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ALCOHOL IN EUROPE

Dr. Peter Anderson MD, MPH, PhD International public health consultant

pdanderson@compuserve.com

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Summary Alcohol consumption While 266 million European adults drink alcohol up to 20g (women) or 40g (men) per day, over 58 million adults (15%) consume above this level, with 20 million of these (6%) drinking at over 40g (women) or 60g per day (men). Looking at addiction rather than drinking levels, some 23 million Europeans (5% of men, 1% of women) are dependent on alcohol in any one year. Harm done by alcohol Apart from being a drug of dependence, alcohol is a cause of some 60 different types of diseases and conditions, including injuries, mental and behavioural disorders, gastrointestinal conditions, cancers, cardiovascular diseases, immunological disorders, lung diseases, skeletal and muscular diseases, reproductive disorders and pre-natal harm, including an increased risk of prematurity and low birth weight. For most conditions, alcohol increases the risk in a dose dependent manner, with the higher the alcohol consumption, the greater the risk. For some conditions, such as cardiomyopathy, acute respiratory distress syndrome and muscle damage, harm appears only to result from a sustained level of high alcohol consumption, but even at high levels, alcohol increases the risk and severity of these conditions in a dose dependent manner. The frequency and volume of episodic heavy drinking are of particular importance for increasing the risk of injuries and certain cardiovascular diseases (coronary heart disease and stroke). Measuring the overall impact of alcohol through Disability-Adjusted Life Years (DALYs) shows that alcohol is responsible for 12% of male and 2% of female premature death and disability, after accounting for health benefits. This makes alcohol the third highest of twenty-six risk factors for ill-health in the EU, ahead of overweight/obesity and behind only tobacco and high blood pressure. This health impact is seen across a wide range of conditions, including 17,000 deaths per year due to road traffic accidents (1 in 3 of all road traffic fatalities), 27,000 accidental deaths, 2,000 homicides (4 in 10 of all murders and manslaughters), 10,000 suicides (1 in 6 of all suicides), 45,000 deaths from liver cirrhosis, 50,000 cancer deaths, of which 11,000 are female breast cancer deaths, and 17,000 deaths due to neuropsychiatric conditions as well as 200,000 episodes of depression (which also account for 2.5 million DALYs). Policies to reduce the harm done by alcohol The drinking-driving policies that are highly effective include unrestricted (random) breath testing, lowered blood alcohol concentration (BAC) levels, license suspension, and lower BAC levels for young drivers. The limited evidence does not find an impact from designated driver and safe drive programmes. Alcohol locks can be effective as a preventive measure, but as a measure with drink driving offenders, only work as long as they are fitted to a vehicle. The impact of policies that support education, communication, training and public awareness is low. Although the reach of school-based educational programs can be high because of the availability of captive audiences in schools, the population impact of these programs is small due to their current limited or lack of effectiveness. Recommendations exist as to how the effectiveness of school-based programmes might be improved. On the other hand, mass media programmes have a particular role to play in reinforcing community awareness of the problems created by alcohol use and to prepare the ground for specific interventions. There is very strong evidence for the effectiveness of policies that regulate the alcohol market in reducing the harm done by alcohol. Alcohol taxes are particularly important in targeting young people and the harms done by alcohol in all countries. If alcohol taxes were used to raise the price of alcohol

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in the EU15 by 10%, over 9,000 deaths would be prevented during the following year and an estimate suggests that approximately €13bn of additional excise duty revenues would also be gained. The evidence shows that if opening hours for the sale of alcohol are extended, then more violent harm results. Restricting the volume and content of commercial communications of alcohol products is likely to reduce harm. Advertisements have a particular impact in promoting a more positive attitude to drinking amongst young people. Self-regulation of commercial communications by the beverage alcohol industry does not have a good track record for being effective. There is growing evidence for the impact of strategies that alter the drinking context in reducing the harm done by alcohol. However, these strategies are primarily applicable to drinking in bars and restaurants, and their effectiveness relies on adequate enforcement. Passing a minimum drinking age law, for instance, will have little effect if it is not backed up with a credible threat to remove the licenses of outlets that repeatedly sell to the under-aged. Such strategies are also more effective when backed up by community based prevention programmes. There is extensive evidence for the impact of brief advice, particularly in primary care settings, in reducing harmful alcohol consumption.

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Further Reading Anderson, P. & Baumberg, B. (2006) Alcohol in Europe. London: Institute of Alcohol Studies. http://ec.europa.eu/health-eu/news_alcoholineurope_en.htm Babor TF, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, Grube JW, Gruenewald PJ, Hill L, Holder HD, Homel R, Österberg E, Rehm J, Room R & Rossow I (2003). Alcohol: No Ordinary Commodity. Research and Public Policy. Oxford, Oxford Medical Publication, Oxford University Press. Rehm J, Room R, Monteiro M, Gmel G, Graham K, Rehn T, Sempos CT, Frick U, Jernigan D. Alcohol. (2004) In: WHO (ed), Comparative quantification of health risks: Global and regional burden of disease due to selected major risk factors. Geneva: WHO.

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The Author Dr. Peter Anderson MD, MPH, PhD International public health consultant pdanderson@compuserve.com Dr. Anderson is an international expert on alcohol and tobacco policy. He was trained as a general practitioner and a specialist in public health medicine at the University of Oxford and the London School of Hygiene and Tropical Medicine in England. His doctoral thesis was on the risk of alcohol. Having worked for eight years as the World Health Organization’s European alcohol and tobacco policy adviser between 1992 and 2000, he now works as an international consultant employed on projects financed by the European Commission, the World Health Organization and several national and regional governmental organizations throughout the world. He holds honorary appointments in public health and primary care at the Universities of Oxford in England and Nijmegen in the Netherlands. He is policy adviser to Eurocare, the key European non-governmental organization on alcohol policy. He is the European Editor for the journal Drug and Alcohol Review, has over 100 publications in international scientific journals and is the author or editor of 16 books on alcohol and tobacco.

