managing alcohol in europe peter anderson md, phd, mph fort myers 5 january 2007

Managing Alcohol in Europe

Peter Anderson MD, PhD, MPH

Fort Myers5 January 2007

1. Alcohol is no ordinary commodity

2. Alcohol is an important health determinant

3. Education not an alternative to regulating the alcohol market

4. Brief advice complements but does not replace regulating the alcohol market

5. Options for regulating the alcohol marketi. Priceii. Availabilityiii.Advertising


2. Alcohol is an important health determinant in Europe




1. is a toxin that can harm almost any system or organ of the body, leading to more than 60 different acute and chronic disorders;

2. can exacerbate pre-existing mental and physical disorders, adversely interact with other prescribed and illicit drugs, and contribute to a wide range of social problems;

3. can pose a significant risk to third parties, including the foetus;

4. can weaken the immune system and thus may increase the risk for communicable diseases such as TB, HIV/AIDS or different forms of hepatitis;

5. can lead to a higher risk of unsafe sex thereby increasing the risk of sexually transmitted diseases;

6. shows wide individual variation in the toxic effects of consuming a given amount;

7. has no threshold below which consumption can be regarded as entirely risk free;

8. produces a state of dependence, CNS depression and stimulation, ill effects, and abuse liability.

Prevalence of abstention in World 2002

Prevalence of abstention in W orld 2002

0 % - 20 %

20 % - 40 %

40 % - 60 %

60 % - 80 %

80 % - 100 %

Rehm 2006

Adult per capita consumption (L pure alcohol)

2002

Average per capita alcohol consumption in litres pure alcohol, 2002

0 - 3

3 - 6

6 - 9

9 - 12

12 - 15

15 - 25

Rehm 2006

Alcohol attributable DALYs

0.25% - 1.00%

1.00% - 4.00%

4.00% - 6.00%

6.00% - 9.00%

9.00% - 17.00%

Alcohol-attributable global burden of disease 2002

0

5

10

15

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0-15 15-29 30-44 45-59 60-69

Age group

% o

f al

l dea

ths

attr

ibu

tab

le t

o

alco

ho

l in

th

e E

U

Males

Females

28% of all male deaths at age 15-29

years are due to alcohol

11% of all female deaths at age 15-29

years are due to alcohol

Although there are individual examples of the beneficial impact of school-based education, systematic reviews and meta-analyses find that the majority of well-evaluated studies show no impact even in the short-term.

05

10152025303540

Baseline 8 months 20 months 32 months

Pro

portio

n (%

)

Control Intervention

The impact of 2 education sessions [] on binge drinking in 13-15 year olds

The impact of 2 education sessions [] on binge drinking in 13-15 year olds

Educational programmes should not be implemented in isolation as an alcohol policy measure, or with the sole purpose of reducing the harm done by alcohol, but rather as a measure to reinforce awareness of the problems created by alcohol and to prepare the ground for specific interventions and policy changes.

Figure 2: Cloud graph showing uncertainty around costs and effectiveness of interventions for heavy alcohol use (European subregion EurA)

0

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1,000

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0 500,000 1,000,000 1,500,000 2,000,000

Effect (DALYs averted per year)

Cos

t (I

$m p

er y

ear)

A. Brief physician advice

B. Random Breath Testing

C1. Taxation (current)

C2. Taxation (current + 25%)

C3. Taxation (current + 50%)

D. Restricted access (sales)

E. Advertising ban

F1. Brief advice + RBT

F2. Tax (highest) + Ad Ban

F4. Brief advice + Tax (highest)

F5. Tax (highest) + Ad Ban + Restrict access

F8. Brief advice + Tax (highest) + Ad Ban + Restrict Access

F11. Brief advice + Tax (highest) + Ad Ban + RBT + Restrictaccess

A

D-E

C1-C3

F2

F5B

F11

F8

F4F1

5. Options for regulating the alcohol marketi. Increasing the price of alcohol reduces

alcohol-related harm, particularly amongst younger and heavier drinkers

ii. Increasing the availability of alcohol increases alcohol-related harm

iii.Both the content and volume of alcohol advertising need to be regulated in order to reduce young people’s drinking

Principles of EU tax policy:

Taxes should be shifted from labour to social costs to contribute to the EU goals of increasing employment and reducing negative health impacts in a cost-effective way

Increases in alcohol taxes:

cirrhosis death rates road traffic accidents and fatalities intentional and unintentional

injuries workplace injuries sexually transmitted disease rates rapes and robberies homicides crime child abuse wife abuse

Alcohol taxes have a greater impact:

Younger drinkers Heavier drinkers Poorer drinkers

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Imp

ort

s o

f alc

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op

s (m

illio

ns o

f 275

ml b

ottle

s)

Before alcopop

tax

After alcopop

tax

Principles of EU tax policy:

New revenues can be allocated to specific funds to be used for financing measures to lessen or offset external costs

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Before Before

Intervention

Control

Acute alcoholdeaths/100,000

Northern Territories, Australia

Control region, Australia

Levy introduced on alcohol (>3% strength) to

fund a community programme, with

restricted availability, and improved education and

treatment

Chronic alcoholdeaths/100,000

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4

6

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Before After Before After

Intervention

Control

Acute alcohol Chronic alcoholdeaths/100,000 deaths/100,000

Effectiveness Breadth ofResearchSupport

CostEfficiency

Minimum drinking age +++ +++ ++

Government retail outlets

+++ +++ +++

Number of outlets ++ + +++

Density of outlets ++ ++ +++

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

Finnish studies have found an overall impact on alcohol consumption from changes in the number of outlets.

