Prevalence of alcohol problems

It is estimated that alcohol causes 2.5 million preventable deaths per year worldwide. Alcohol is the third leading cause of death in the USA (85 000 deaths per year; Reference Mokdad, Marks and StroupMokdad 2004) and, worldwide, alcohol is the third leading risk factor for the total burden of disease (Reference Lim, Vox and FlaxmanLim 2012). In the UK, alcohol causes 8700 deaths and 1.2 million hospital admissions, at a cost of £21 billion per annum (Reference BrownBrown 2014).

Developing countries have a disproportionately higher disease burden per litre of alcohol than Western countries and this is predicted to increase (Reference Anderson, Chisholm and FuhrAnderson 2009). Developing countries also have higher rates of alcohol problems per capita and fewer resources to address these (Reference Anderson, Chisholm and FuhrAnderson 2009). There is a close relationship between average alcohol consumption and alcohol-related problems, and binge drinking contributes disproportionately to alcohol-related mortality in lower-income countries (Reference Blakely, Hales, Kieft, Ezzati, Lopez and RodgersBlakely 2004).

In low doses (e.g. 10 g every other day, equivalent to one-third of a pint of beer per day), alcohol may actually be cardioprotective (Reference Corrao, Rubbiati and BagnardiCorrao 2000). However, doubt remains as to the effect of confounding factors on these findings, such as the tendency of people with chronic illness to abstain completely (Reference Fillmore, Stockwell and ChikritzhsFillmore 2007; Reference Chikritzhs, Fillimore and StockwellChikritzhs 2009). Alcohol promotes cardiovascular disease at high doses, especially when consumed in irregular binges (Reference Taylor, Rehm and RoomTaylor 2008; Reference Anderson, Chisholm and FuhrAnderson 2009). Alcohol misuse increases the risk of liver cirrhosis, cancer, sexually transmitted diseases (including HIV), tuberculosis, alcoholic dementia, fetal alcohol syndrome and cardiovascular disease (Reference Lim, Vox and FlaxmanLim 2012). Whereas mortality from most other diseases has fallen, there has been a four-fold rise in deaths from alcohol-related liver disease in the UK since the 1970s. These deaths accounted for over 80% of the 7000 alcohol-related deaths in 2011 in the UK (Office for National Statistics 2013). However, medical reviews often overlook the overwhelming social problems commonly associated with alcohol misuse, including acquisitive and violent crime, job loss, accidents at work, road traffic accidents, child abuse and neglect, domestic violence, suicide, homicide and rape (Reference Anderson, Chisholm and FuhrAnderson 2009).

Alcohol, family problems and crime

There are several comprehensive surveys of the links between alcohol use, violence and crime in the UK (Reference English, Holman and MilneEnglish 1995; Reference Single, Robson and XieSingle 1998; Reference Rehm, Patra and PopovaRehm 2006; Reference MeierMeier 2008). Recent alcohol intoxication affects either the victim or the perpetrator in 25% to 50% of violent incidents (including 60% of homicides). For example, in Scotland one in every eight violent incidents occurred in or around pubs or clubs where alcohol was available. Alcohol was also involved in the majority of assaults (72%) and incidents of domestic violence (62%) (ISD Scotland 2011).

A UK Home Office study calculated that young adults who often got drunk were 5.5 times more likely to commit a violent offence than others (Reference Richardson and BuddRichardson 2003). The 2003 Offending, Crime and Justice Survey found that although binge drinkers comprised 6% of the overall adult sample, they accounted for 30% of all crimes reported and 24% of all violent incidents (Reference Matthews and RichardsonMatthews 2005). Alcohol misuse is involved in 25–33% of cases of child abuse (Institute of Alcohol Studies 2014). Marriages in which one or both partners have an alcohol problem are twice as likely to end in divorce, and one in three divorce petitions in the UK cite excessive drinking by a partner (Prime Minister's Strategy Unit 2003).