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Alcohol policy and the European Union Introduction This paper discusses the prevention of mental and behavioural disorders due to alcohol use, including (1) intoxication, defined as a transient condition resulting in disturbances in level of consciousness, cognition, perception, affect or behaviour or other psycho-physiological functions and responses; (2) harmful use, defined as a pattern of alcohol use that is causing physical (e.g., liver cirrhosis) or mental (e.g., episodes of depressive disorder secondary to heavy consumption of alcohol) damage to health; and (3) dependence syndrome, defined as a cluster of physiological, behavioural, and cognitive phenomena in which the use of the alcohol takes on a much higher priority for a given individual than other behaviours that once had greater value. Although not part of ICD-10 nomenclature, the term hazardous use is commonly defined as a level or pattern of consumption that is likely to result in harm should present consumption patterns persist (Babor et al. 1994). The emphasis is on health and not on crime; the terminology used is alcohol use disorders rather than alcoholism and alcohol abuse. Both the prevention of the disorders due to alcohol use (intoxication, harmful use and dependence), and the resulting physical and mental harm done by alcohol, and the prevention of the use of alcohol itself in certain circumstances (e.g. pregnancy) are considered. Epidemiological profile and burden 14% of the 374 million European adults do not drink alcohol. 58 million (15% of the adult population drink at hazardous or harmful levels, of whom 22 million, representing 6% of the adult population of the EU drink at harmful levels, Table 1. Some 5% of adult men and 1% of adult women are alcohol dependent – that is, 23 million people are addicted to alcohol in any one year.

Table 1 Drinking in the European Union (age 16+ years)

Definition (g/day) Adults Men Women EU25 (m)

Abstinent 0 0 53

Level I >0-40g >0-20g 263

Level II >40-60g >20-40g 36

Level III >60g >40g 22

Source: Anderson & Baumberg 2006. The use of alcohol is unevenly distributed throughout the population (Skog 1991); most of the alcohol in a society is drunk by a relatively small minority of drinkers. Lemmens (2001) estimated for the Netherlands in the mid-1980s that the top one-tenth of drinkers consumed more than one-third of the total alcohol, and that the top 30% of the drinkers accounted for up to three-quarters of all consumption.

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There are causal relationships between alcohol consumption and more than 60 types of disease and injury (Rehm et al 2004). Intoxication, the harmful use of alcohol and alcohol dependence are related to the dose, the patterns of use and the duration of use (Anderson and Baumberg 2006). Positive associations are found between alcohol use and incidence and death from intentional and unintentional injuries, cirrhosis of the liver, cancer and cardiovascular diseases. No matter how drinking is measured, the risk of alcohol dependence begins at low levels of drinking and increases linearly with both volume of alcohol consumption and a pattern of drinking larger amounts on an occasion (Caetanoand Cunradi 2002). Positive associations are also found between alcohol use and the incidence of a wide range of social harms that affect friends, family and work (Anderson and Baumberg 2006). There is no threshold effect and any use of alcohol can be regarded as hazardous and harmful for conditions, other than for coronary heart disease. Prenatal exposure to alcohol can impair brain development (Chen et al 2003) and be associated with a distinctive pattern of intellectual deficits that become apparent later in childhood, including reductions in general intellectual functioning and academic skills as well as deficits in verbal learning, spatial memory and reasoning, reaction time, balance, and other cognitive and motor skills (Kodituwakko et al 2001). Some deficits, like problems with social functioning, appear to worsen as these individuals reach adolescence and adulthood, possibly leading to an increased rate of mental health disorders. Although these deficits are most severe and have been documented most extensively in children with Foetal Alcohol Syndrome (FAS), children pre-natally exposed to lower levels of alcohol can exhibit similar problems (Gunzerath et al 2004). There is some evidence that alcohol can increase the risk of low birth weight, prematurity and intra-uterine growth retardation. Nevertheless, alcohol is responsible for 1%-2% of low birth weight, with some 60,000 underweight births each year in the EU. Alcohol is responsible for the loss of over 4.5 million DALYs every year in the EU (7.4% of all DALYs). Again, this is principally for men, accounting for 12% of all male ill-health and premature death and a smaller but still sizeable 2% of all female ill-health and premature death. The larger proportion of the burden arises from alcohol-related neuropsychiatric conditions and accidents. This health impact is seen across a wide range of conditions, including 17,000 deaths per year due to road traffic accidents (1 in 3 of all road traffic fatalities), 27,000 accidental deaths, 2,000 homicides (4 in 10 of all murders), 10,000 suicides (1 in 6 of all suicides), 45,000 deaths from liver cirrhosis, 50,000 cancer deaths, of which 11,000 are female breast cancer deaths, and 17,000 deaths due to neuropsychiatric conditions as well as 200,000 episodes of depression (which also account for 2.5 million DALYs). Determinants of substance use, and risk and protective factors There are a number of factors that place individuals, and in particular young people, at increased risk of alcohol use, dependence, and the social and health consequences (Loxely et al 2004). Risk factors act in a cumulative way over time. Some are present from the early years, others emerge in adolescence. Earlier and problematic alcohol use during adolescence is more likely among young people who are raised in circumstances of extreme economic deprivation (Lynskey et al 1995; Daniels et al 1999), in a sole parent household (Fergusson et al 1994a), and/or where parents or other family members use drugs (Fergusson et al 1994b). An easy temperament in early childhood is protective, both helping the child to adjust in positive ways and reducing the influence of risk factors (Williams et al 2000).

