1. Alcohol policy
Dr Bruce Ritson
SHAAP

2. Alcohol policies in a public health perspective
Alcohol problems are not only prevalent throughout the world they are preventable
Alcohol problems affect the whole spectrum of drinkers not just alcoholics
Average amount of alcohol consumed in a society affects the prevalence of problems
One of the most effective ways to prevent alcohol related problems is through policies that reduce average alcohol consumption,especially limitations on physical and economic availability.
Bruun et al 1975

3. What works? International Review of Policy Measures
Authored by Public Health Academics
Sponsored by WHO 3

4. Population Consumption and Harm
The more alcohol a nation consumes, the greater the burden of harm it will experience, and vice versa.
Changes is per capita consumption are reflected in changes in harm.
There is a statistically significant relationship between changes in per capita alcohol consumption and liver cirrhosis mortality.
(Calling Time: The nation’s drinking as a major health issue, Academy of Medical Sciences, March 2004)

5. Population Measures
International evidence confirms that if overall alcohol consumption falls, reductions in alcohol-related harm can follow within a relatively short time.
Efforts to reduce alcohol harm need to reach the majority of drinkers and not just high risk groups.
It is the greater number of risky drinkers in a population who account for most of the alcohol-related harm.
More harm associated with the acute effects (drinking to intoxication) rather than chronic effects (sustained drinking over a period of time).
A reduction in overall consumption can be expected to have a positive effect on the whole population as well as reducing harm in high risk groups.
(Evidence-based strategies and Interventions to reduce alcohol-related harm, WHO A60/14 Add.1, 5 April 2007)

6. “The only purpose for which power can be rightfully exercised over any member of a civilised community against his will is to prevent harm to others. His own good, either physical or moral is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so because it will make him happier, because in the opinion of others, to do so would be wise or even right. The only part of the conduct of anyone for which he is amenable to society is that which concerns others. In the part which merely concerns himself this independence is of right absolute; over himself, over his own body and mind the individual is sovereign”.
JS Mill (1859)

7. No man is an island, intire of it selfe: every man is a peece of the Continent, apart of the maine John Donne (1624)

8. Prevention; What measures work best?
Price
Availability (licensing Act)
Drink driving counter measures
Community action (night time economy)
Early recognition plus Brief interventions
A extensive evidence base has identified what the most effective alcohol policy measures are. These are measures on price; availability; measures to counter drink driving and screening and brief interventions for alcohol problems Less effective are interventions such as education and mass media campaigns.

9. The UK’s concentration on binge-drinking youngsters and the antisocial or criminal consequences of heavy drinking has allowed politicians to project the problem onto a small part of the population, which no doubt suits the marketing strategies of the drinks industry. When the Chief Medical Officer in England called for a minimum unit price for alcohol, the proposal was instantly dismissed by Prime Minister Gordon Brown in saying we “don’t want the responsible, sensible majority of moderate drinkers to have to pay more or suffer because of the excesses of a small minority”.
Sir Ian Gilmour, Lancet, 2009

10. “We have decided to reverse the previous Government’s plan to increase the duty on cider by 10 per cent above inflation and the reduction will come intoeffect at the end of this month – just in time to celebrate England’s progress to the quarter finals, or else to drown our sorrows.”
George Osborne, Budget Statement

11. The Big Society Can Solve Problems of Binge Drinking
“The truth is that problems associated with excessive irresponsible drinking requires that the new government recognise it. The new government has rightly recognised that the solution lies not in heavy handed state action but a more nuanced approach that seeks to utilise the powerful influences that drive behavioural change.”
Chris Sorek, Telegraph, 7/9/10

12. 12

13. UK Alcohol Consumption Litres of pure alcohol consumption per capita in the UK, [Tighe Brewer’s Statistical Handbook 2007]
This slide shows alcohol consumption in the UK over the last century*. Having fallen in the beginning of the 20th century, notably during the two world wars, has more than doubled since 1950, with the rate of increase particularly noticeable since the early 1990s
Tighe A. (ed) (2007) Statistical Handbook 2007, Brewing Publications Limited
*These figures are a proxy for consumption. They are based on alcohol released for sale. Not all alcohol released will necessarily be consumed, however, this is counter balanced by consumption of the population abroad; home production; alcohol brought in from abroad etc. but is an internationally recognised indicator for population consumption.
WHO International Guide for Monitoring Alcohol Consumption and Related Harm 13

14. Price & Consumption Trends
That is why tackling price – as part of the wider package of measures - is so important.
We cannot afford to ignore the clear link between price and consumption.
I mentioned earlier that alcohol consumption had increased by almost 19% since 1980.
Over the same period the affordability of alcohol of alcohol has increased by 70%.
This chart graphically demonstrates the inter-relationship between consumption and affordability. 14

15. The Scottish Parliament
Established July 1999
Proportional representation
Reserved for Westminster :
Foreign Policy, Defence, Social Security, most fiscal issues, Excise Duties, Drug Legislation
Devolved : Health, Education, Justice, Agriculture
Health Spend £10 Billion out of total £26 billion budget.

16. Scottish Strategy 2008

17. SCOTTISH PROPOSALS 2008
No discount for multiple purchase
Minimum retail price per unit
No off sales to under 21s
Social responsibility fee
Separate alcohol retail areas
Separate alcohol checkouts
No under 18s to sell alcohol
Lower driving limit and random testing
Introduce widespread screening and brief
Intervention in Primary Care
Substantial investment in care and treatment services

18. Office National Statistics 2007

19. Liver Cirrhosis Death Rates 1950 - 2006
Updated for Scottish Alcohol Consultation. 2008 19

20. ALCOHOL RELATED DEATHS IN SCOTLAND 1990-2003
Clear evidence that rates of alcohol related harm are increasing.
So increasing public concern relates to well established trends.