Economics of alcohol

Over the past three decades, the price of alcohol has fallen dramatically in real terms. Alcohol is 61% more affordable in Britain today than in 1980, as real incomes have increased (Reference BrownBrown 2014). A bottle of whisky currently retailing at £10 would cost the equivalent of £65 if the price was adjusted for real earnings in the mid-1970s. ‘Off-sales’ is a term used to describe the sale of alcoholic beverages for consumption off the seller's premises. Off-sales now account for over two-thirds of alcohol consumption in the UK (ISD Scotland 2011). There has been a massive increase in off-sales, which are made usually from supermarkets. In addition, 64% of all cheap off-trade alcohol is consumed by harmful drinkers, compared with only 9% by moderate drinkers (Reference MeierMeier 2008). It is estimated that 75% of the profits of alcohol companies come from sales to hazardous and harmful drinkers (Reference GornallGornall 2014a).

The Organisation for Economic Co-operation and Development estimates that alcohol misuse costs the UK 2–3% of its gross domestic product annually (£12 per week or £625 per year per person) (Reference Anderson and BaumbergAnderson 2006; Office for National Statistics 2013; WHO 2014). In the UK, alcohol causes 8700 deaths and 1.2 million hospital admissions annually, at a cost of over £21 billion (£2.7 billion in National Health Service (NHS) costs, £11 billion in criminal justice costs and £7.3 billion in lost productivity; Reference BrownBrown 2014). This greatly exceeds the ∼£10 billion generated in tax on alcohol (Daily Mail 2013; Office for National Statistics 2013). Surprisingly, alcohol taxes are generally below their maximum revenue-producing potential (Reference AndersonAnderson 2008). These so-called ‘externalities’ (the additional societal cost of a product not borne by the manufacturer) – for example, crime, lost productivity, accidents and multiple health costs – are rarely publicised (Reference Rehm, Mathers and PopovaRehm 2009).

Consumption of illicit alcohol is a major health problem in lower-income countries. This could be countered by a tax system that encourages lower-alcohol products, such as beer, along with rigorous enforcement including tax stamps to indicate duties have been paid (Reference Parry, Myers and ThiedeParry 2003). Around a third of alcohol consumption worldwide is from illicit sources although this occurs disproportionately in lower-income countries.

Effective strategies to reduce alcohol problems

Methods that are likely to reduce alcohol problems include increasing price (especially minimum pricing), restricting licensing hours for alcohol sales, restricting the density of outlets, restricting age of purchase, reducing the drink-driving blood-alcohol limit, banning alcohol advertising and increasing the availability of alcohol treatment (Reference Babor, Caetano and CasswellBabor 2003; Reference Anderson, Chisholm and FuhrAnderson 2009). Methods that are less effective, or do not work, tend to be those supported by the industry: education and public health campaigns (especially in schools), voluntary self-regulation by the industry (Department of Health 2010; Reference Mathews, Thorn and GiorgiMathews 2013; Reference Bosque-Prous, Espelt and GuitartBosque-Prous 2014) and product labelling with warnings (Reference Babor, Caetano and CasswellBabor 2003; Reference Crombie, Irvine and ElliottCrombie 2007; Reference ZeiglerZeigler 2009).

An extensive review from The Lancet (Reference Anderson, Chisholm and FuhrAnderson 2009) makes uncomfortable reading for politicians and the drinks industry:

The disappointingly small effect of school and public education programmes on rates of alcohol problems might be due to the inability of health education programmes to compete with sophisticated mass-media marketing and advertising campaigns. In addition, attitudes towards and use of alcohol are determined primarily by the family and peer group (Reference Jones, James and JeffersonJones 2007; Reference Petrie, Bunn and ByrnePetrie 2007). Unlike tobacco products, warning labels on alcohol packaging are ineffective (Reference Anderson, Chisholm and FuhrAnderson 2009). See Box 2 for a comparison of alcohol and tobacco regulation.