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Parents continue to be an important influence throughout the primary school years but other factors, including relationships with teachers, adjustment to school and experiences with peers, play an increasing role. Early school failure is a risk factor for later alcohol problems (Hawkins et al 1992). Children with behaviour problems through primary school are at risk of later drug use problems, with conduct disorder possibly more important in this regard than Attention Deficit and Hyperactivity Disorder (ADHD) (Lynskey et al 1995). Aggression is a risk factor for later drug use (Williams et al 2000) but the role of childhood depression is unclear. Children who are socially and emotionally competent are more resilient in the face of risk factors and, therefore, less likely to engage in alcohol and illicit drug use (Pulkkinen & Pitkanen 1994). In the teenage years, young people become increasingly independent of the family, making choices about their own identity including their attitudes and behaviours about substance use. Relationships with parents, other adults, and the peer group all influence the risk of substance use (Loxely et al 2004). At the same time, the attitudes, behaviours and relationships developed at earlier stages of childhood continue to be influential. The risk of harmful substance use is heightened in a community where there are higher levels (perceived and/or actual) of substance use (Hawkins et al 1992), community disadvantage and disorganisation (Smart et al 1994), ready availability of substances (Hawkins et al 1992), and positive media portrayals of substance use (Flynn et al 1997). Factors that help to protect adolescents against harmful substance use include attachment to the family (Fergusson et al 1994b), parental harmony (Fergusson & Horwood 1997), and parents who monitor and supervise their children and have good skills in communication and negotiation (Perry et al 1993). Young people are at increased risk where there is parent-adolescent conflict (Brody et al 1993), favourable parental attitudes to substance use (Lynskey & Fergusson 1995), parental substance use problems (Fergusson et al 1994b), and parental approval of substance (e.g. alcohol) use in childhood or early adolescence (Fergusson et al 1994b). Substance use problems are more likely in young people who do not complete high school and this is influenced by earlier childhood development, including school adjustment and behaviour problems (Campo et al 1992). Academic achievement and feelings toward school are also relevant to illicit drug use (Campo et al 1992). Adolescents are more likely to use substances if they associate with other young people who are using them (Fergusson et al 1995). Delinquency in adolescence is also a risk factor (Williams et al 2000), but the influence of adolescent anxiety and depression is unclear (Loxely et al 2004). Other risk factors at this age include sensation seeking and an adventurous personality (Hawkins et al 1992) and favourable attitudes to substance use (Fergusson & Horwood 2000). The use of substances escalates after the age of about 18 years and often peaks in early adulthood. Substance use in these years is strongly influenced by behaviours developed during the adolescent years, but other influential factors include relationships with peers and spouse, and patterns of behaviour in social, educational and employment settings (Loxley et al 2004). Effective regulation of alcohol in the community (Homel et al 2001) and marriage are both protective (Kandel et al 1986). Unemployment in early adulthood is associated with harmful alcohol use but this may be because both are outcomes of earlier risk factors (Darke et al 2000). There is strong co-morbidity between adult mental health problems and harmful drug use (Regier et al 1990; Kessler et al 1996), with clear evidence, at least for alcohol, that harmful drug use is a causal factor for depression (Anderson and Baumberg 2006). In some populations, the years of retirement and old age see the emergence of late onset drinking problems but these often appear to be a continuation of earlier high levels of non-problematic social drinking (Fingerhood 2000). Losing a spouse, loneliness, and reduced social support have been associated with late-onset drinking problems.

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Adolescent health and social problems tend to cluster (Hawkins et al 1992; Catalano & Hawkins 1996). Thus a young tobacco user is more likely to be a heavy drinker, use cannabis, engage in risky sexual activity, have higher antisocial behaviour and, if female, experience symptoms of depression. Similarly, different social settings (e.g. schools, local neighbourhoods) vary markedly in the rates and range of problems experienced. This clustering reflects the clustering of social and individual risk and protective factors. An adolescent's positive connection or attachment to family, school and community protect against a range of risk behaviours as well as promoting positive educational and social outcomes. Many adolescent health problems share important risk factors. Academic failure and school dropout are associated with antisocial behaviour, higher rates of substance use, tobacco use and emotional problems; factors such as poor family attachment and family conflict are linked to a broad range of adolescent health problems. Adolescents with a high level of risk factors and a low level of protective factors are more likely to use all types of substances in a potentially harmful manner. However, the majority of weekly tobacco smoking and binge drinking occurs amongst students with average rather than high levels of risk factors. This find suggests that prevention strategies for legal drugs need to be universal in their application and relevance to all young people. In contrast, the majority of illicit drug use is evident amongst students with high levels of risk factors. Targeted programmes for high-risk adolescents should be initiated early in the developmental pathway, in pre-school and primary school, with a view to preventing later illicit drug use. Finally, there are marked temporal and developmental sequences concerning the ages of first use and the order of onset of use of substances (Loxley et al 2004). It is apparent that early use of tobacco and alcohol is predictive of later problems with tobacco dependence, alcohol and illicit drugs. It is also clear from longitudinal research that use of alcohol and tobacco at an early age predicts progression to heavier drug use, even after adjusting for the influence of a range of known developmental risk factors (McGee et al 2000). The mechanisms by which legal drugs serve as 'gateways' in some sense for illegal drugs are not clear. Adolescent use of cannabis significantly increases the risk of later use of other illicit drugs (Newcomb et al 1992), but nonetheless, only a small proportion of cannabis users progress to use other illicit drugs (Williams et al 2000). Effective interventions, strategies, policies and their outcomes Effective interventions, strategies and policies to prevent and reduce alcohol use disorders can be categorised as regulatory (largely universal and population based), community based (including education and problem directed policies) and individual based (including social welfare and health service based) (Godfrey & Maynard 1995). Regulatory and community based interventions are mainly universal in nature, while individual based interventions target at risk populations, both selective and indicated. The evidence base includes time series analyses, econometric analyses, community studies and randomized controlled trials of health service interventions. Prevention of the harm done by substance use has to be embedded in sound social welfare and fiscal policies. Social and economic policies that seek to improve conditions for the healthy development of children and youth, reduce disadvantage, increase equity, and strengthen communities will have a range of benefits including lower rates of use of both illicit and licit drugs and of the harm done by them (Blane et al 1996; Marmot & Wilkinson 1999).

