CONTENTS. W orld Health Organization 1996

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2 CONTENTS T W orld Health Organization 1996 Acknowledgements 4 Foreword 5 Introduction 7 Alcohol in Europe-thefacts 9 Health,societyandalcohol 12 European Charter onalcohol 20 Ethicalprinciples 22 Tenstrategiesfor action 28 References 38 3

3 ACKNOW LEDGEM ENTS T 4 FOREW ORD 5 D

4 IN T R O D U C T IO N The most importanttaskforthis Conferenceisto make things happen when the delegates gohome.iseethis Conference as a machine for manufacturingmotivation. ThewillofthepeopleofEuropeisthat Europe as a whole takesresponsibility for Europe-wide healthandsocial policies.ibelieve thatitwillbeseverelytothecostofeuropeifitneglects havingalcoholpoliciesinplace.thereis aplacefornational policies,thereisa placeforvillagepolicies,smallstreet policies,formypersonalpolicy,but thereisalsoaplace inalcoholproblems foreuropestanding together. People haveaclearidea whathastobedone andithinkthey havebeenstrengthenedintheircommitment and determinationtogetout thereanddoit. Griffith Edwards, United Kingdom T (1) (2) (3) 1 1 A number of background papers and scientific reviews arising from the Conference will be published in a special issue of the journal Addiction.A video report of the Conference, entitled Health, society and alcohol is available from the Lifestyles and Health unit at the W H O Regional Office for Europe. The photographs used in this report are taken from the conference video. 6 7

5 ALCOHOL IN EUROPE THE FACTS Ifthestatesandthe internationalbodieslet thecommercialinter- estsactwithoutrestrictions,theywillcreate accomplished factsthat willbeveryhardto change. Free markets foralcoholicbeverages rapidly produce strong vestedinterestsand stronglobbyingforces, who will work vigorouslytostopeffortstoreduce alcohol consumption,andwhowilldo whattheycantodismantleexistingrestrictionsontheproduction, sale and marketing of alcohol.maybethese commercial interests arenotyetsostrongin thecentralandeastern European statesandin thedevelopingnations. Itispossiblethatthere isstilltimetoactinthe interestofpublichealth, andintroducelegislationthatgivespriority tosocialvaluesandthe long-termwellbeingof thepopulation,rather than to commercial freedom and shortterm economic gains. Gabriel Romanus, Sweden Alcoholandhealth (4) 8 9

