Prof Frank Murray Registrar RCPI Consultant Gastroenterologist/Hepatologist, Beaumont Hospital/RCSI, Dublin 9 Alcohol in Ireland. Major health burden. Major economic burden. Major opportunity.

Main drug of harm in Ireland

Policies that reduce the availability of alcohol though: Price increases or Reducing outlets and hours of sale Have been shown to be effective

Europe is the heaviest drinking region in the world Alcohol is the main cause of liver disease in Europe The prevalence of alcoholic liver disease is rising in Ireland

Problems addressing the alcohol problem in Ireland!!!! Drinking alcohol can be harmless, in contrast to cigarettes Alcohol is strongly rooted in our society The alcohol industries receive the majority of their turnover in UK from harmful and hazardous drinkers

Policies that reduce the availability of alcohol though Price increases or reducing hours of sale Have been shown to be effective

Alcohol in Europe Europe is the highest drinking region in the world 200,000 deaths per year Cost €125 billion per year. 1.3% of GDP Third commonest cause of premature death and disability Main cause of liver disease and death

DALY (Disability adjusted life year) The sum of the life years lost due to premature death or years lived in disability

Alcohol cause huge health problems WHO: –4% of global mortality –5% of global DALY Europe worse –7% mortality –12% of DALY

Alcohol cause huge health problems Worse in males: 17% of DALYs( vs 4%) Worst in young males Alcohol cause 35% of deaths aged

Alcohol responsibility for many youth deaths 25% of male 10% of female

Major disease burdens attributable to alcohol Cirrhosis Cancer Diabetes Mellitus Neuropsychiatric Injuries BP CVA/stroke Cardiomyopathy Cancer –ENT. –Most of GI tract, breast, liver.

Main cause of alcohol DALY Liver disease 75% men 85% women

There is a direct correlation between amount of alcohol consumed and cirrhosis mortality

Cirrhosis and Portal Hypertension Cirrhosis and Portal Hypertension CIRRHOSIS AND PORTAL HYPERTENSION

Months Probability of survival All patients with cirrhosis Decompensated cirrhosis 180 Decompensation in cirrhosis Shortens Survival Gines et. al., Hepatology 1987;7:122 Median survival ~ 9 years Median survival ~ 9 years Median survival ~ 1.6 years Median survival ~ 1.6 years SURVIVAL TIMES IN CIRRHOSIS

Mortality due to cirrhosis in Ireland

There is a big human cost here Ill and dying patients Often young Often little opportunity to change Families

Does not end there Absenteeism Loss of professional performance Domestic violence Unhappiness

3 main types of alcohol misuse Hazardous Harmful Dependent drinking.

Hazardous drinking Drinks over the recommended weekly limit of alcohol 21/17 units for men and 14/11 units for women. It is also possible to drink hazardously by binge drinking, even if within weekly limit.

Harmful drinking Drinks more than the recommended weekly maximum amount of alcohol and experiences health problems that are directly related to alcohol. Cirrhosis depression an alcohol-related accident, such as a head injuryhead injury acute pancreatitis (inflammation of the pancreas)pancreatitis (inflammation of the pancreas) high blood pressure some types of cancer heart disease

Dependent drinking Both physically and psychologically addictive Become dependent on it Feels unable to function without alcohol Consumption of alcohol becomes an important, or sometimes the most important, factor in their life Can experience withdrawal symptoms (both physical and psychological) if they suddenly stop drinking alcohol.

A few words about cirrhosis Most alcoholics drink every day

Binge drinking 4 (female) 5 (male) units in 2h –or 8 (male) 6 (female) units in 24 hours Rapidly increasing in prevalance

So most alcohol consumption is mostly drunk safely?….. 75% of alcohol consumed in UK is by hazardous and harmful drinkers in the UK

Absolute risk of death from alcohol- related disease

Adult alcohol consumption in 49 European states

Adult alcohol consumption in 3 European bands

Adult alcohol consumption

Heavy episodic drinking of at least 60g of pure alcohol in last 7 days (women)

Irish consumption 11.9 litres of alcohol per adult (>15y) in 2010 Over half Irish drinkers have a harmful drinking pattern Much more affordable

Irish costs of alcohol €3.7 billion Healthcare €1.2 billion (8% of total) Approx 2,000 hospital beds per night 7% of GP costs 30% of Emergency Department costs

Cancer attributable to alcohol 5% men 2% women

Alcohol consumption and mortality has fallen in many countries in Western Europe

Deregulation of sales of alcohol Mediterranean style of drinking in Ireland

Fundamental problem in Ireland Too much alcohol Binge drinking Availability Number of outlets Opening hours

Availability Off-licences Convenience store Supermarkets Petrol stations Pubs Hotels Restaurants

Supermarkets Promotions Special offers Packaging in larger units Not quarantined, all over the shop

Concerts

Sports sponsorship

Advertising

Under-age drinking

Social order

Marketing towards young people

Options Do nothing Do “something” Take thought-through series of steps. Leads to immediate health social and political gains

Systematic reviews and meta-analyses. Proven policies. Policies regulating the environment in which alcohol is marketed (particularly its price and availability) are effective in reducing alcohol-related harm. Making alcohol more expensive and less available, and banning alcohol advertising, are highly cost-effective strategies to reduce harm.

Key messages A substantive evidence base of systematic reviews and meta-analyses inform alcohol policy

Making alcohol more expensive and less available are highly cost- effective strategies to reduce harm

Banning of alcohol advertising Drink-driving countermeasures Individually-directed interventions to drinkers already at risk are also cost-effective approaches

School-based education does not reduce harm, but public information and education programmes can increase attention to alcohol on public and political agendas

If more stringent alcohol policies are not put into place, global alcohol-related harm is likely to continue to increase

Actions Reduce number of outlets dramatically Increase cost-minimum unit pricing Expand and enforce legislation re alcohol consumption in public and public order offences All of proven international proven benefit

Minimum unit pricing Joint North South approach option Must result in significant increase in cost of cheap alcohol Increase could include excise and tax components

Successful legislated constructive social changes in Ireland Smoking ban Reduction in alcohol driving limit Cycling helmets

RCPI alcohol group RCPI established a national policy group to address the health and social burden of alcohol in Ireland. The policy group brings together experts from a wide range of medical specialist bodies to speak with one voice on the issue of alcohol, to support Propose practical solutions backed up by a robust, international evidence base Focused on reducing the harm caused by alcohol to health and society.

Policies that reduce the availability of alcohol though: Price increases and Reducing outlets and hours of sale Have been shown to be effective

Policies that reduce the availability of alcohol though Price increases or reducing outlets and hours of sale Have been shown to be effective