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Regulatory interventions Regulatory interventions, which can be implemented at international, national, regional and local jurisdictional levels include taxation, restrictions on availability and total bans on all forms of direct and indirect advertising. Taxation and price Increases in alcohol taxes reduce both the prevalence and consumption of alcohol products. A 10% increase in price can reduce the long term consumption of alcohol by about 7% (Babor et al 2003). Young drinkers and frequent and heavy drinkers are more sensitive to price than older drinkers or infrequent or light drinkers (Anderson and Baumberg 2006). Increases in alcohol taxes reduce the incidence and prevalence of alcohol-related liver disease, traffic accidents, and other intentional and unintentional injuries. In the European Union, it has been estimated that a 10% price increase in the price of alcoholic beverages through taxation would save over 9,000 deaths and would also give around €13bn of additional excise duty revenues each year (Anderson and Baumberg 2006). Availability For young people, laws that lower the minimum legal drinking age reduce alcohol sales and problems among young drinkers (Grube and Nygaard 2001; Babor et al 2003; Anderson and Baumberg 2006). Reductions in the hours and days of sale, numbers of alcohol outlets, and restrictions on access to alcohol, are associated with reductions in both alcohol use and alcohol-related problems (Babor et al 2003; Anderson and Baumberg 2006). Advertising There is evidence for targeting of alcohol advertisements to underage drinkers (Garfield et al 2003), and consistent evidence that exposure to television, music videos and sponsorship which contain alcohol advertisements predicts onset of youth drinking and increased drinking (Van den Bluck and Beullens 2005). Consumer studies have shown that alcohol advertisements lead to positive expectancies and attitudes about alcohol and there is increasing evidence that exposure to alcohol advertisements increase initiation of alcohol use amongst adolescents (Ellickson et al 2005; Snyder et al 2002; Stacy et al 2004; Anderson and Baumberg 2006). Despite the difficulties of population based studies, there is a range of evidence with some econometric studies finding a relationship between the volume of advertising and drinking behaviour and outcomes, and others not (Saffer and Dave 2003). There is some evidence that advertising affects brain activity linked to rewards and desires (Tappert et al 2003). Community based programmes The evidence suggests that community-based interventions that target structural policy change at the local level are more effective than approaches with the less focused aim of community mobilisation. Thus, community action to increase enforcement of drink-driving laws, and restrict local alcohol availability, are reported to have achieved the most positive results. Community based social marketing and public education campaigns have less effectiveness, with school based education programmes having the least effectiveness in changing behaviour in the long run. Drinking and driving The risk of drinking and driving increases with both the amount of alcohol consumed and the frequency of high volume drinking occasions (Midanik et al. 1996), and blood alcohol concentration levels (Blomberg et al. 2002; Hingson & Winter 2003). Lowering the legal level of blood alcohol concentrations (BAC) consistently reduce alcohol-related road traffic accidents across all BAC

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concentrations (Jonah et al., 2000; Anderson and Baumberg 2006). The impact of the reduction from 0.8g/l to 0.5g/L BAC limited in four Australian states between 1976 and 1992 reduced fatal accidents from 8% in New South Wales to 18% in Queensland (Henstridge et al., 1997). The introduction of low BACs of 0.2g/L for young or inexperienced drivers in the US and Australia led to reductions in fatal crashes of from 9% to 24%. Not only should BAC levels be reduced, but they need to be consistently enforced. The introduction of random breath testing (whereby motorists are stopped with no restrictions by police and required to take a breath test, even if they are not suspected of having committed an offence or been involved in an accident) is known to result in more than a 20% reduction in fatal crashes (Henstridge et al., 1997; McKnight & Voas 2001). Twenty three studies of random breath testing and selective testing have found a decline of 22% (range 13%-36%) in fatal crashes, with slightly lower decreases for non-injury and other accidents for such enforcement strategies (Shults et al., 2001). Increasingly, interventions focusing on reducing the harm from drinking when drinking is occurring are being developed and implemented, especially in societies and settings where drinking is widely accepted (Homel et al 2001). This approach to prevention is relatively new, however, and many of the interventions currently in practice have not been adequately evaluated. The most effective options to date have involved enhanced enforcement of regulations around serving and legal liability of bar staff and owners for the actions of those they serve (Homel et al 2001). Training programmes for bar staff and managers have also demonstrated reductions in high risk drinking and drinking problems, although these effects tend to be fairly modest and have not been found in all evaluations (Graham 2000). Community mobilization focused on licensed premises has proven to be a powerful strategy in reducing problem behaviour; however, the long-term sustainability of these efforts remains to be demonstrated (Homel et al 1997). Comprehensive community based programmes Community based prevention programmes can be effective in reducing drinking and driving, alcohol related traffic fatalities and assault injuries (Giesbrecht 2003; Stockwell and Gruenewald 2001; Holmila 1997; Holder 1998; Hingson et al 2005; Clapp et al 2005). A review of ten community-based prevention trials which have sought to reduce harm from alcohol found that strategies included education and information campaigns, media advocacy, counter-advertising and health promotion, controls on selling and consumption venues and other regulations reduced access to alcohol, enhanced law enforcement and surveillance, and community organizing and coalition development (Giesbrecht et al 2003). Interventions which showed promise were those that paid particular attention to controls on access, included the environmental contexts of where the products are sold and distributed, and involved enforcement of public health polices (see also (Holder, 1998a; Holder1998b). Community and neighbourhood characteristics are important in moderating the pricing and promotion of beer (Harwood et al 2003), as well as reducing binge drinking (Nelson et al 2005). Communities with higher enforcement of minimum purchase ages have lower rates of alcohol use and binge drinking (Dent et al 2005). Since 1996, a multi-component program based on community mobilization, training in responsible beverage service for servers and stricter enforcement of existing alcohol laws has been conducted in Stockholm, Sweden, leading to a 29% reduction in violent crimes in the intervention area, compared with the control area (Wallin et al 2003). The Community Trials Project (Holder et al. 1997) was a five-component community-level intervention to reduce alcohol-related harm among all residents of three communities. The project included a media and mobilization component, a responsible beverage service component, a sales to youth component to reduce underage access to alcohol, a drinking and driving component, and an access component to reduce the availability of alcohol. The project led to reduction in drink driving accidents, assault injuries, and harmful alcohol use (Holder et al. 2000).