21. Mortality rates - Liver cirrhosis all ages per 100,000 per year
Men
Women
England & Wales
3.4
2.2
8.3
5.4
14.1
7.7
Finland
9.9
5.5
23.8
8.1
28.7
France
48.4
19.9
31.9
28.1
10.8
Ireland
3.9
7.8
5.3
11.1
6.5
Scotland
8.2
6.1
16.9
34.4
16.1
Sweden
9.2
4.7
13.7
6.2
13.5
5.6
Source: Leon & McCambridge

22. Sales Data Neilsen analysis 2008
Population 16 +
Scotland
2005
2006
2007
Litres pure alcohol
11.9
11.6
11.8
England
10.1
10.0
9.9

23. What is SHAAP? An independent medical advocacy body
Set up in November 2006 by the Scottish Medical Royal Colleges and Faculties with start-up funding provided by the Scottish Executive
To provide authoritative medical opinion on the impact of alcohol on health.

24. SHAAP Advocacy
Influencing policy for whole population approaches including regulatory policies such as controls on price and availability.
Promoting the public health case for protecting young people from experiencing alcohol-related harm.
Highlighting third party damage caused by alcohol.
Advocating for effective treatment for people with alcohol-related problems and appropriate training for clinicians.
Collaborating with UK, European and international colleagues to advocate for the public health interest in alcohol policy.

25. Tackling the Issue - Price and Availability
Alcohol 62% more affordable in 2005 than in 1980.
Large increase in the amount of alcohol bought in shops, supermarkets and off-licences.
SHAAP would like to see:
New Licensing (Scotland) Act, restricting the ability of pubs and clubs to run cheap drinks promotions, extended to cover supermarkets, off-licences and corner shops
The discretionary code in the Act requiring alcohol to be displayed separately from other goods made a mandatory condition
Stricter enforcement of laws relating to alcohol sales.
References:
1. Alcohol more affordable: Alcohol Statistics Scotland, ISD, 2007
2. Increase in off-sales of alcohol: Alcohol Statistics Scotland, ISD, 2007

26. Who drinks the cheap booze?
64% of all cheap off-trade alcohol is consumed by harmful drinkers (only 9% by moderate drinkers).
26% of harmful drinkers’ alcohol is “cheap”, 17% of moderate drinkers’.
Meier 2008

27. The Licensing Objectives
- Prevention of Crime and Disorder
- Securing Public Safety
- Preventing Public Nuisance
- Protecting and Improving Public Health
- Protecting Children from Harm.

28. Tackling the Issue -Treating People with Alcohol Problems
SHAAP would like to see:
Effective treatments from brief interventions to residential programmes available to people with alcohol problems
Staff trained and supported to deliver evidence-based interventions
Services of sufficient capacity to meet the needs of the populations they serve.

29. SCOTTISH GOVERNMENT PUBLIC HEALTH ALLOCATIONS 08/09
Increased screening for alcohol misuse will have a knock-on effect on the volume of downstream services required. As a consequence the overall package delivers a considerable
uplift in funding for early intervention and treatment (including support for newly identified dependent drinkers), and for prevention activities.
Where appropriate, services should comply with guidance contained in the Health Technology Assessment Report 3 on Prevention and Relapse in Alcohol Dependence.

30. Tackling the Issue - Educating Doctors about alcohol
Doctors of tomorrow need to be educated about alcohol problems to be able to detect problems and treat patients.
SHAAP would like to see:
A core curriculum on alcohol for both undergraduate and postgraduate medical education
The five Scottish Medical Schools, the Deaneries, the Royal Colleges and NHS Education Scotland collaborating to deliver a core curriculum on alcohol across the career span
Training for medical students and doctors on the potential for alcohol-related impairment in themselves and accessing help for a medical student or doctor.

31. MINIMUM PRICING – WHO WINS?
The public’s health
Deprived communities
Heavy drinkers or their families
Moderate drinkers
Pubs and restaurants
Premium Brands
Small retailers
Public health – Lives saved
Deprived comms most affected, most to gain
Price sensitivity heavy drinkers
Moderate drinkers minimum effect. Wider savings.
Pubs. SLTA, BII, Punch Taverns, Publican magazine “Make it the minimum”
Premium brands. Will narrow price gap. Increase market share. Keep money.
Small retailers. Level playing field.
ALL OF THE ABOVE

32. SCOTTISH GOVERNMENT PROPOSALS 2009
A Minimum Price for Alcohol
(Example of 40p per unit.)
No discounts for multiple purchase. (3 for 2, 20 for 12)
Age limit of 21 in off sales.
Social responsibility fee to pay for city centre management.
More support and treatment.

33. Trends in Drinking Venue
Scot Gov / Nielsen 2010 33

34. The 1990s
The 2000s
35p per unit p per unit p per unit 34

35. Perception of Alcohol as a Problem
60% Adults (16+) viewed alcohol as a serious issue in Scotland
46% reported that people being drunk or rowdy in public places had an effect on their own quality of life
People living in the most deprived areas were more likely to be affected by alcohol use
(SCVS)

36. What do you need for a public health strategy ? Involvement
NHS public health, Local authority health
Improvement, Police, retailers and producers.
Information
National and local. Health, crime, sales data
Monitoring
Key performance indicators. (Improved health,
Less crime, child welfare, reduced consumption.) 36

37. Inequalities and Mortality in Scotland
Death Rate per
100,000 population
2001
Leyland et al, Medical Research Council 2007 37

38. SHAAP www.shaap.org.uk Tel 01312473667 Tom Roberts 12 Queen Street,
Edinburgh. EH2 1JQ