialistpositions in universities and hospitalswould be a good step forward.

General practitioners and workplacephysicians could play a much biggerrole in both detection and primarycare.

Various avenues could be used toencourage general practitioners tostep up their use of alcohol screeningand brief intervention. This procedureneeds to be part of a global approach toaddictions, such as inclusion in publichealth objectives-based remuneration(ROSP), the addition of extended

consultations for addiction detectionand care to the list of procedures, anddevelopment of shared case manage-ment by physicians and clinicalnurses.

Hospitals, notably emergency units,also need to be part of efforts to stepup primary care involvement. It isimportant to encourage emergencyunits to do more to spot patientswith alcohol problems and guidethem towards primary care throughchannels that are coordinated withaddiction services. These arrangementsneed to be adjusted on a case by casebasis to reflect the interventioncapabilities of addiction liaison andtreatment teams (ELSAs) and the scopefor cooperation among interestedservices.

Raise prices to reduce harmful use

Pricing and tax-based measures arementioned in all recent papers(including the OECD's most recentstudy in 2015) as among the mosteffective ways to promote publichealth and lower the social costs ofalcohol.

Minimum pricing essentially targetsthe consumption of low-cost alcoholicbeverages by regular excessive drin-kers, who often come from disadvan-taged backgrounds. Following a refe-rence for a preliminary ruling broughtby the Scottish Court of Session, theCourt of Justice of the EuropeanUnion (CJEU) ruled that the introduc-tion of a minimum price had to beconditional on the establishment ofprecise public health goals and thatthe inadequate effectiveness of natio-nal taxation would have to bedemonstrated.


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policy priority

More effective rules governingadvertising, product informationand lobbying

Restrictions on advertising are viewedas an appropriate and effective way tolimit consumption, particularly amongyoung people, who are a priority groupin France. Restrictions on advertisingneed to cover all disseminationchannels, including digital ones.

Lessons also need to be drawn fromthe way in which lobbying by producershas seen public health come offsecond-best in decisions on mostmeasures involving the sale of alcoholicbeverages. There are procedures tomake lobbying as transparent aspossible, along the lines of long-standing arrangements withinEuropean institutions or, morerecently, for tobacco lobbyists.

Overhaul the laws on licensedpremises and set aside resourcesto enforce compliance

The rules governing licensed premisesare outdated and not subject toadequate checks. They need to beoverhauled and enforced, sincesome offences, such as the sale ofalcohol to minors, are not subjectto adequate checks.

Improve the effectivenessof DUI measures

Future measures should be guided bythe need to punish those who driveunder the influence of alcohol moreeffectively and decisively and to getpublic opinion behind the idea thatdrinking and driving do not go together.

Communication campaigns need tobe more effectively directed throughbetter assessment, while the preventiveaspect of insurance could be moreeffectively directed through progressivepenalties for offenders. At the sametime, steps should be taken to build upa prevention system, primarily bydeveloping self-test procedures.

Without ruling out the notion of loweringthe blood alcohol concentration limitfor all drivers to 0.2 g/l, the firstpriority should be to simplify testingprocedures, which are currently random,time-consuming and complicated, toincrease the likelihood that individualdrivers may be checked, emulating theeffectiveness of automatic speedcameras.

To make testing more efficient, standardfines for offences involving excessiveblood alcohol concentrations need to berevised, and the maximum level shouldbe raised from 0.8 g/l to 1.2 g/l. Thiswould lead to more effective punishmentof the most common cases of excessiveblood alcohol concentration.

Moreover, it would be more efficient touse a single type of device to measureblood alcohol concentration andestablish the burden of proof. Thisnew device would combine the fea-tures of the existing testing andmeasurement units and could thusidentify blood alcohol concentrationif the authorised threshold has beenbreached.

The requirement to install alcolocks,which have shown their effectiveness onrepeat offenders, could be extended bystrengthening the network of garagesauthorised to install such devices.

Conclusion

and recommendations

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In concluding this evaluation, the Cour des comptes offers six main findingsand proposes three guidelines to achieve more effective prevention of harmfulalcohol use.

