!Allaman Allamani, Michela Baccini, Giulia Carreras,!!Francesco Maccari, Pasquale Pepe, Fabio Voller! and the 12 country partners!

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1 ! Alcohol consumption changes ( s): Contextual Determinants! and Preventive Alcohol Policies.! work package 3, part of AMPHORA project, which has been co-funded by the European Commission ( )!Allaman Allamani, Michela Baccini, Giulia Carreras,!!Francesco Maccari, Pasquale Pepe, Fabio Voller! and the 12 country partners! Agenzia Regionale Toscana di Sanità, Firenze!

2 Culture, social, economic, demographic determinants and alcohol policy AMPHORA WP3 Contextual Determinants of Alcohol Consumption Changes and Preventive Alcohol Policies: a 12-Country European Study 12 par'cipa'ng European Ins'tu'ons Allaman Allamani, Fabio Voller, Francesco Maccari, Pasquale Pepe, Michela Baccini, Giulia Carreras ARS leading Institution, Italy, Florence Zsuzsanna Elekes BCE, Hungary, Budapest Irmgard Eisebach-Stangl, Gabriele Schmied ECV, Austria, Vienna Gerhard Gmel, Beatrice Annaheim, Hervé Kuendig- SIPA, Switzerland, Lausanne Toni Gual, Silvia Matrai HCPB, Spain, Barcelona Juliette Guillemont INPES, France, Paris Ronald Knibbe, Mieke Derick - UniMass, the Netherlands, Maastricht Sturla Nordlund, Øystein Skjælaanen SIRUS, Norway, Oslo Börje Olsson, Philip Rumeliotis SU, Sweden, Stockholm Esa Österberg, Thomas Karlsson, Mikaela Lindeman THL, Finland, Helsinki Moira Plant, Patrick Miller, Nikki Coghill UWE, UK, Bristol Grażyna Świątkiewicz, Lukasz Wieczorek- IPiN, Poland, Warsaw

3 The viewpoint that in each European country alcohol consumption can be affected not just by alcohol policy per se, but by a mix of planned policy measures and unplanned, or partly planned (contextual) factors over time moved 12 EU countries to do a study whose results are able to allow policy makers to take into better account a range of identified contextual factors in order to help to identify and adapt the most country effective alcohol prevention policies.

4 country'(bound(,(( locally(generated( policies( consum'( ption(changes( no( policies( European,( globalised(!

5 The WP3 STUDY QUESTIONS Both at (a) country level and (b) at the European level (all the countries together) 1- what contextual factors affect consumption? 2- what policies affect consumption? 3- what part of consumption changes which are not explained by " policies may be explained by contextual factors? 4- all preceding questions towards alcohol-related deaths?

6 WP3 STUDY PHASES 1- defining, operationalising, identifying variables (2008-9) 2- data collection in each country (Dec 2009-May 2011), " integrating country data with international sources (2011) 3- data analysis ( )

7 THE VARIABLES (DEPENDENT VARIABLES) - alcohol consumption 15 years per country, (WHO, GISAH) - deaths for chronic liver disease & cirrhosis, and transport accidents " " " " " " (WHO,HFA) "

8 WP3 THE CONTEXTUAL VARIABLES social $cultural $ economical $ demographic $political $ health, $ religious $ $ $ $ $ $ $determinants of alcohol consumption changes over time. When lacking, country data were integrated with data from international sources

9 WP3 THE POLICY MEASURES (either restrictive or permissive) $ $ Price control: excises, VAT $ Advertising control: TV, radio, newspapers, sport $ Availability: minimum age to buy alcohol $ $ licensing rules for different types of selling places $ $ trading hours & specific rules $ Drink driving: BAC limit $ Number of major nationwide prevention & treatment plans. " " " $

10 WP3 METHOD OF ANALYSIS

11 WP3 STUDY METHOD- UNPLANNED VARIABLES Due to missing entries in some unplanned variables, a multiple imputation procedure was performed. A time series regression model for both the logged pro capita alcohol consumption and liver and transport harm, accounting for linear time trend, income, alcohol prices, percentage of elderly males, and the best unplanned variables among four selected ones (i.e. mothers age at childbirths, female employment, female education, urbanization), as well as for policy measures, was specified for each country.

12 WP3 STUDY METHOD - POLICY MEASURES ü After having selected the best unplanned predictor for each selected policy measure, a model was specified. ü We assumed that all interventions had the same effect. ü We did not account for possible cumulative effects of interventions. ü The impact of each policy was modelled as immediate and constant over time. ü The effect of price control policies was not analyzed since the model already accounts for changes in alcohol prices (as contextual factor). $

13 WP3 STUDY RESULTS SOME RESULTS

14 WP3 STUDY RESULTS - ALCOHOL CONSUMPTION AND UNPLANNED VARIABLES Results support the viewpoint that urbanization, age of mothers at childbirth, female employment, and education are associated with alcohol consumption even if this may appear not so evident for some countries (like Finland, France, Italy).

