Alcohol policy:research and practice

Professor Colin Drummond

Institute of Psychiatry

King’s College LondonMSc AddictionJanuary 2011

Topics

• What are the drivers?

• What are the policy options?

• What is happening in England?

• What about Europe?

• Conclusions

What are the drivers?

“Rising consumption over the last 25 years have been accompanied by an increase in

availability”

• 68% increase in licensed hotels and restaurants

• 100% increase in off licences

• 145% increase in on licence applications

• Increased capacity of on licenses:

“Super pubs” are now 20 times bigger than typical pubs

The Licensing Act 2003

explained:

Flexible opening hours for

premises, with the potential for

up to 24 hour opening, seven days a week.

This will help to minimise public

disorder resulting from fixed closing

times.

Laranjera et al., in press, Am J Public Health

Laranjera et al., in press, Am J Public Health

Policy options

What the experts said…..• Bruun et al., 1975

• Royal College of Psychiatrists, 1986

• British Medical Association, 1989

• Faculty of Public Health Medicine, 1991

• Edwards et al., 1994

• Royal College of Physicians and the British Pediatric Association, 1995

• Babor et al., 2003

• Academy of Medical Sciences, 2004

• WHO expert committee, 2007

• NICE, 2010

DISCLAIMER:DISCLAIMER:NO EFFECTIVE STRATEGIES HAVE BEEN NO EFFECTIVE STRATEGIES HAVE BEEN

USED IN THE MAKING OF THIS DOCUMENTUSED IN THE MAKING OF THIS DOCUMENT

AHRSE, 2004• The two main supply-side levers that are commonly cited as influencing

harm are price and availability:– price is controlled by Government through levels of taxation; it is also governed

by the laws of supply and demand – for example, price promotions; and– availability is controlled through restrictions on suppliers (planning and licensing

law) and individuals.

• There is a clear association between price, availability and consumption. But there is less sound evidence for the impact of introducing specific policies in a particular social and political context: – our analysis showed that the drivers of consumption are much more complex

than merely price and availability;– evidence suggested that using price as a key lever risked major unintended side

effects;– the majority of those who drink do so sensibly the majority of the time.– Policies need to be publicly acceptable if they are to succeed; and measures to

control price and availability are already built into the system.

Alcohol strategy optionsBabor et al. (2003) Alcohol: No ordinary commodity

• High impact– Taxation & pricing– Restricting availability– Limiting density of outlets– Lower BAC limits– Graduated driving licences

• Medium impact– Brief interventions– Treatment– Safer drinking environment– Heavier enforcement

• Low impact– Unit labelling– “Sensible” drinking

campaigns– Public education– School based education– Voluntary advertising

restrictions

ALCOHOL HARM REDUCTION STRATEGY FOR ENGLAND (AHRSE)2004

Some major problems

• No money• No targets• No high impact strategies• Licensing relaxation• Voluntary codes for alcohol industry• Less effective controls on alcohol

consumption• Increased criminalisation

University of Sheffield report on pricing and promotion (Nov 2008)

• Commissioned by DH• High impact of tax increase• Increases across the board have more impact• High impact of minimum price• Greater impact on heavy drinkers and under-age• Impact on harm (40p min price->41,000 less

hospital admissions; £500M health cost savings, also reduced crime, unemployment)

• Smaller impact of banning promotions

Impact of minimum price per unit of alcohol on consumption

minimum price (p)

Change in consumption (%)

What the government said• March 2009: Donaldson: minimum price of 50p per unit of

alcohol to reduce consumption, idea of passive drinking• March 2009: Brown: “But . . . it’s also right that we do not want

the responsible sensible majority of moderate drinkers to have to pay more or suffer as a result of the excesses of a small minority”

• March 2009: Lansley: "There is clearly a need for action. But it is very important to recognise that to deal with this problem we need to deal with people's attitudes and not just the supply and price of alcohol. Higher taxes on high-alcohol drinks aimed at young people

• March 2009: Donaldson: “I take a different view as to whether heavy drinking is a minor and insignificant problem.”

• April 2009: Darling Budget: Retains plan for 2% above inflation increase in alcohol tax

The growing influence of industry, UK• 2004, AHRSE proposes industry levy,

threatens legislation• 2004, Diageo hosts meeting with PM• 2004, CEO of Portman Group joins AERC,

and is member of Better Regulation Commission, Scottish Ministerial Advisory Committee on Alcohol Problems, Director, Advertising Standards Agency, Trustee, Drinkaware Trust.

