Alcohol Prevention day Alcohol in Europe Peter Anderson, MD, MPH, PhD Rome 17 April 2008

Structure of presentation 1.Alcohol causes a high level of harm 2.Young people are vulnerable to alcohol 3.Alcohol causes harm to people other than the drinker 4.Help needs to be available for people with problems 5.By focusing on their product, economic operators have the potential to reduce harm

Structure of presentation 1.Alcohol causes a high level of harm 2.Young people are vulnerable to alcohol 3.Alcohol causes harm to people other than the drinker 4.Help needs to be available for people with problems 5.By focusing on their product, economic operators have the potential to reduce harm

Average daily consumption (grams pure alcohol) Risk per 1,000 Source: Taylor & Rehm, based on Taylor et al., AJE, 2008; Rehm et al. IJMPR, 2008 Estimates for United Kingdom This is a graph that tells us what is the likelihood, when we die, that the cause of our death will be due to a disease caused by alcohol, related to how much we drink, on average, over our lives

Consumption per occasion (grams of pure alcohol) Risk per 1,000 Source: Taylor & Rehm, based on Taylor et al., AJE, 2008; Rehm et al. IJMPR, 2008 Estimates for United Kingdom So, this is a graph that tells us, when we die, what is the likelihood that the cause of our death is due to an injury caused by alcohol, But, since this risk is also affected by how often we drink, this graph is for when we drink every second day But, of course, the risk of death is not just about how much we drink on average, but also about how much we drink on an occasion

The disease and injury risks are additive: For all of us (both men and women) who drink 4-5 glasses of wine on an occasion every second day over our lives, the risk that we will die from alcohol is about 10%

Source: Eurobarometer 2007 Age (years) % Proportion of European people who have had 5+ drinks on one occasion at least once a week during past 12 months by age

Source: Office for National Statistics, UK 2008 The risks for the middle aged are also shown in the UK, where alcohol-related deaths have more than doubled over the last 15 years

Occupational group % Proportion of European people of have had 5+ drinks on one occasion at least once a week during past 12 months by occupational group

Source: Goldacre et al 2004 Death certificate mentions alcohol Death certificate states alcohol as underlying cause The increase in alcohol-related deaths in the UK occur not only in the middle- aged, but also in the middle class.

Source: Eurobarometer 2007 % Proportion of European people of have had 5+ drinks on one occasion at least once a week during past 12 months by selected country

Structure of presentation 1.Alcohol causes a high level of harm 2.Young people are vulnerable to alcohol 3.Alcohol causes harm to people other than the drinker 4.Help needs to be available for people with problems 5.By focusing on their product, economic operators have the potential to reduce harm

As we know, adolescents are vulnerable to the effects of alcohol Let, us look at the example of the hippocampus, a structure of the forebrain involved in memory and spatial navigation In fact, taxi drivers in London have increased hippocampal size

Source: DeBellis et al 2000

10% reduction

Impact of school education: synthesis of 14 systematic reviews Source: Jones et al 2007

Impact of school education: synthesis of 14 systematic reviews Source: Jones et al /19

Impact of school education: synthesis of 14 systematic reviews Source: Jones et al /9 3/19

Impact of school education: synthesis of 14 systematic reviews Source: Jones et al /19 1/9 0/19

Impact of school education: synthesis of 14 systematic reviews Source: Jones et al /19 1/9 0/19 2/12

Impact of school education: synthesis of 14 systematic reviews Source: Jones et al /19 1/9 0/19 2/12 6/59

We undertook a systematic procedure to find and describe all studies that investigated the impact of media and advertising exposure on subsequent alcohol use We found 9 such studies, 8 of which were from the US and one from Belgium. All 9 studies found that the greater the exposure to media, alcohol advertisements, or promotional material, the greater the likelihood of starting to drink and the greater amount of alcohol consumed overall and on an occasion. No studies were found which did not show an impact Anderson, de Bruijn, Hastings et al (in preparation)

Californian study of the impact of exposure to alcohol advertisements on TV on alcohol use in 2, to 13 year old school children followed up for one year. At baseline, 16% reported drinking beer in the past month, 15% reported drinking wine in the past month, and 8% reported three-drink episodes in the past month. One year later, those who had watched 60% more alcohol advertisements on TV were 44% more likely to have used beer, 34% more likely to have ever used wine/liquor, and 26% more likely to have had 3 or more drinks on one occasion. Stacey et al (2004)

Structure of presentation 1.Alcohol causes a high level of harm 2.Young people are vulnerable to alcohol 3.Alcohol causes harm to people other than the drinker 4.Help needs to be available for people with problems 5.By focusing on their product, economic operators have the potential to reduce harm