6 ALCOHOL IN EUROPE THE FACTS Drinking and harm in Europe The European Region shows a varied and changing picture of alcohol consumption and related harm. 2 Between 1980 and 1993 average recorded consumption of pure alcohol per head decreased by about 18%, to 9.65 litres, in the 15 countries of the European Union. The downward trend was particularly noticeable in France, Italy and Spain. Nevertheless, seven European Union countries have an annual consumption per head of 10 or more litres of pure alcohol. Outside the European Union, the most striking feature is the high level of consumption in many of the countries of central and eastern Europe and the newly independent states of the former USSR. In the European Region only 9 of the 40 countries for which data are available had consumption levels of less than 5 litres per head (with unrecorded consumption included where known); 90% of countries exceed 2 litres per head. About 21 countries have experienced increases in alcohol consumption, either over the entire period or in more recent years. Consumption has declined in about 11 countries, and remained relatively stable in 8. Alongside changing levels of consumption, the European Region also presents a picture of changing patterns of consumption in many Member States. In general, drinking patterns are converging. The more obvious indicators of alcoholrelated harm death rates from chronic liver disease and cirrhosis and admission rates for alcoholic psychosis show wide variation throughout the Region. Of the 11 countries with particularly high rates of death from liver cirrhosis, 9 are in the eastern half of the Region. Of the 43 countries for which data are available, the rates are increasing in about 10 and decreasing in about 19. In the remaining 14, either the rates are stable or the time series is too short to infer a trend. Information on admission or treatment rates for alcoholic psychosis is not so comprehensive but it suggests that, of the eight countries with particularly high admission rates, seven are in the eastern part of the Region. Admissions are increasing in all of these. In addition, 12 of the countries with the highest death rates from external causes are in the eastern part of the Region. 2 (3) AlcoholpolicyinEurope In many ways the most telling aspect of alcohol control policy in Europe is that, as of early 1995, only eight (21%) of the 39 countries providing information on the issue assessed their national policies as comprehensive; five of these eight are the Nordic countries. Six (15%) consider that their national policies are almost nonexistent; four of these six countries are in the eastern part of the Region. 3 The most common priorities in the 1990s have been: developing specialized treatment services; working in particular settings (mainly schools); dealing with drink driving; and developing mass media campaigns. Between 40% and 60% of countries mentioned all of these. Significant but somewhat less frequent priorities include using price policy to reduce demand, developing the role of the social welfare and/or criminal justice systems in preventing and managing alcohol problems, and reducing the availability of alcohol. Many countries have embodied aspects of their alcohol policy in legislation. One of the most widespread examples is legislation on drink driving. V irtuallyall countries have some limit on the blood alcohol content (BAC) permitted while driving. A level of mg per 100 ml blood (40 50 mg%) is the most common, with 42% of the 36 countries that supplied data having this limit; 31% still have a BAC limit of 80 mg%. Of the 40 countries for which such information was available, about 60% had legislation to create or support environments free from alcohol, mainly in schools and their vicinity, workplaces, transport, parks, discos and clubs. Some such restrictions are found in all parts of the Region. Age limits for buying alcohol vary from 16 to 21 years, although a few countries have no limit. The most frequent age limit is 18 years; about 50% have set this limit and others apply it in specific circumstances, such as buying spirits. Only about 15 countries consider the limit to be reasonably effectively enforced. Restrictions on hours or days of sale or on types of alcohol outlet are in place in less than 50% of countries, with those in the eastern half of the Region being underrepresented. Fifteen countries have restrictions on the location of outlets; these are more evenly spread through the Region, although enforcement appears to be less effective in the countries of central and eastern Europe and the newly independent states. Of the 24 countries that presented information on taxation as a percentage of price, roughly half had levels of taxation of 20% or less for beer and wine. At the other end of the scale, about one sixth (in the case of beer) and over a quarter (in the case of wine) had levels of between 41% and 60%. For spirits, a third had a level of 80% or more, and a further one fifth had a level of between 61% and 80%. Restrictions on advertising vary widely in the Region. At one end of the scale, five countries ban alcohol advertising in all media, and three others have recently made moves in this direction. At the other end of the scale, seven countries have no restrictions on advertising. A variety of legal and voluntary codes lies between these two extremes. Fourteen countries ban the advertising of spirits and wine on television; thirteen of these extend the ban to radio, although the effectiveness of enforcement varies. Voluntary codes on advertising of spirits, wine and beer in all media are in place in eight countries. A state monopoly on the production and/or distribution of alcohol has been a traditional instrument of alcohol and/or economic policy,particularly in the Nordic countries and the eastern countries of the Region. This has been changing recently owing, on the one hand, to the accession to the European Union of Finland and Sweden and, on the other, to the socioeconomic consequences of the dissolution of the USSR. Licensing continues to be the predominant method of control in many western European countries. New issues for alcohol policy are arising. Many countries in the Region consider alcohol advertising on transnational media to be undermining their own initiatives in this area. Meanwhile, many eastern countries are experiencing particular difficulties arising from their state of political, social and economic transition. Their old policy frameworks may no longer command the allegiance of their populations or may be otherwise outdated. Both economic factors (such as the rush to start private businesses in unregulated environments) and many pressing social problems may make it particularly difficult for some of these countries to take the longterm view in pursuing effective national alcohol policies. 3 This section is based on Harkin et al. (3). 11