Young people are particularly vulnerable to alcohol problems. Increasing the age of legal alcohol purchase and reducing the density of outlets are particularly effective at reducing alcohol consumption in young people (Reference Wagenaar and ToomeyWagenaar 2000, Reference Huckle, Huakau and SweetsurHuckle 2008). Policies that increase alcohol prices delay the start of drinking, slow young people's progression towards drinking large amounts, and reduce young people's heavy drinking and the volume of alcohol consumed per occasion (Reference CookCook 2007). A systematic review of training bar staff to identify customers with alcohol problems and to promote responsible drinking revealed that it has little effect unless backed up by police enforcement and licence inspectors (Reference Ker and ChinnockKer 2006).

Market-based interventions, such as blanket advertising bans on alcohol products and restricting times during which alcohol can be sold, are estimated to have a cost-effectiveness of US$500–1000 per disability-adjusted life-year, although these interventions must be rigorously enforced (Reference Anderson, Chisholm and FuhrAnderson 2009).

A meta-analysis of nine studies in the USA reported that reducing the threshold for legal driving to a concentration of 0.8 g/L alcohol in the blood resulted in a 7% decrease in alcohol-related deaths in road traffic accidents (Reference Mann, Macdonald and StodutoMann 2001; Reference Anderson, Chisholm and FuhrAnderson 2009). Scotland, with one of the highest cirrhosis rates in Europe, reduced the drink-driving blood-alcohol limit from 80 mg/100 mL blood to 50 mg/100 mL, in line with many European countries, in late 2014. The higher limit remains in place in England.

Random alcohol testing and mandatory alcohol testing at sobriety check-points are also effective (Reference Shults, Elder and SleetShults 2001). Driver-related alcohol interventions such as these are estimated to have a cost-effectiveness of US$700–1200 per disability-adjusted life-year (Reference Anderson, Chisholm and FuhrAnderson 2009). A meta-analysis of 215 studies of mandatory drink-driving programmes reported a reduction in recurrence of alcohol-related driving offences and accidents of 8–9% (Reference Wells-Parker, Bangert-Drowns and McMillenWells-Parker 1995; Reference Anderson, Chisholm and FuhrAnderson 2009). Designated driver schemes, however, are not effective (Reference Ditter, Elder and ShultsDitter 2005).

Observations following changes in alcohol price and taxation in the single market of European countries consistently show that reduction in price leads to increased consumption and alcohol-related problems (Reference Rabinovich, Brutscher and De VriesRabinovich 2009). A meta-analysis of 112 studies (Reference Wagenaar, Salois and KomorWagenaar 2009) reported overall price elasticity for all alcoholic beverage types of −0.52 in the short term and −0.82 in the long term. In other words, a 10% increase in price produces a 5% reduction in short-term consumption and an 8% reduction in long-term consumption. Reductions in consumption in response to price increases are lower for beer than for wine or spirits (price elasticity −0.46 for beer, −0.69 for wine and −0.80 for spirits; Reference Wagenaar, Salois and KomorWagenaar 2009). Price-based measures to reduce consumption are estimated to have a cost-effectiveness of US$500 per disability-adjusted life-year (Reference Anderson, Chisholm and FuhrAnderson 2009).

Brief interventions from health professionals are one of the most cost-effective means of reducing alcohol-related harm, although there is no advantage in using more prolonged psychological treatment in primary care (Reference Kaner, Beyer and DickinsonKaner 2007). Brief interventions are estimated to have a cost-effectiveness of US$2000–4000 per disability-adjusted life-year (Reference Anderson, Chisholm and FuhrAnderson 2009). Unfortunately, brief interventions, unlike increased taxation, are costly and slower to implement, as they require the training of substantial numbers of health professionals.