15 WP3 STUDY RESULTS - ALCOHOL CONSUMPTION AND POLICY MEASURES Also the effect of policies support the hypothesis of their variable impact according to each country, in different combination with unplanned factors. - even if this may appear not so evident for some countries (like Hungary, France, and Netherlands).

16 WP3 STUDY RESULTS EFFECT OF POLICIES AND UNPLANNED FACTORS ON ALCOHOL CONSUMPTION AND HARM In order to check the overall relative role of policies and unplanned factors on consumption changes, and alcohol-related harm, the partial square correlation coefficients between consumption and harm on the one hand, and policies taken together, and unplanned factors taken together, on the other hand, were calculated for each country.

17 WP3 STUDY RESULTS Policy measures and unplanned variables: par;al correla;ons with total alcohol consump;on, 12 EU countries, Unplanned Policies AT FI FR HU IT NE NO PL ES SE CH UK!

18 WP3 STUDY RESULTS Policy measures and unplanned variables: par;al correla;ons with chronic liver and cirrhosis deaths in 12 EU countries, Unplanned Policies AT FI FR HU IT NL NO PL ES SE CH UK!

19 WP3 STUDY RESULTS Policy measures and unplanned variables: par;al correla;ons with transport accident deaths in 12 EU countries, Unplanned 80 Policies AT FR HU IT NL NO PL ES UK

20 WP3 STUDY RESULTS The figures above show that both the measured planned alcohol policies and measured unplanned factors (which also include the price of alcohol) impact on alcohol consumption and on alcohol-related harm, with, in general, the measured unplanned factors having higher impacts.

21 WP3 STUDY RESULTS Analysis of BAC country effect on total alcohol consump;on, all the 12 European countries cons. increase cons. decrease

22 WP3 STUDY RESULTS The figure above, built on random effect metanalysis of BAC country effect on total alcohol consumption, shows that there is a strong heterogeneity of the effect of BAC policy measures on total alcohol consumption among the European countries - and that for some countries (like the Netherlands) the effect may be not so obvious (unless the different types of beverages are considered). cons. increase cons. decrease

23 WP3 STUDY WHAT DOES IT MEAN? This study, the first of its kind, indicates that alcohol policies and, even more, unplanned factors have a measurable impact on alcohol consumption and on alcohol-related harm.

24 WP3 STUDY WHAT DOES IT MEAN? Although further work is still to be done with the data, urbanization, women s increasing levels of employment and improved education, and older maternal age at childbirth, seem to be the most important unplanned factors, mirroring the large social changes that have occurred in European countries over the last fifty years.

25 WP3 STUDY WHAT DOES IT MEAN? Understanding and evaluating the role of contextual (unplanned) factors enables policy-makers to take these into account when implementing existing evidence-based polices and designing new policies.

26 The research leading to these results has received funding from the European Community's Seventh Framework Programme (FP7/ ) under grant agreement nº Alcohol Measures for Public Health Research Alliance (AMPHORA). Partners in AMPHORA are: 1) Coordination: Hospital Clínic de Barcelona (HCB), Spain; 2) Agenzia Regionale di Sanità della Toscana (ARS), Italy; 3) Alcohol & Health Research Unit, University of the West of England, UK, 4) Anderson, Consultant in Public Health, Spain; 5) Anton Proksch Institut (API), Austria; 6) Azienda Sanitaria Locale della Città di Milano (ASL MILANO), Italy; 7) Budapesti Corvinus Egyetem (BCE), Hungary; 8) Central Institute of Mental Health (CIMH), Germany; 9) Centre for Applied Psychology, Social and Environmental Research (ZEUS), Germany; 10) Chemisches und Veterinäruntersuchungsamt Karlsruhe Technische Universität (CVUAKA), Germany; 11) Dutch Institute for Alcohol Policy (STAP), Netherlands; 12) Eclectica snc di Amici Silvia Ines, Beccaria Franca & C. (ECLECTICA), Italy; 13) European Centre for Social Welfare Policy and Research (ECV), Austria; 14) Generalitat de Cataluña (Gencat), Spain; 15) Institute of Psychiatry and Neurology (IPIN), Poland; 16) Institute of Psychiatry, King s College London (KCL), UK; 17) Istituto Superiore di Sanità (ISS), Rome, Italy; 18) Inštitut za raziskave in razvoj (UTRIP), Slovenia; 19 ) IREFREA, Spain; 20) Liverpool John Moores University (LJMU), UK; 21) National Institute for Health and Welfare (THL), Finland; 22) Nordiskt välfärdscenter (NVC), Finland; 23) Norwegian Institute for Alcohol and Drug Research (SIRUS), Norway; 24) State Agency for Prevention of Alcohol-Related Problems (PARPA), Poland; 25) Stockholms Universitet (SU), Sweden; 26) Swiss Institute for the Prevention of Alcohol and Drug Problems (SIPA), Switzerland; 27) Technische Universität Dresden (TUD), Germany; 28) Trimbos-instituut (TRIMBOS), Netherlands; 29) University of Bergen (UiB), Norway; 30) Universiteit Twente (UT), Netherlands; 31) University Maastricht (UM), Netherlands; 32) University of York (UoY), UK.