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Finally, cost-benefit analyses estimated that the trial resulted in savings of €2.9 for every €1 spent on program implementation based upon reductions in automobile crashes alone (Holder et al. 1997). A community intervention project in the Northern Territories in Australia aimed to reduce levels of alcohol consumption and related harm down to national levels by 2002 by using a range of strategies including education, increased controls on alcohol availability, and expanded treatment and rehabilitation services. The Living With Alcohol (LWA) program was originally funded by a specific alcoholic beverage Levy on the sale of alcohol products with more than 3% alcohol by volume until 1997, when a federal ruling prohibited states and territories from raising licence fees and additional taxes on alcoholic beverages, tobacco and petrol. As a direct result, the LWA Levy was removed in August 1997 which in turn resulted in a fall in the real price of alcoholic beverages with more than 3% alcohol by volume. The Federal government continued to fund the LWA program at the same level until the year 2000. After this time, LWA funds were dispersed directly to the existing programs and services. The programme was effective in reducing acute (by 4.6 per 100,000 adults) and most likely chronic (by 3 per 100,000 adults) alcohol related deaths in the Northern Territories, compared with reductions of 1.6 per 100,000 acute and 1.7 per 100,000 chronic alcohol related deaths in the control area (Chikritzhs et al 2005). Public education and persuasion strategies When applied to alcohol, education and persuasion strategies usually deal with “responsible drinking,” the hazards of driving under the influence of alcohol, and related topics. Despite their good intentions, public service announcements are considered an ineffective antidote to the high-quality pro-drinking messages that appear much more frequently as paid advertisements in the mass media (see Ludwig 1994; Murray et al. 1996; Agostinelli & Grube 2002). Previous reviews point to the limited impact on alcohol use and alcohol-related problems from mass media interventions that use a "universal" strategy (Gorman 1995). In most countries, the number of public service announcements and counter-advertisements on alcohol issues are at best a small fraction of the volume of alcohol advertisements (see Fedler et al. 1994; Wyllie et al. 1996) and are rarely seen on television. Moreover, the quality of counter-advertising is often poor. However, mass media marketing can be used to reinforce community awareness of the problems created by alcohol use and to prepare the ground for specific interventions (Casswell et al 1990; Holder & Treno 1997). A fairly extensive amount of research has been conducted in connection with mandated warning labels on alcoholic beverage containers in the United States, (Kaskutas 1995). Studies have found that a significant proportion of the population report having seen warning labels (Hilton, 1993; Graves 1993; Greenfield et al. 1993; Kaskutas and Greenfield 1992), and there is some evidence that warning labels may increase knowledge regarding the risks of drinking and driving and drinking during pregnancy (Kaskutas and Greenfield 1992; Greenfield 1997; Greenfield and Kaskutas 1998; Greenfield et al. 1999; Kaskutas and Greenfield 1997), with some evidence for a dose-response relationship between pregnancy-related conversations about drinking while pregnant and the number of types of messages seen (Kaskutas et al. 1998). No direct impacts of warning labels on consumption or alcohol-related problems have been reported (MacKinnon et al., 2000; Grube & Nygaard, 2001; Agostinali & Grube, 2002). School based strategies Earlier school-based interventions relied solely on informational approaches and taught students about the effects and the dangers of alcohol use. Such programs have not been found to be effective (Botvin et al. 1995a 1995b; Hansen 1994; Tobler 1992). Although they can increase knowledge and change attitudes toward alcohol use, actual use remained largely unaffected. In addition, there is

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some evidence that simply providing information about the dangers of different substances may, in some cases, actually increase use (Hansen 1980, 1982). Scientific evaluations of school and university based resistance and normative education interventions have produced mixed results with regard to alcohol, with some evidence for effectiveness (Dielman 1995; Botvin and Botvin 1992; Hansen 1992, 1993, 1994; Ellickson, 2003), including educational programmes based on the social norm concept (e.g. the need to conform to what is acceptable to their peers) (Mattern & Neighbors, 2004; Kypri & Langley, 2003, Perkins, 2002); but also criticisms of the methodology discounting the effectiveness (Brown and Kreft 1998; Foxcroft et al. 1997; Gorman 1996, 1998). The Alcohol Misuse and Prevention Study (AMPS) is typical of school-based education programs that focus on pressures to use alcohol, risks of alcohol use, and ways to resist pressures to drink (Shope et al. 1996a, 1996b). The AMPS program had positive effects on alcohol knowledge (Shope et al. 1992), but few effects on drinking behaviour (Shope et al. 1996a). Other school-based alcohol resistance skills programs have produced similar results (Botvin et al. 1995a; Klepp et al. 1995). A good example of a well-designed study is the School Health and Alcohol Harm Reduction Project (SHAHRP study) from Australia, which aimed to reduce alcohol-related harm in secondary school students (McBride et al 2004). The study found that the intervention group (which received eight to ten 40 to 60 minute lessons on skill-based activities to minimize harm at age 13 years, and twelve further skills based activities delivered over 5-7 weeks at age 14 years) consumed significantly less alcohol at 8-month follow-up, after the first phase of the intervention (31% difference). However, at final follow-up, 17 months after the intervention, the total amount of alcohol consumed by intervention and comparison had lessened to a 9% difference. After the first phase of the programme at 8-month follow-up, intervention students were less likely to consume to risky levels (26% difference), but by seventeen months after programme completion, the difference was only 4%. There was a significant difference between the study groups in the harm they reported associated with their own use of alcohol after both phases of the intervention, which was maintained 17 months after the intervention (23% difference). Some programs include both individual-level education and family or community-level interventions (Werck et al., 2003; Bauman et al., 2002; Turrisi et al., 2001). Project Northland, was a school and community intervention designed to prevent or delay the onset of drinking among young adolescents in 10 communities in north-eastern Minnesota (Perry et al. 1993, 1996). The primary intervention was a series of school-based resistance-skills, media literacy, and normative education sessions. The program also provided parents with information on adolescent alcohol use. Task forces in some communities were involved in local policy actions such as the passage of local laws requiring responsible beverage service training. Evaluation of the project found that although it had a positive influence on alcohol knowledge and family communication about alcohol, it had no sustained impact on alcohol use (Williams et al. 1995; Perry et al. 1996; Perry et al. 1998). The Midwestern Prevention Project was implemented in 50 public schools in 15 communities in the State of Kansas (USA). A replication was conducted in 57 schools and 11 communities in another state. The intervention consisted of five components: (a) a 10-13-session school-based program with 5 booster sessions, (b) a mass media program, (c) a parent education and organization program, (d) training of community leaders, and (e) local policy changes initiated by the community organization. Differences between program and comparison schools in self-reported prevalence of monthly drinking were significant after one year (MacKinnon et al. 1991; Pentz et al. 1989) but they did not differ after 3 years (Johnson et al. 1990).

