What the AMPHORA project says for European alcohol policy
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1 AMPHORA NEWSLETTER DECEMBER 2012 What the AMPHORA project says for European alcohol policy Potential impact The main outcomes of the scientific work of the AMPHORA project drive the need for stepped-up implementation of a number of alcohol policy actions. Were these actions implemented, there would be considerable benefit in terms of health gain, disability adjusted life years averted, and premature deaths avoided. This applies to price increases, restrictions on the availability of alcohol and bans on alcohol advertising. It also applies to brief interventions for risky drinking and treatments for alcohol dependence. Such actions not only improve health, but can also reduce crime, improve personal security and improve productivity at work. Alcohol tax increases also bring in much needed government revenue. The ten core messages of the project are: 1. EU adults drink 27g alcohol (nearl y three drinks) a da y, more than twice the world s average. 2. About 138,000 EU citizens, aged years, die prematurel y from alcohol in any one year. 3. EU drinkers consume more than 600 times the exposure level set by the European Food Standards Authorit y for genotoxic carcinogens, of which ethanol is one. 4. Countries with more strict and comprehensive alcohol policies generall y have lower levels of alcohol consumption, and policies are tending to get stricter in recent years. 5. Alcohol policies need to take into account trends in urbanization and female employment, both of which tend to increase overall alcohol 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 need treatment who actuall y access it ranges from only 1 in 25 to 1 in Young people are often already drunk by the time they go out, fuelled by cheap alcohol from shops and supermarkets, with the design of drinking venues exacerbating problems further. 10. Monitoring alcohol policy and its impact needs much improvement.
2 The core policy options that derive from these findings, which are consistent with the extensive published literature on alcohol policy, are: 1. European countries should, in general, strengthen alcohol policy further as a matter of urgent public health policy to reduce alcohol consumption and the estimated 138,000 preventable deaths that occur annually. The most cost-effective way to do this is through implementing the three best busy for alcohol policy recommended by the World Economic Forum and the World Health Organization in their joint submission to the 2011 United Nations High Level Meeting on non-communicable disease, increase the price of alcohol, reduce the availability of alcohol and ban alcohol advertising. 2. Pricing policy should include the implementation of a minimum price per gram of alcohol, an alcohol policy option that reduces consumption and harm, and one which targets in particular young people s heavy drinking and drunkenness. 3. Reducing the availability of alcohol should be matched with a licensing system for the sale of alcohol in all countries, with the receipt and maintenance of the license dependent on adherence to a minimum set of environmental standards in the licensed premise. 4. Given their importance in promoting adolescent drinking, bans on alcohol advertising should include bans on digital alcohol advertising and alcohol branded sports sponsorship. 5. The availability and standards of brief advice and treatment for risky drinking and alcohol use disorders should be dramatically improved and harmonized upwards across all European Union member states to improve the existing poor coverage. 6. Standardized monitoring and reporting on alcohol consumption, alcohol-related harm and alcohol policy responses should be improved and harmonized upwards across all European Union member states to ensure a monitoring system that can evaluate up-to-date change in health status. It is possible to estimate the impact, cost and cost-effectiveness of a range of policies in reducing disability adjusted life years (DALYs) in European Union countries, and this has been done in Table 1. Tax increases (of 20% or even 50%) are estimated to be highly cost effective throughout Europe. Even accounting for longer life, and thus potentially increased social welfare costs, taxation remains a highly cost effective alcohol policy option. The effect of alcohol tax increases could be mitigated by illegal production, tax evasion and illegal trading, which account for approximately 12% of all consumption in Eur-A countries and 40% in Eur-B and Eur-C countries. Reducing this unrecorded consumption (by 20 50%) via concerted tax enforcement efforts is estimated to cost % more than a tax increase but to produce similar levels of effect. In settings with higher levels of unrecorded production and consumption, increasing the proportion of consumption that is taxed (and therefore more costly to the price-sensitive consumer) may represent a more effective pricing policy than a simple increase in excise tax, which may only encourage further illegal production, smuggling and cross-border purchases. Reducing access to retail outlets for specified periods of the week and implementing a comprehensive advertising ban are estimated to have the potential to be cost effective countermeasures, but only if they are fully enforced (each healthy year of life restored costs between I$ 567 and I$ 2509). The estimated cost effectiveness of brief interventions in the health sector is not as favourable as the population-level policy instruments because they require direct contact with health care professionals and services. Although brief interventions are the most expensive of the policy options to implement, it should be noted that within health service expenditure, brief interventions for hazardous and harmful alcohol consumption are one of the most cost effective of all health service interventions in leading to improved health.
3 Table 1 Costs, impact and cost effectiveness of different policy options in three sub-regions of the WHO European Region 1 1 Anderson, P., Møller, L. & Galea, G. (Eds.) Alcohol in the European Union. Copenhagen, Denmark: World Health Organization, 2012.
4 Modelling the impact of treatment Given that three-fifths of all alcohol-related deaths occur in people who are dependent on alcohol, it is also possible to model the impact of treatment in reducing alcohol related deaths and this has been done for men and women in Figures 1 and 2 below. Assuming that 40% of people with alcohol dependence are treated, the model estimates that about 10,000 male deaths could be avoided with pharmacological treatment, and more than 1,700 female deaths. The difference between the sexes is due to more men being dependent on alcohol than women and the all-cause mortality rate of women being lower than that of men. Brief interventions for heavy drinkers who are also acute-care hospital patients (BI hospital 2) yield almost the same number of deaths avoided, whereas the other two treatments are associated with a considerably smaller numbers of deaths avoided. While the number of women s deaths avoided by any given treatment is only up to 30% of the men s deaths avoided, the proportional differences between the treatments are much smaller. Figure 1 Male deaths avoided over the course of a year in the EU in the age range years due to treatment for alcohol use disorders 2. Figure 2 Female deaths avoided over the course of a year in the EU in the age range years due to treatment for alcohol use disorders 2. 2 Rehm, J., Shield, K., Rehm, M., et al Alcohol consumption, alcohol dependence, and attributable burden of diseasen in Europe: potential gains from effective interventions for alcohol dependence. Toronto, ON, Health, C. F. a. a. M.
5 Broader impact on society But, of course, it is not just health that alcohol impacts on, but also on other areas of individual and societal well-being. As an intoxicant, alcohol impairs personal security and is a causal factor in harm to people other than the drinker, including interpersonal violence, suicide, homicide, crime and drink-driving fatalities, and a casual factor for risky sexual behaviour, sexually transmitted diseases and HIV infection. There is also evidence, although not from all studies that drinking, and in particular heavy drinking can impair educational attainment and human capital formation, employability and productivity at work. These other harms can be summarized in social costs estimates, as is done in Figure 3 below in billion, with alcohol costing the EU some 156 billion in the year Figure 3 Social costs of alcohol in the European Union, Of course, not all of these costs can be averted, but there is evidence that implementation of alcohol policy can lead to reductions in social costs, can improve productivity, and, with tax increases, can generate increased revenue for countries, outcomes sorely needed in times of economic recession. 3 Rehm, J., Shield, K., Rehm, M., et al Alcohol consumption, alcohol dependence, and attributable burden of diseasen in Europe: potential gains from effective interventions for alcohol dependence. Toronto, ON, Health, C. F. a. a. M.
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