• 2004, Advertising industry threats to sue Academy of Medical Sciences over Calling Time report

The growing influence of industry, UK• Nov 2004, Portman group named as agency

responsible for delivering public health messages on alcohol in England, in Choosing Health White Paper

• 2005, DCMS sides with alcohol industry (BBPA) on implementation of Licensing Act

• 2006, Drinkaware trust, new incarnation of Portman Group, £5M p.a. budget, supported by a national producers fund, “independent” steering group

• 2005-6, EU alcohol policy roundtable for DG Sanco. Hosted by European Policy Centre. UK companies active in attempting to rubbish public health research.

Improving health and treatment services

• Improve staff training on early identification

• Pilot early identification and treatment

• National Needs Assessment

• MOCAM, evidence review

• Better help for vulnerable groups (e.g. homeless, drug addicts, mentally ill, young people)

Treatment: a spectrum of need

Harmful

Hazardous

Dependence

Increasing consumption

Brief interventions

Specialist interventions

Residential interventions

Assisted withdrawal

The potential of ‘stepped care’

• Caters for a range of needs

• Intensive interventions delivered only to those who do not respond to brief interventions

• Practical clinical algorithm (care pathway)

• Already accepted in a range of conditions

• New method of shared care with specialists supporting GPs

Gap between need and access (PSUR) by region

Alcohol Screening and Brief Intervention Research Programme

national brief intervention research consortium

A&E St. Mary’s 'Scientia Vincit

Timorem'

June 2007

Safe, Sensible, SocialSafe, Sensible, Social– No specific funding commitmentNo specific funding commitment– Local needs assessmentLocal needs assessment– Redefinition of target groups: young binge Redefinition of target groups: young binge

drinkers & older adults drinking over 50/35 unitsdrinkers & older adults drinking over 50/35 units– New PSA targets: alcohol-related hospital New PSA targets: alcohol-related hospital

admissionsadmissions– National Audit Office studyNational Audit Office study– Roll out of units campaign, social marketing, Roll out of units campaign, social marketing,

brief interventionsbrief interventions– NTA role: NATMSNTA role: NATMS

Safe, Sensible, Social & young people

• Young people<18 and 18-24 binge drinkers• Sharpened criminal justice for drunken behaviour• Toughened enforcement of underage sales• Trusted guidance for parents and young people• Public information campaign to promote sensible

drinking• Public consultation on alcohol pricing and promotion• Local alcohol strategies and partnerships: universal

education, targeted support, specialist drug and alcohol treatment (£62M Young People’s Substance Misuse Grant)

PSA 25

• To reduce the rate of alcohol related hospital admissions by 2011

• Alcohol related admissions rising by 73,000 pa

• Aim to reduce the rate from 25% to 11% pa• NHS contribution to this of 6%• Through the Alcohol Improvement

Programme

Early Implementor PCTs

NHSPlanned delivery on RA-RHAs

Impl

emen

tatio

nSu

ppor

t

Prio

rity

acce

ss

lear

ning

learning

Evid

ence

Trailblazers (SIPS), ANARPEffectiveness review, HES data,etc

Trailblazers (SIPS), ANARPEffectiveness review, HES data,etc

PCTs (Unplanned) delivery on targets through implementation of elements of the high

impact actions

learningAlcohol Interventions Improvement Centre

Enabling changePriority support to early implementor PCTs.Tools: Learning sets, collaboratives, etc

Learning CentreCollects, co-ordinates and disseminates learning and good practice. Tools: SIPS toolkits, HuBCAPP, e-learning resource

NST(DH)Supports 18 struggling PCTs P.A.Strategic reports & follow-up

visits

Revi

ew

Supp

ort

Regional co-ordinators (DH/SHA)

Responsibility to ensure delivery

of targets

learning

National Alcohol Improvement Programme

DH Policy TeamRole: Work with outside bodies to facilitate frontline delivery. Develop policy, Develop Guidance, Commission, co-ordinate and contract manage support projects, channel expertise,