The six findings are as follows:

- first, there is no consensus in France on such basic points as the overalleconomic impact of harmful alcohol use or the relationship between consumptionand risk for individuals;

- second, notwithstanding the overall decline in consumption, risky behaviouris on the rise, particularly among young people, women and vulnerable groups,and it is now established that regular, non-excessive drinking may also carry risk;

- third, insufficient research is being done to robustly document the damagingeffects of different forms of alcohol use so as to more effectively design appropriatehealth strategies;

- fourth, public action is struggling to change behaviour because of insufficientlyeffective use of tools that have proven their usefulness in other countries;

- fifth, health responses to harmful alcohol use come too late and are inadequatelycoordinated;

- the sixth and final finding relates to policy design and implementation: notonly is there not a clear roadmap for participants in the shape of a specific nationalprogramme focused on preventing harmful alcohol use, but also no authority hasthe necessary clout to advocate for public health in the face of business interests andensure the necessary interministerial coordination of measures. These governanceproblems are found at the local level as well.

Therefore the Cour des comptes proposes the following broad guidelines:

- as part of the national addiction plan, draw up a programme to prevent harmfulalcohol use, which should be based on scientific evidence and led at the very top levelof government. This programme should come with indicators so that measures canbe carefully tracked over time, enabling the programme to be regularly evaluated andadjusted based on actual outcomes;


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Conclusion and recommandations

To the Prime Minister:

1. design a national programme toreduce harmful alcohol use; theprogramme should come withadequate indicators and establishprocedures to ensure that it iseffectively steered both at nationaland local levels. Regularly evaluate theprogramme using an internationallyrecognised method and make itsresult public;

To the Minister for HigherEducation and Research:

2. set up a multi-year policy foralcohol research (fundamental,translational, clinical, publichealth, social sciences) with afocus on interdisciplinary work andinternational collaboration;

To the Health Minister, the InteriorMinister, the MILDECA and theNational Public Health Agency:

3. tailor messages targetingconsumers with a risky behaviourbased on the findings of work ondrinking guidelines and currentresearch on morbidity and mortalityrates attributable to alcohol;

To the Health Minister, the MILDECAand the National Public HealthAgency:

4. develop prevention and commu-nication measures targeting themost vulnerable groups (youngpeople, pregnant women with aview to preventing foetal alcoholsyndrome, people in difficulty);pay special attention to preventingviolence against women;

To the Labour Minister and theHealth Minister:

5. legislate to eliminate the autho-risation to bring and consumewine, beer, cider and perry in theworkplace, as currently providedfor by the Labour Code, and referto company bylaws as regardsimplementation requirements andapplicable exemptions;

To the Health Minister and theMinister for Higher Education andResearch:

6. expand detection and follow-upfor at-risk drinkers based on thecodified procedure for alcoholscreening and brief interventionwithin the framework of the medical

- raise awareness and prevent the risks of harmful alcohol use throughappropriate information campaigns and prevention initiatives that are informedby the latest scientific progress;

- strengthen the impact of existing tools, which are not efficient enough inmany cases. While some tools deserve special attention because they arecurrently underused (such as screening and brief intervention or price andtaxation measures), others could be more simply overhauled and adjusted tomeet public policy needs (such as the rules on distribution, lobbying, advertising,and DUI checks and penalties).

approach. To this end, step up initialand ongoing addiction training,involve nursing staff more closely inimplementing alcohol screening andbrief intervention and systematicallycheck for the presence of alcoholwhen admitting people to emergencyunits or healthcare establishments;

To the Minister for the Economyand Finance and the HealthMinister:

7. increase the excise duties on allalcoholic beverages to reduce at-riskdrinking;


8. prepare to introduce a minimumprice per unit of pure alcoholcontained in each beverage, consistentwith European law, to reduceconsumption by alcohol-dependentpeople;


9. apply restrictions on advertisingalcoholic beverages to all digitalmedia (internet and social media),consistent with the judgment byCour de cassation, France'ssupreme court on 3 July 2013;

To the Minister for Economy andFinance, the Interior Minister andthe Health Minister:

10. extend the training rulesapplicable to on-premises salesestablishments to all other formsof sale of alcoholic beverages andset up a national digital repositoryof permanent and temporarylicense applications, which may beconsulted by law enforcementagencies; ;

To the Interior Minister, theJustice Minister, the Minister forthe Economy and Finance, andinsurance companies:

11. increase the likelihood of beingchecked and receiving on-the-spotpenalties: by using a single approvedportable device for measuring bloodalcohol concentration levels thatbreach the thresholds for standardand more serious offences; byincreasing flat-rate fines for DUI upto class 5; by applying the regime ofon-the-spot penalties for offences toblood alcohol concentration levelsof up to 1.2 g per litre of blood.

Conclusion and recommandations

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Documents

POLICIES TO TACKLE HARMFUL ALCOHOL USE · The consequences of harmful alcohol use have not been thoroughly assessed The effects of harmful alcohol use have only been partially assessed