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Over the longer term (more than 3 years), the Strengthening Families Programme (SFP), showed promise as an effective prevention intervention, with a number needed to treat (NNT) for three alcohol initiation behaviours (alcohol use, alcohol use without permission and first drunkenness) of 9 (Spoth et al 2001a; 2001b). This means that nine students have to receive the programme for one to benefit. One other study also highlighted the potential value of culturally focused skills training over the longer-term (NNT = 17 over 3.5 years for 4 + drinks in the last week) (Schinke et al. 2000). This means that 17 students have to receive the programme for one to benefit. A Cochrane review of long term prevention for the primary prevention in young people found that 23 of 56 studies reviewed were ineffective in the short term (Foxcroft et al 2003). The review was unable to make any firm conclusions about the effectiveness of prevention interventions in the short- and medium term. A number of suggestions have been made as to how the impact of school based education programmes might be improved (Marlatt et al., 2002, Hawks et al., 2002, (McBride 2002; 2003; 2005). Individual based interventions Reducing alcohol use during pregnancy Of three good-quality behavioural counselling interventions in primary care settings that targeted pregnant women making prenatal visits, two found no evidence for an effect on alcohol consumption (Handmaker et al 1999; Chang et al 1999) and one a possible effect which just failed to reach statistical significance (Reynolds et al 1995). There is evidence for the impact of home visits for women with harmful alcohol use during an index pregnancy (Grant et al 2005); home visits that assisted women in obtaining alcohol treatment and staying abstinent, and linking them with comprehensive community resources led to improved attendance at treatment, better treatment outcomes, and a greater likelihood of subsequent pregnancies being alcohol free. Social welfare based programmes Programmes of structured home visits to support mothers, before and in the first two years after birth, have evidence supporting their effectiveness and cost effectiveness when targeted to vulnerable families (Mitchell et al 2001). These programmes offer basic advice, practical assistance with nursing, and advocacy for access to services. They show evidence of positive outcomes for maternal drug use and infant health. Some programmes targeted specifically at vulnerable (e.g. drug using) mothers have shown benefits for later problem behaviours in childhood and adolescence, including some modest reductions in drug use. Olds et al. (1997; 1998; 1999) evaluated a programme involving regular home visiting by a nurse from late pregnancy until the child's second birthday for low income, unmarried and adolescent women having their first babies. The programme focused upon supporting the mother, promoting positive attachment with the child and teaching parenting skills. Follow-up associated the programme with reduced rates of smoking and alcohol use for the mothers during pregnancy, leading to reductions in cigarette and alcohol-related cognitive impairment in the children as pre-schoolers. The children have been followed up to age 15 years, documenting reductions in their early initiation of smoking and alcohol use. There is evidence for the value of both universal and selective parenting programmes for pre-primary school age children to reduce child behaviour problems that predict the emergence of harmful drug use (Serketich & Dumas 1995). There is evidence for positive outcomes (school adjustment and academic attainment) and good cost-benefit ratios from targeted programmes to prepare children from high-risk families for primary school. Outcomes from these studies have been documented by following children through to adolescence. Results have found reduced smoking and alcohol use as

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well as reductions in other adolescent problem behaviours. The Perry Pre-school Project in the United States found long-term programme effects up to age 27, including a lower incidence of drug use and teenage pregnancy, lower risk of school drop out, increased likelihood of employment and reduced reliance on welfare (Schweinhart et al 1993). Cost benefit analyses suggested savings of up to $6 for every $1 invested in the programme for a one year programme (Barnett 1993). Benefits can be obtained through programmes that target individuals and groups with a high number of developmental risk factors. Settings include disadvantaged areas, family crisis, police and court contacts, and mental health (Loxely et al 2004). Brief interventions for adults A large number of individual studies, reviews and meta-analyses confirm that brief interventions in primary health care settings are effective in reducing hazardous and harmful alcohol consumption and alcohol-related harm for different population groups and in different countries (Moyer et al 2002; Miller & Wilbourne 2002). The number needed to treat is about 8 for both hazardous and harmful alcohol consumption and for alcohol-related harm (Anderson et al 2005). This means that 8 patients at risk need to be offered advice for one to benefit. In a controlled study of mass screening and brief intervention with follow-up, for men in Malmo, Sweden, there was a significant decline in hospital admissions and mortality in the treated group over a four year follow-up period, an 80% reduction in absenteeism in the four years following the study, a 60% reduction in total hospital days over five years, and a 50% reduction in all cause mortality over six years (Kristenson et al 2002). Effectiveness of policy choices Over the last twenty five years, considerable progress has been made in the scientific understanding of the relationship between alcohol policies, alcohol consumption and alcohol-related harm (Bruun et al. 1975; Edwards et al. 1994; Babor et al. (2003), which is summarized in Table 2 (Anderson & Baumberg 2006).