7 HEALTH, SOCIETY AND ALCOHOL HEALTH, SOCIETY AND ALCOHOL Drinking problems arenotcarriedbyan uncontrollabletide. IfEuropecan asa pluralityofnations develop a shared and rationalresponseto alcohol problems, whichtakestheevidentialtruthasbasis for common purpose, thatwillbean advance of very wide significance. Griffith Edwards, United Kingdom Alcoholpolicyand thepublicgood The European Conference on Health, Society and Alcohol was a historic event. 4 That it was held and attracted such strong support indicates the emergence of a European consensus that alcohol problems are cause for significant health and social concern. The gathering also signals that a strong and concerted response to these problems will now be mounted on a Regionwide scale. The diverse mix of countries that constitute the Region varies in, for example, the place given to drinking in popular culture, the significance of alcohol to trade and the economy, the stance on drinking taken by organized religion, the strength of the temperance movement, and the perceived legitimacy of the state s role in controlling access to drinking. From this background of contrasting experiences and conflicting beliefs has emerged a shared European commitment to reducing the harm done by alcohol. This development is perhaps as surprising as it is welcome. As recently as, say, five or ten years ago, the achievement of such a broad agreement might have appeared unlikely, even impossible. A framework of ideas is giving shape and cohesion to European thinking on alcohol; it is often described as the alcohol problems perspective. This perspective was not built in a day; neither did it emerge from any single report. In retrospect, the intellectual foundations for the problems perspective can be seen as including a remarkably broad European input. Alcohol problems perspective What is being formulated is truly a perspective, a way of seeing things, a down-toearth empirical approach, rather than a grand theory. The concept and its core implications can be delineated very simply. The target for public policy is the prevention or alleviation of population-wide alcohol-related problems. The issues of concern are thus not obscure, abstract or value-laden, but evident: the damage done by alcohol. This position is likely to win wide public support because society experiences these costs and pains. Alcohol problems are broadly defined and go far beyond the restrictive medical concept of alcoholism.such problems: are physical, psychological and social; involve acute events and accidents as well as chronic illness; and relate to the damage done both to the drinker and to those who are harmed by someone else s drinking. This formulation immediately indicates the need for multisectoral responses congruent with the modern meaning of public health. The test of the worth of public policy on alcohol is whether it succeeds. The primary test of a policy s worth is whether it can be demonstrated empirically to reduce the burden and costs of society s alcohol problems in relation to one or severaltargets. Beyond effectiveness, important questions are related to cost effectiveness. The book Alcohol policy and the public good (5) gives the main conclusions affecting policy. Some of these include the following. Policy must be willing to take the totality of the drinking population as defining the scope for public health action. Its aim must be to reduce the occurrence of problems. There is no panacea. The needed policies will be a mix rather than a master stroke. Political feasibility and public acceptance are crucial in selecting alcohol policies. The taxation of alcohol is an effective environmental mechanism for reducing alcohol problems. Environmental measures that influence physical access to alcohol can make a significant contribution to prevention. Drink driving countermeasures are effective if vigorously enforced and given a high public profile. No present research evidence can support the deployment of school-based and public education as lead policy choices. Treatment can substantially support public health policies. The assumption underlying this approach is that Europe is a union of nations capable of using and honouring science in the design of public policy. Science will never be the only determinant of alcohol policy; political context and public sentiment must be taken into account. The interpretation of science must be handled with care, but there is broad consensus on where the evidence points. Scientific debate should continue, but should not distract attention from these solid, policy-relevant conclusions. Most independent scientists see them as standing out from the research and giving a robust underpinning for informed policy choice. 4 (6). Itseemsmorelikely, given our knowledge oftheactiverolepeopletakeinattending toandinterpreting mass media messages, thatheavierdrinkers willinterpretthe alcoholisgoodforthe heart messageasreinforcementfortheir currentdrinkinglevels. Sally Casswell, New Zealand Healthandalcoholpolicy Policy development is always a process of resolving conflicting demands. 5 Issues in alcohol policy are often hotly contested, and the conflicting demands include those of the market and the public good. Policy must strike a balance between the perceived benefits and enjoyment of drinking and the costs of alcohol use. Evidence accumulating during the 1980s and early 1990s showed a reduced risk of coronary heart disease among drinkers as compared with abstainers. This has significantly contributed to the public, academic and policy debate on the cost benefit ratio of alcohol use. At a population level, the risk-reducing effect of drinking is essentially cancelled by increases in other causes of death. In France, for example, a particularly low death rate for coronary heart disease does not result in a decrease in premature mortality overall. A reduction in deaths from heart disease means a transfer to deaths from other causes, including cancer.itisestimatedthat reductions in aggregate consumption would have only minimal effects on premature mortality: an increase of 0.3% if consumption dropped by 25% in a country with a high level of coronary heart disease. Heart disease is only significant in later life, and much of the harm associated with alcohol occursinearlierlife. Alcohol use therefore leads to a greater number of potentialyearsoflifelost,even in countries in which it has been estimated to have a beneficial effect on mortality from heart disease. Such loss of life in young adults is a particularly serious consequence from an economic perspective. Alcohol and harm Alcohol creates much of its harm to people who are members of the drinker s primary social group: family members, co-workers and neighbours. Given that men drink three times as much alcohol as women in most industrialized countries, and that alcohol is associated with violence in the family, many of those experiencing alcohol-related harm are women and children. Harm to people other than the drinker is probably of greatest importance in the policy debate on alcohol, particularly in the liberal state. The focus is shifting to include alcohol s role in violent behaviour and family functioning, while the impact of alcohol on trafficaccidents and other forms of injury remains an important concern. Strategies: targeted or population-wide? A considerable amount of literature has evaluated school-based education and mass media campaigns. Almost all of it has shown no shortterm impact on drinking or alcohol-related harm. Alcohol education must often compete with messages about alcohol from commercial producers. These contradict the emphasis of the educational efforts and are likely to reinforce the prevailing cultural and social patterns of drinking. Some strategies focusing on environments have been shown to reduce alcohol-related harm. While some of these address heavier consumption or drinking in particularly risky circumstances, others address the population as a whole. No definitive statement can yet be made on the likely impact of these effective public policies on what might be described as heart healthy drinking.a detailed analysis of policy approaches, however, suggests that those addressing public drinking, young people and the prevention of intoxication are unlikely to have a major direct impact on drinking by older people. The direct impact of strategies applied across the population including random breath testing, advertising restrictions and taxation is more difficult to assess, but the available evidence suggests a disproportionate effect on the younger and/or heavier drinker. The evidence of an association between drinking and a reduced risk of coronary heart disease has introduced an important new element into the policy equation. Nevertheless, an examination of some of the relevant issues leads to the conclusion that it does not provide a definitiveargument against the use of populationlevel policies that are known to be effectivein reducing alcohol-related harm. Continued commitment to population-level policies rests on theireffectiveness, and the ineffectiveness of the strategiestargeting high-risk drinkers. Shaping the collective environment, to make healthy choices easier choices, is more effective than trying to persuade individuals to change while leaving the environmental influences unchanged. 5 (7)