Effective industry strategies to prevent restrictions on alcohol

There is a certain irony to the fact that the headquarters for the alcohol manufacturer Diageo's flagship distillery in Fife is immediately adjacent to the base for the NHS Community Alcohol and Drug Team at the Cameron Hospital, Leven. After a visit to the distillery in Fife, the then Prime Minister David Cameron referred to whisky as ‘an iconic product with a rich heritage and a fantastic future’ (Reference Collin, Johnson and HillCollin 2014). The alcohol industry is the example par excellence of how powerful corporations can lobby governments and influence policy to promote their products, irrespective of public health, social order and economic reality (Reference Babor, Hall and HumphreysBabor 2013). The UK is home to two of the largest alcohol multinationals, Diageo (producers of Johnnie Walker, Smirnoff and Guinness) and SABMiller (producers of Carling).

Minimum pricing

Minimum pricing involves setting a floor price per unit of alcohol, below which it is illegal to sell alcohol beverages. Alcohol-related harm is directly related to dose and consumption is partly determined by price, particularly for heavy drinkers (Reference StockwellStockwell 2014). It is estimated that the majority of alcohol problems arise from a small minority of heavy drinkers (80% of consumption occurs in 20% of users, known as the Pareto principle). A 2008 alcohol strategy consultation document from the Department of Health (2008) stated that drinkers who regularly drank at levels above recommended limits were responsible for 76% of UK alcohol consumption. As previously mentioned, the majority of the profits of alcohol companies (and alcohol tax revenues) come from sales to hazardous and harmful drinkers (Reference GornallGornall 2014a).

Reference Sheron, Chilcott and MatthewsSheron and colleagues (2014) estimated that a minimum price of 50p per unit of alcohol would reduce consumption in harmful drinkers around 200 times more than in low-risk drinkers. People drinking the equivalent of 4 bottles of spirits (120 units) per week spend 33p per unit, regardless of income, whereas moderate drinkers spend around £1.10 per unit; 80% of alcohol is consumed at home (off-sales) by heavy drinkers. With a minimum unit price of 50p, heavy drinkers would have to pay around 13% of their income to maintain their heavy consumption levels (compared with 0.03% of income for moderate drinkers to maintain their consumption). Minimum unit pricing would not affect sales in bars and restaurants, as virtually all sales in these venues exceed the minimum price. It has been estimated that a minimum unit price of 40p would save around 1000 lives and result in 50 000 fewer crimes per year in England (Reference MeierMeier 2008; Reference Meng, Brennan and HolmesMeng 2013).

Canada was the first county to introduce minimum pricing, and has benefitted from a significant reduction in alcohol-related harms. The Canadian government, however, introduced minimum pricing to protect revenue rather than to improve public health (Reference StockwellStockwell 2014). Therefore, the Canadian drinks industry supported minimum pricing, in contrast to the vehement opposition observed in Europe.

Below-cost selling, or selling alcohol for less than the value of tax paid on the beverage, has been prohibited by the UK government. However, this affects only 0.7% of the UK market, compared with 23% for a 45p minimum unit price (Reference Brennan, Meng and HolmesBrennan 2014). In practical terms, the ban on below-cost selling prevents around 14 deaths and 500 hospital admissions annually in England, but a 45p minimum unit price could prevent 624 deaths and 23 700 admissions (Reference Brennan, Meng and HolmesBrennan 2014).

Minimum pricing was intended to be introduced around the same time in England and Scotland (HM Government 2012). However, it was abandoned in England on 17 July 2013, the day before the Parliamentary summer recess, nominally because there was not enough ‘concrete evidence’ that it would not penalise responsible drinkers and low-income families (Reference GornallGornall 2014d). There was also concern about a drop in tax revenues. Numerous private conversations took place between ministers and representatives of the drinks industry and major supermarket chains (the principal retailers of off-sale alcohol) in the months prior to this decision, which was highly suggestive of skulduggery (Reference GornallGornall 2014a,Reference Gornalld).