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Table 2 Effectiveness of different policy options

Effectiveness Breadth of Research Support

Cost Efficiency

Drink driving counter measures

Lowered BAC levels +++ +++ +++

Random breath testing (RBT) +++ ++ +

License suspension +++ ++ ++

Alcohol locks + + +

Low BAC for youth +++ ++ +++

Graduated licensing ++ ++ +++

Server training and civil liability + ++ +

Designated drivers and ride services

O + ++

School based education courses ?/O + +

Community programmes ++ ++ +

Education and public awareness

Public service messages O +++ ++

Warning labels O + +++

Alcohol education in schools O/+ +++ +

Pricing and taxes

Taxes +++ +++ +++

Availability

Minimum drinking age +++ +++ ++

Government retail outlets +++ +++ +++

Number of outlets ++ + +++

Density of outlets ++ ++ +++

Hours and days of sale ++ +++ +++

Advertising

Reducing the volume of advertising

+/++ ++ +++

Advertising content controls ? O ++

Drinking environments

Responsible beverage service + +++ ++

Active enforcement ++ + +

Server liability +++ + +++

Enforcement of on-premise ++ + +

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regulations

Public transport ? + +

Safer bar environment/containers ? O ++

Community mobilization

Community mobilization ++ ++ +

Advice and help

Social welfare based programmes

+ + +

Pregnancy based programmes + + +

Work based programmes ++ + +

Brief advice in primary care +++ +++ ++

Brief advice in accident and emergency departments

++ ++ ++

Source: Anderson & Baumberg (2006), updated and adapted from Babor et al. (2003).

Effectiveness Breadth of Research Support Cost Efficiency

This criterion refers to the scientific evidence demonstrating whether a particular strategy is effective in reducing alcohol consumption, alcohol-related problems or their costs to society. The following rating scale was used: 0 Evidence indicates a lack of effectiveness + Evidence for limited effectiveness. ++ Evidence for moderate effectiveness. +++ Evidence of a high degree of effectiveness ? No studies have been undertaken or there is insufficient evidence upon which to make a judgment.

The highest rating was influenced by the availability of integrative reviews and meta analyses. Breadth of research support was evaluated independent of the rating of effectiveness (i.e., it is possible for a strategy to be rated low in effectiveness but to also have a high rating on the breadth of research supporting this evaluation). The following scale was used: 0 No studies of effectiveness have been undertaken + Only one well designed study of effectiveness completed. ++ From 2 to 4 studies of effectiveness have been completed. +++ 5 or more studies of effectiveness have been completed. ? There is insufficient evidence on which to make a judgment.

This criterion seeks to estimate the relative monetary cost to the state to implement, operate and sustain this strategy, regardless of effectiveness. For instance, increasing alcohol excise duties does not cost much to the state but may be costly to alcohol consumers. In this criterion, the lowest possible cost is the highest standard. Therefore, the higher the rating, the lower the relative cost to implement and sustain this strategy. The following scale was used: o Very high cost to implement and sustain + Relatively high cost to implement and sustain. ++ Moderate cost to implement and sustain. +++ Low cost to implement and sustain. ? There is no information about cost or cost is impossible to estimate.

Source: Babor et al. (2003).

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Estimates and costs of policy impact are derived from the results of the World Health Organization’s CHOICE (CHOosing Interventions that are Cost-Effective) model, which provides estimates of the impact and cost of implementing policies in reducing Disability Adjusted Life Years (DALYs) (see Chapter 6) due to harmful alcohol use (Tan Torres et al. 2003; WHO 2002; Ezzati et al. 2002; Rehm et al. 2004; Chisholm et al. 2004; Rehm et al. 2003a,b; 2004; Rehm et al. 2001; Stouthard et al. 2000), re-calculated for the European Union. The CHOICE model determines intervention effectiveness via a state transition population model (Lauer et al. 2003), taking into account births, deaths and the impact of alcohol. Two scenarios are modelled over a lifetime (100 years): 1) no interventions available to reduce hazardous and harmful alcohol use (defined in the CHOICE model as more than 20g alcohol a day for women and more than 40g alcohol a day for men); and 2) the population-level impact of each specified intervention, implemented for a period of 10 years. The difference represents the population-level health gain due to the implementation of the intervention, discounted at 3% and age-weighted. Costs covered in the CHOICE model are costs to governments and include programme-level costs associated with running the intervention, such as administration, training and media (Adam et al. 2003; Johns et al. 2003), and patient-level costs such as primary care visits (Fleming et al. 2000). The costs were calculated in international dollars (Adam et al. 2003; Johns et al. 2003) and converted into euros, such that one euro buys the same quantity of health care resources in England as it does in Hungary. The model does not capture potential increases in workforce and household productivity among heavy drinkers following intervention, nor does it incorporate the economic consequences of alcohol-related crime, violence and harm reduction. Government’s receipts from taxes are not counted. The results are presented for three regions of the European Union, based on the WHO classification in Figures 1 and 2. WHO classification of European Union countries based on mortality rates. Europe A Very low child and very low adult mortality

Europe B Low child and low adult mortality

Europe C Low child and high adult mortality

Austria Belgium Czech Republic Denmark Finland France Germany Greece Ireland

Italy Luxembourg Malta Netherlands Portugal Slovenia Spain Sweden United Kingdom

Cyprus Poland Slovakia

Estonia Hungary Latvia Lithuania

Drinking and driving Two independent effects on alcohol-related traffic injuries were modelled: drink-driving laws, estimated to reduce traffic fatalities by 7% if widely implemented within a region (Shults et al. 2001), adjusted for the current level of implementation; and enforcement via random breath testing (RBT), estimated to reduce fatalities by a further 6-10% (Peek-Asa 1999; Shults et al. 2001). The model found that the full implementation of random breath testing (compared to no random breath testing) throughout the European Union (EU) prevents between 161 (EuroB countries) and 460 (EuroC countries) DALYs per million people per year, at an estimated cost of between €43 (EuroC countries) and €62 (EuroB countries) per 100 people per year. The model estimated that unrestricted breath testing in Europe, compared with no breath testing, can avoid 111,000 years of disability and premature death at an estimated cost of €233 million each year (adapted from Chisholm et al. 2004).