 2,000 homicides (4 in 10 of all murders)  10,000 deaths of people other than the drink- driver from road traffic accidents (3 in 5 of all road traffic fatalities)  16% of all child abuse / neglect  5-9 million children living in families adversely affected by alcohol  60,000 underweight births

Pain and suffering €68bn Crime €12bn Lost life €258bn Value of suffering and loss of life due alcohol €270bn

Source: Streissguth et al 1994

Structure of presentation 1.Alcohol causes a high level of harm 2.Young people are vulnerable to alcohol 3.Alcohol causes harm to people other than the drinker 4.Help needs to be available for people with problems 5.By focusing on their product, economic operators have the potential to reduce harm

Volume of consumption efficacy trials Volume of consumption effectiveness trials Kaner et al 2007 On average, drinkers reduced their consumption from 320g/week (32 drinks) to 280g/week (28 drinks) The reduction in drinking was similar in the normal clinical setting as in a research setting with greater resources This is called a forest plot, because it appears as a forest of lines. Treatment effect No treatment effect

Proportion of heavy drinkers

Proportion of binge drinkers

Longer BI did not achieve significant extra benefits in terms of reduced drinking (a small extra reduction of 1.1 grams/week for every extra minute of counselling)

Risk of ICU admission and hospital death after general surgery Source: Delgado Rodriguez et al /59 Alcohol consumption (g/day) Relative risk

Structure of presentation 1.Alcohol causes a high level of harm 2.Young people are vulnerable to alcohol 3.Alcohol causes harm to people other than the drinker 4.Help needs to be available for people with problems 5.By focusing on their product, economic operators have the potential to reduce harm

Strength and Price:  economic operators can consider ways in which the strength and the price of the product can be managed to reduce the harm done by alcohol

Common organization in the market of wine: From 01/08/2009, enrichment limits reduced; e.g., in zone A of Germany when unfavourable climatic conditions:  currently a wine with a natural alcohol content of 8% can be produced, and the alcohol content can be increased by 4.5% to 12.5%  under the new rules, the same wine cannot become more than 11.5% since only a maximum of 3.5% of enrichment will be possible

Illegally traded and illicit alcohol: 1.Negative impact on producers and retailers 2.Lower price, more harm 3.Contamination from post-production handling 4.No quality control 5.Lost tax revenue to governments

Percentage of unrecorded consumption to total consumption: Older Member States: 11% Newer Member States:38% Do not know distribution between: 1.Legally traded 2.Illegally traded

Illegally traded and illicit alcohol: 1.Joint working in tracing and tracking illegal and illicit alcohol 2.Tax stamps to trace products

1.Alcohol causes a high level of harm We continually need to remind people of the high level of harm that alcohol can cause through to old age: C OMMUNITY AND MUNICIPAL PROGRAMMES need to be strengthened and implemented to raise awareness and support for alcohol policies W ARNING LABELS need to be added to alcohol containers Europe-wide to help establish a social understanding that alcohol is a special and hazardous commodity

2.Young people are vulnerable to alcohol We need to better protect young people: There needs to be much better regulation, enforcement and monitoring of alcohol marketing, which, not only deals with the content, but which substantially REDUCES THE EXPOSURE OF ALCOHOL MARKETING TO YOUNG PEOPLE The rules relating to the marketing of alcoholic products should be APPROXIMATED ACROSS E UROPE, noting the need to specify the extent to which alcohol marketing in certain categories of media and publications is allowed.

3.Alcohol causes harm to people other than the drinker There needs to be tougher action on reducing third party harm: The ECONOMIC AND PHYSICAL AVAILABILITY of alcohol should be regulated, and limited to reduce third party harm, including the implementation of alcohol-free zones. In particular, a MAXIMUM BAC LIMIT OF 0.5 G /L eventually reduced to 0.2 G /L, should be implemented Europe-wide with a lower limit of 0.0 G /L FOR NOVICE DRIVERS and drivers of public service and heavy goods vehicles.

4.Help needs to be available for people with problems There needs to be a considerable health systems investment in APPROPRIATE STRATEGIES to ensure the widespread availability and uptake of early identification and brief advice programmes in primary care settings, in cost effective treatment for alcohol use disorders, and in support for sufferers of third party harm. Making all health care settings, including hospitals ALCOHOL - FREE would send an important health message.

5.By focussing on their product, economic operators have the potential to reduce harm Economic operators should consider ways in which the price and strength of their product can be managed to reduce harm, for example a commitment to support regulation for a MINIMUM PRICING STRUCTURE Producers and retailers could commit to share intelligence and knowledge of ILLEGALLY TRADED AND ILLICIT ALCOHOL, together with a commitment to support Europe- wide TAX STAMPS

Thank you for your attention!