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

2. Main drug of harm in Ireland

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

4. 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

5. 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

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

7. 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

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

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

10. Alcohol cause huge health problems Worse in males: 17% of DALYs( vs 4%) Worst in young males Alcohol cause 35% of deaths aged 35- 50

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

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

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

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

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

16. 60 40 80 100 120 140 160 0 0 40 60 80 20 0 0 100 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

17. Mortality due to cirrhosis in Ireland

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

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

20. 3 main types of alcohol misuse Hazardous Harmful Dependent drinking.

21. 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.

22. 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

23. 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.

24. A few words about cirrhosis Most alcoholics drink every day

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

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

27. Absolute risk of death from alcohol- related disease

28. Adult alcohol consumption in 49 European states

29. Adult alcohol consumption in 3 European bands

30. Adult alcohol consumption

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

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

42. 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

47. Cancer attributable to alcohol 5% men 2% women

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

49. Deregulation of sales of alcohol Mediterranean style of drinking in Ireland

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

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

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

53. Concerts

55. Sports sponsorship

57. Advertising

58. Under-age drinking

59. Social order

60. Marketing towards young people

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

62. 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.

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

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

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

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

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

68. 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

69. 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

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

71. 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.

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

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