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Taxation The impact of a tax on alcohol set at the current level increased by 25%, compared with no tax at all was modelled, adjusted for the observed or expected level of unrecorded use (taken as a close proxy measure for untaxed consumption) due to illicit production and smuggling, using published price elasticities (Ornstein and Levy 1983; Babor et al. 2003). The model estimated that the current level of taxation plus a 25% increase can prevent between 503 (EuroB countries) and 1576 (EuroA countries) DALYs per million people per year, at a cost of between €18 (EuroC countries) and €38 (EuroA countries) per 100 people per year. The model estimated that the current level of tax with a 25% increase in the tax rate throughout Europe, compared with no tax on alcohol, can prevent an estimated 656,000 years of disability and premature death at an estimated cost of €159 million each year (adapted from Chisholm et al. 2004). Availability Reduced access to and availability of alcohol was modelled through estimating what would happen if alcohol could not be purchased for a 24-hour period at the week-end (although not politically acceptable across contemporary Europe, this option was chosen by the WHO team, based on Scandinavian data, which has been shown to reduce consumption and alcohol-related harm (Leppanen 1979; Nordlund 1984; Norström and Skog 2003)). Based on these studies, a modest reduction of 1.5-3.0% in the incidence of hazardous drinking and 1.5-4.0% in alcohol-related traffic fatalities was modelled. If implemented throughout the European Union, the model estimated that such an intervention can prevent between 251 (EuroA countries) and 689 (EuroC countries) DALYs per million people per year, at a cost of between €12 (EuroC countries) and €23 (EuroA countries) per 100 people per year. Although it is not known for how long the effects might last, the model estimated that such an intervention throughout Europe can prevent an estimated 123,000 years of disability and premature death at an estimated cost of €98 million each year (adapted from Chisholm et al. 2004). Advertising The impact of advertising controls based on a 2%-4% reduction in the incidence of hazardous alcohol use was modelled, derived from international time-series analyses of the impact of an advertising ban (Grube and Agostinelli 2000; Saffer 2000; Saffer and Dave 2002). Although not politically acceptable in contemporary Europe, were an advertising ban to be implemented throughout the Union, the model estimated that it can prevent between 300 (EuroB countries) and 616 (EuroC countries) DALYs per million people per year, at a cost of between €12 (EuroC countries) and €23 (EuroA countries) per 100 people per year. The model estimated than a ban on advertising implemented throughout the Union, could prevent 202,000 years of disability and premature death, at an estimated cost of €95 million each year (adapted from Chisholm et al. 2004). Brief advice programmes Brief interventions such as physician advice provided in primary health care, which involve a small number of education sessions and psychosocial counselling, were modelled to influence the prevalence of hazardous drinking by increasing remission and reducing disability (Higgins-Biddle and Babor 1996; Moyer et al. 2002; Babor et al. 2003), which would have the effect of shifting the entire distribution of hazardous drinking downwards if applied to the total population at risk (a reduction in overall prevalence of 35-50%, equivalent to a 14-18% improvement in the rate of recovery over no treatment at all). The estimates were adjusted for treatment adherence (70%) and target coverage in the population (25% of hazardous drinkers). If implemented throughout the European Union, the model estimated that a brief intervention programme reaching 25% of the at risk population can prevent between 512 (EuroB countries) and 1056 (EuroC countries) DALYs per million people per year, at a cost of between €26 (EuroB countries) and €185 (EuroA countries) per 100 people per year. The model estimated that the provision of primary care based brief interventions to 25% of the at-risk

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population throughout the Union can prevent an estimated 408,000 years of disability and premature death at an estimated cost of €740 million each year (adapted from Chisholm et al. 2004).

0

200

400

600

800

1000

1200

1400

1600

1800

Euro A Euro B Euro C

DA

LYs

prev

ente

d pe

r m

illio

n pe

ople

per

yea

r Brief advice

Drink drive measures

Current tax + 25%

Restricted sales

Advertising ban

Figure 1 The impact of different policy options (DALYs prevented per million people per year) in the three sub-

regions of EU25. Source: Chisholm et al. (2004) (adapted).

0

20

40

60

80

100

120

140

160

180

200

Euro A Euro B Euro C

Cos

t pe

r 10

0 pe

ople

per

yea

r(€)

Brief advice

Drink drive measures

Current tax + 25%

Restricted sales

Advertising ban

Figure 2 The cost of different policy options (per 100 people per year (€)) in the three sub-regions of EU25.

Source: Chisholm et al. (2004) (adapted).

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In all three regions, taxation (current tax levels with a 25% increase in tax, compared to no tax) has the greatest impact in reducing the harm done by alcohol, followed by brief interventions delivered by primary providers to 25% of the at risk population. The three regulatory measures, (taxation, restricted sales and advertising controls) are the cheapest in terms of cost to implement, with drink driving measures and brief interventions being the most expensive. Although brief interventions are the most expensive to implement, it should be noted that within health service expenditure, brief interventions for hazardous and harmful alcohol consumption are one of the most cost effective of all health service interventions in leading to health gain (Anderson et al. 2005).

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