8 HEALTH, SOCIETY AND ALCOHOL HEALTH, SOCIETY AND ALCOHOL Dimitra Gefou-Madianou, Greece Alcoholandculture Clear proof that alcohol consumption and alcohol-related harm can be reduced comes from the countries of southern Europe, where consumption has sharply declined. Southern European countries also provide a cultural framework within which alcohol policy can be implemented. Why alcohol consumption has decreased 6 Several factors have led to the reduction in consumption in southern European countries: 1. marketing factors 2. new beverages 3. public health policies 4. economic factors 5. pricing and taxation 6. public opinion 7. the homogenization of lifestyles. In the last 20 years, beer and spirits have been extensively advertised at the expense of wine. Sodas, fruit juices and mineral waters were almost unknown 30 years ago and they have received much more advertising investment than wine. In the last 15 years, awareness has grown of the harm produced by drinking. New rules have thus been implemented to limit the availability of alcoholic drinks and the hours and places in which advertising can be shown. The alcohol policies of the European Union affected some aspects of wine production. Greece, Portugal and Spain, for example, had to accept dramatic cuts in production to enter the European Union. In addition, these policies have directly affected alcohol prices and taxation. In Spain, the price of wine increased 24% between 1985 and 1992, while that of beer increased just 14%. Over the same period, flavoured sodas have kept their real price almost stable. Trafficcasualties,particularly in young drivers, have convinced people of the dangers of alcohol. In general, Europe is tending towards a progressive homogenization of lifestyles. For example, lunch is losing its central role as a family meal in southern Europe, which in the end means less wine consumption. Lessons for alcohol policy 7 Southern European countries provide important lessons to be learned for alcohol policy.the values and codes associated with the traditional patterns of alcohol and food consumption contain what could be called informal, built-in regulating mechanisms: 1. the commensal nature of alcohol consumption and its association with food, including the presence of women during drinking by males in the household; 2. the collective and integrative character of drinking, and the reciprocal exchange markingit; 3. people s familiarity with alcohol from an early age; 4. the institutionalization of occasions and places for drinking and the highly ritualistic ways in which alcohol is consumed; and 5. the underlying emphasis on moderation, the stigmatization of solitary drinking and the strict social sanctions exercised by the family, community and society on people understood to have problems with alcohol. These informal mechanisms have served to prevent problems related to alcohol use. They could be seen as a kind of cultural prophylaxis. These societies do have alcohol-related problems. The increase in accidents due to drink driving and the vulnerability of some social groups are as evident as the changes in drinking habits. Despite the integration of European culture, differences remain in the informal systems of social control of alcohol consumption. Social change within southern European societies, as well as cultural homogenization across Europe as a whole, through population movements and the mass media, do not seem to have wiped out the traditional values and codes that regulate drinking and serve as informal controls on alcohol-related problems. These values and codes have historical and cultural roots in society. Policy-making strategies need to take them into account. 6 (8) 7 (9) The production of alcoholic drinks has become increasingly industrialized, not only in developed countries but all over the world. Multinational corporations increasingly control alcohol production and consumption. The concentration of control of the markets, and the push of multinational corporations into new markets, have been greatly assisted by the growth of freetrade areas and agreements and of an ideology of free trade. In this perspective, local structures for alcohol control which may limit the harm from drinking are attacked as impediments to trade. Producers and governments have used free-trade agreements to break down local controls. For commodities that may threaten public health or order (such as psychoactive drugs), countries control exports and support each other s market controls through international agreements. No such agreements exist for alcohol. The drift towards an ethic of free international trade in alcoholic drinks particularly threatens one of the most effective public health tools for limiting alcohol-related harm. Duty-free cross-border transportation (and smuggling) can effectively undercut taxes designed to discourage heavy consumption.

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