The most dramatic change was observed in 1969, when beer up to 4.7% alcohol was allowed to be sold by grocery stores, and it also became easier to get a restaurant license.

The number of off-premise sales points increased from 132 to about 17,600, and on-premise sales points grew from 940 to over 4000.

In the following year: alcohol consumption increased by

46%.

In the following five years: mortality from liver cirrhosis

increased by 50% hospital admissions for alcoholic

psychosis increased by 110% for men and 130% for women

arrests for drunkenness increased by 80% for men and 160% for women.

Figure 1: Assaults against Women per 1,000 Residents

0

0.05

0.1

0.15

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0.25

Jul-00

Oct-00

Jan-01

Apr-01

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After closing-time regulationBefore closing-time regulation

Note: Assault rates for July 2000 and July 2005 are based on half-months of data.

Figure 2: Homicides per 1,000 Residents

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0.08

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95

Jul-9

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After closing-time regulationBefore closing-time regulation

Note: Homicide rate for July 2005 is based on half-month of data.

In England, since 1980:

Bars and nightclubs 10% Licensed hotels and restaurants 68%Off licences 100%Licence applications 145%

Alcohol 54% more affordable than in 1980

Manchester capacity 250% 1996-2000

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

1988

1990

1992

1994

1996

1998

2000

2002

Year

Per

cent

age

exce

edin

g w

eekl

y li

mit

s

Men Men 16-24Women Women 16-24

Rickards et al, 2004, Deehan and Saville, 2003, Anderson and Hughes, 2006; Fuller, 2005

Office for National Statistics, 2006

02

46

810

1214

1618

20

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

Alc

ohol

-rel

ated

dea

ths

per

100,

000

popu

lati

onMalesFemales

0

5

10

15

20

25

30

35

40

45

1991

1992

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1995

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1998

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2000

2001

2002

2003

2004Alc

ohol

-rel

ated

dea

ths

per

100

,000

mal

esAge 15-34

Age 35-54

Age 55-74

Age 75+

0

10

20

30

40

50

1997 1999 2001 2003Year

%

Man

Woman

Spanish 15-29 year olds

0

10

20

30

40

50

1997 1999 2001 2003Year

%

Man

Woman

Spanish 30-64 year olds

18/mn

10/mn

14/mn

Homicide rate/million

Homicides due to alcohol (%)

50%

55%

61%

– Ellickson et al.:

– Exposure to in-store beer displays predicts drinking onset;

– exposure to alcohol ads in magazines or beer concession stands at sports or music events predicts greater frequency of drinking.

– (Addiction 2005)

– Stacy et al.:

– One standard deviation increase in viewing television programs containing alcohol commercials in seventh grade (11-12 year-olds) associated with an excess risk of

– beer use (44%), – wine/liquor use (34%), – and 3-drink episodes (26%) – in eighth grade (12-13 year-olds).

– (Am J Health Behav 2004)

– Snyder et al.:

1. For every additional alcohol ad kids saw above the average of 23 on TV, radio, billboards and in magazines, they drank 1% more.

2. For every additional dollar per capita spent above the average of $6.80 in their media market on alcohol advertising, they drank 3% more.

(Arch Ped Adol Med, 2006)

– Saffer and Dave:

– A 28% decrease in alcohol advertising would lead to

– a between 4% and 16% drop in monthly youth drinking, and

– an 8% to 33% drop in youth binge drinking

– (Health Economics 2006)

Youth are drawn particularly to elements of music, characters, story and humor.

Young people who liked ads believed that:– positive consequences of drinking were

more likely– their peers drink more frequently– their peers approve more of drinking

These beliefs interact to produce greater likelihood of drinking, or of intention to drink within the next year.

New Beer Institute code:

May contain romantic or flirtatious interactions but should not portray sexually explicit activity as a result of consuming beer.

Please visit http://www.visit4info.com/details.cfm?adid=15279 to view this ad.

Current regulation:

1. Enforcement of marketing regulations is more often regulated by law, than by self-regulation.

2. Statutory regulation is very well controllable, although it is not always actively enforced.

4. Self-regulation mainly concerns restrictions of style and content of marketing; it is not easily controlled and its rules are multi-interpretable.

5. In countries where self-regulation exists, alcohol producers have considerably more freedom in marketing than in countries using regulations by law.

5. Statements on the success (and claiming the success) of self-regulation are not based on scientific research.

6. Complaints against alcohol marketing associating alcohol with, for example, social or sexual success, are commonly rejected.

The ‘loi Evin’

• No advertising is permitted :- when targeted to young people- on TV and cinema

• No sponsorship is permitted

• Messages and images should refer only to the qualities of the products

• Before the law • After the law

The ‘loi Evin’

The ‘loi Evin’ These ads were judged illegalin France in 2004

The French Government was taken to court, alleging that the Loi Evin, by prohibiting alcohol advertising on hoardings visible during the retransmission of bi-national sporting events on TV, entail restrictions on the freedom to provide advertising services and television broadcasting services

Cross border advertising

1. It is in fact undeniable that advertising acts as an encouragement to consumption

2. The French rules on TV advertising do not go beyond what is necessary to achieve such an objective

3. They are appropriate to ensure their aim of protecting public health

Cross border advertising

0

2

4

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810

12

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18

20

Str

ictn

es

s (

EC

AS

sc

ale

)

19502005

managing alcohol in europe peter anderson md, phd, mph fort myers 5 january 2007

Documents

alcohol slide

alcohol market i

pure alcohol

alcohol policy measure

advertising slide

foetus slide

important health determinant

brief advice complements