DH brandedle

arni

ng

NWPHO

Provide local data on need and key evidence

Start delivering RA-RHAs

Receive priority support from AIIC

Implement high impact actions

Supp

ort

Influ

ence

£600k

£2.7m

£250k

£750k

£4m

£1.2m

£60k

Total £9.66m for 2009/10

£100k

“High Impact Changes”1. Work in partnership2. Develop activities to control alcohol misuse 3. Influence change through advocacy 4. Improve the effectiveness and capacity of

specialist treatment • 100 extra people treated can save 28 admissions

5. Appoint an Alcohol Health Worker• Can save 15 admissions per month = 180 per year

6. IBA - Provide more help to encourage people to drink less

• IBA in A&E can save 40 admissions per year

7. Amplify national social marketing priorities

NICE Guidance 2010-11

• Alcohol use disorders– Preventing harmful drinking (PH24)

– Diagnosis and clinical management of alcohol related physical complications (CG100)

– Diagnosis, assessment and management of harmful drinking and alcohol dependence (CG)

• Related guidance– Psychiatric comorbidity (CG)

– Complex pregnancies (CG)

Government’s Alcohol Strategy 2013

• Minimum unit price

• Revision of licensing act

• Responsibility deal for industry

• Drinkaware

• Review drinking guidelines

• NHS health check

• Under 18 A&E pathway

• Payment by results

What about Europe?

Policy score

Less than 9½

9½ to 10½

10½ to 12½

More than 12½

Source: Anderson & Baumberg, 2006

AMPHORA• EU research programme grant• 4m Euros, 4 years• 9 Workpackages, including

– Price consumption and harm– Availability– Cultural determinants– Marketing and advertising– Brief interventions and treatment– Drinking environments– Illegal production

1.1. EU adults drink 27g alcohol (nearly three drinks) a day, more than twice the world's average.

2. About 138,000 EU citizens, aged 15-64 years, die prematurely from alcohol in any one year.

3. EU drinkers consume more than 600 times the exposure level set by the European Food Safety Authority for genotoxic carcinogens, of which ethanol is one.

4. Countries with stricter and more comprehensive alcohol policies generally have lower levels of alcohol consumption, and policies are tending to get stricter in recent years.

5. Alcohol policies impact on alcohol consumption, even when talking into account broader socio-demographic changes, such as increased urbanization which is associated with increased consumption and increased maternal age at all childbirths which is associated with decreases in consumption.  

6. Online alcohol marketing and alcohol branded sports sponsorship increase the likelihood of 14 year olds to drink alcohol.

7. Brief interventions for risky drinking and pharmacological treatments for alcohol use disorders are effective.

8. The proportion of people who actually access treatment out of those who need it ranges from only 1 in 25 to 1 in 7.

9. Young people are often already drunk by the time they go out, fuelled by cheap alcohol from shops and supermarkets, with drinking venues exacerbating problems further.

10. 10. Monitoring alcohol policy and its impact needs much improvement.

European Alcohol Strategy

• WHO Global alcohol strategy 2010

• WHO Implementation plan 2013

• WHO European Alcohol Action Plan 2012

• EU Alcohol Strategy?

Conclusions

• Effective strategies are available

• Implementation variable across Europe

• Influence of the alcohol industry

• Lack of political will

• Lack of public support?

References• Bruun et al. (1975) Alcohol control policies in public health

perspective. Finnish Foundation for Alcohol Studies. New Brunswick, New Jersey.

• Prime Ministers Strategy Unit (2003) Interim Analysis. Cabinet Office.

• Prime Ministers Strategy Unit (2004) Alcohol Harm Reduction Strategy for England. Cabinet Office, London

• Drummond et al. (2005) Alcohol Needs Assessment Research Project. Department of Health

• Anderson and Baumberg (2006) Alcohol in Europe. Institute of Alcohol Studies

• NTA (2006) Models of Care for Alcohol Misusers• Raistrick et al (2007) Review of the effectiveness of treatment

for alcohol problems. Department of Health• National Audit Office (2008) Reducing alcohol harm. NAO

References contd

• Oforei-Adjei, Casswell, Drummond et al (2007) World Health Organisation Expert Committee on Alcohol Problems, Second Report. WHO, Geneva.

• Babor et al (2003) Alcohol, no ordinary commodity. OUP, Oxford

• Room et al., (2005) Alcohol and publi health. Lancet, 365, 519

• Lancet series 2009:• http://www.thelancet.com/series/alcohol-and-global-health• http://amphoraproject.net/w2box/data/e-book/AM_E-

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