Managing Alcohol in Europe Peter Anderson MD, PhD, MPH Fort Myers 5 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 market i.Price ii.Availability iii.Advertising

1.Alcohol is no ordinary commodity 2.Alcohol is an important health determinant in Europe 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 market i.Price ii.Availability iii.Advertising

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.

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 market i.Price ii.Availability iii.Advertising

Prevalence of abstention in World 2002 Rehm 2006

Adult per capita consumption (L pure alcohol) 2002 Rehm 2006

Alcohol-attributable global burden of disease 2002

28% of all male deaths at age years are due to alcohol 11% of all female deaths at age years are due to alcohol

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 market i.Price ii.Availability iii.Advertising

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.

The impact of 2 education sessions [  ] on binge drinking in 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.

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 market i.Price ii.Availability iii.Advertising

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 market i.Price ii.Availability iii.Advertising

5.Options for regulating the alcohol market i.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

5.Options for regulating the alcohol market i.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

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

Acute alcohol deaths/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 alcohol deaths/100,000

Acute alcoholChronic alcoholdeaths/100,000

5.Options for regulating the alcohol market i.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

EffectivenessBreadth of Research Support Cost Efficiency Minimum drinking age Government retail outlets +++ Number of outlets Density of outlets Hours and days of sale+++++

EffectivenessBreadth of Research Support Cost Efficiency 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.

Mean

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%

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

Office for National Statistics, 2006

Spanish year olds

Spanish year olds

18/mn 10/mn 14/mn Homicide rate/million

Homicides due to alcohol (%) 50% 55% 61%

5.Options for regulating the alcohol market i.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

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

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 market i.Price ii.Availability iii.Advertising

5.Options for regulating the alcohol market i.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