Scotland is the first European country to attempt to introduce minimum pricing. Minimum pricing laws were planned to take effect in April 2014, having been passed by the Scottish Parliament in May 2012 (Reference GornallGornall 2014d). Scotland has the highest rate of cirrhosis mortality in Europe and alcohol (primarily spirits) became 62% more affordable between 1980 and 2005. There is widespread international opposition (based on free-trade arguments) from the drinks industry, which fears that creating a precedent of minimum pricing will encourage other European countries to introduce minimum pricing (similar to the spread of smoking bans after smoking in public spaces was banned in Ireland).

At the time of writing (July 2016), minimum pricing for alcohol has been delayed in Scotland, and was abandoned in the rest of the UK in July 2013, presumably because of legal challenge and lobbying from the drinks industry, despite overwhelming evidence for its effectiveness (Reference Babor, Caetano and CasswellBabor 2003; Reference Meier, Brennan and PurshouseMeier 2010; Reference BarnesBarnes 2013; Reference MaddoxMaddox 2013; Reference GodleeGodlee 2014b). The alcohol industry, represented as the Scotch Whisky Association, had been performing ‘massive lobbying’ over the summer of 2012. By contrast, the industry's attempt to block minimum pricing in the Scottish courts was overturned on 3 May 2013 in the ruling that ‘none of the challenges to the minimum pricing measures is well founded’ (Reference GornallGornall 2014d).

The European Court of Justice heard the case against minimum pricing in early 2016 on the basis of the petition that minimum pricing in Scotland ‘would artificially distort trade in the alcoholic drinks market’ (Reference McCambridge, Hawkins and HoldenMcCambridge 2014). The European Court suggested that minimum pricing was a ‘disproportionate’ way of tackling Scotland's alcohol problems, but ultimately referred the case back the Scottish Court to rule whether tax increases would be a more effective or ‘proportionate’ measure. Whether this will lead to a further legal challenge in the European Court of Justice remains to be seen. The case continues (Reference NicholsonNicholson 2016).

Minimum pricing in Scotland may have been promoted because the Scottish Parliament is a recent institution, having been established in 2000. The unhealthy relationship between established political parties and the drinks industry had not been created in Scotland. This is surprising, as income from the drinks industry ranks second only to oil in the Scottish economy. It might be that the Scottish National Party has been largely ignored by the drinks industry until very recently and has not been influenced by industry lobbying, in comparison with the established political parties in London. By contrast, there are four all-party parliamentary groups in the UK parliament notionally created to support the interests of the beer, wine, spirits and cider industries in Westminster. The beer group contains 300 Members of Parliament, almost half of the House of Commons.

MCQs

Select the single best option for each question stem

1. 1 It is estimated that alcohol, as the third most common preventable cause of death, is responsible for how many deaths per year, worldwide?

   1. a 100 000

   2. b 500 000

   3. c 2.5 million

   4. d 10 million

   5. e 40 million.

2. 2 Effective measures to reduce alcohol-related harm include each of the following except:

   1. a price increases for alcoholic drinks

   2. b minimum pricing for alcoholic drinks

   3. c restricting licensing hours for alcohol sales

   4. d educational campaigns in schools

   5. e increasing the availability of alcohol treatment.

3. 3 A typical bottle of whisky, priced around £10 now, would have cost the equivalent of what in the mid-1970s?

   1. a £20

   2. b £40

   3. c £50

   4. d £60

   5. e £65.

4. 4 Methods used by the alcohol industry to influence marketing and sales of alcohol worldwide include:

   1. a government lobbying

   2. b political donations

   3. c targeting unregulated markets in developing countries

   4. d legal action against minimum pricing

   5. e all of the above.

5. 5 Effective industry strategies to prevent restrictions on alcohol sales have included all of the following except:

   1. a targeting unregulated markets

   2. b regulatory capture

   3. c land banking

   4. d confusion marketing

   5. e creating social aspect organisations.

MCQ answers

1

c

2

d

3

e

4

e

5

c