Evidence base for EU strategy released

‘Alcohol in Europe: a public health perspective’ sets out our habits, harms and hopes over 400 pages, but how much will be included in the strategy?

By Ben Baumberg, co-author of the report and Policy and Research Officer at the Institute of Alcohol Studies

Five years ago, the leaders of the countries that then made up the EU signed a resolution on alcohol and young people, setting in train a process that will ultimately give us the first EU strategy on alcohol. We are not there yet – the strategy itself is due out this autumn – but May 2006 saw at least one staging post along the way, with the release of the evidence base on which the strategy will be based. Entitled ‘Alcohol in Europe: a public health perspective’, the report spells out the effects of alcohol in the 25 countries of Europe, and what we can do to change these effects.

While the report has 10 (lengthy) chapters within its 400-plus pages, there are two main themes running through it which have crucial importance for the EU’s strategy – (1) what alcohol in Europe looks like now, and (2) how we can make it look better in the years to come.

Where we are now
While alcoholic drinks have been around for millennia, alcohol was only rarely seen as a social problem before medieval Europe. Aside from more recent medical developments showing the health consequences of drinking, the biggest change was a series of associated parts of ‘modernization’ – industrialization, improved communication links – combined with the spread of knowledge about how to distil alcohol into stronger spirits. The increase in drinking and drunkenness these allowed was met by large ‘temperance’ movements across much of Europe in the nineteenth and early twentieth centuries, campaigning against the ‘evils of spirits’ before sometimes moving on to an opposition to all alcoholic drinks.

While these temperance movements have today faded to insignificance in most (but not all) EU countries, the modern era of strong, available alcohol is still with us. The EU is the heaviest drinking region in the world, drinking 11 litres of pure alcohol per adult per year, although a minority of 55 million adults (15%) do abstain. An estimated 23 million Europeans are dependent on alcohol (5% men, 1% women), while 100 million (1 in 3) are estimated to ‘binge-drink’¹ at least monthly in the 15 ‘old’ EU countries alone, and 1 in 6 adolescents aged 15-16 bingedrink¹ at least three-times per month. Drinking levels and patterns differ between different groups within the EU population, with lower socioeconomic groups and particularly men more likely to be drunk or be dependent on alcohol.

While changes in recent years are not as dramatic as those of medieval times, the picture is still noticeably different in 2006 from what it was in 1966 – or even in 1996. The ‘spirits drinking’ countries of northern Europe now drink more beer than spirits, while the high consuming ‘wine-drinking’ countries of southern Europe drink much less wine and indeed, much less overall than they used to. While there is still a clear north-to-south gradient in some aspects of drinking behaviour (such as frequency of drinking), the differences are much less than many still believe; Greece, for example, drinks more of its alcohol in spirits than Norway, while recent data also suggests that Spaniards drink more beer than wine. Adolescents and young adults have moved even faster, with the cliché of French and British drinking belied by UK young adults drinking more often with meals than their French counterparts.

The down sides of this level of drinking are there for all of us to see. The crime caused by alcohol leads to 33 billion Euros worth of costs – partly in police time, but also in criminal damage and needless security guards – while 17bn Euros is spent on alcohol-caused health care across the EU, and 60bn Euros worth of potential economic contributions are lost. This is aside from the lowered quality of life for addicts, and the associated pain and suffering of family members (which itself can be valued at 68bn Euros), let alone the pain and suffering of the victims of alcohol attributable crime (valued at 9- 37bn Euros).

Most importantly of all, alcohol is responsible for 195,000 deaths each year. However, this also takes us into the tricky territory of the epidemiology of old age, given the 160,000 deaths delayed, which can be easily misinterpreted: It does not make sense to say that “the full toll of alcohol is 40,000 deaths,” by setting the deaths delayed against the deaths caused. Most of the deaths delayed occur in a different age group (the very old) from most of the deaths caused (youth and middle-age), and for different types of drinkers (frequent light drinkers rather than heavy and binge-drinkers).

The number of deaths delayed is very likely to be an over-estimate, given three substantial errors in the current estimates. Firstly, the epidemiological studies on alcohol often bundle former drinkers in with consistent abstainers, as Kaye Fillmore has recently shown. Secondly, the studies forget that people’s drinking changes over time – a recent British Regional Heart Study paper shows that this error was the difference between drinkers having a lower risk of death than abstainers with the error vs. a higher risk when it was taken out. Finally, heart disease deaths at older ages are highly over-estimated, with many coroners using ‘heart disease’ as a code for both uncertainty or general organ failures.

It is probably more sensible, then, to focus on the more accurate estimate of 115,000 deaths caused up to the age of 70, and the more robust estimate that alcohol is the third most important cause of premature death and disability in the EU – ahead of factors such as illegal drugs, obesity/overweight and lack of fresh fruit and vegetables.

The EU’s political engagement with alcohol has been focused on young people, and it is they that are the group that is most at risk. Alcohol isthe single biggest cause of premature death in young adults – responsible for 1 in 10 premature female deaths at this age, and an appaling 1 in 4 male deaths. What is more, the trend in slightly younger adolescents since the mid-1990s has been for increased binge-drinking,and while this has stabilised more recently, this suggests that the future toll is even greater than the current one.

Alcohol is not a simple substance, and we must get used to its nuances and complexities –causing deaths while saving lives, inflicting pain while producing pleasure. Yet the overwhelming image from a health perspective is the damage that alcohol causes in the EU, touching on nearly every aspect of human life. The complexities, and the need for action, raise challenges as to the best future action on alcohol in Europe, which takes us into the rest of the report.

Reducing harm in Europe
At its simplest, there are three things that we need to know before deciding on a European alcohol strategy. The first is what the law allows us to do. The second is which policies work in reducing harm. And for each policy that works, the third is considering the costs of that policy compared to its benefits.While the second area is the one most people think of when they hear the siren call of ‘evidence based policy’, the policy debate can benefit from the research contribution in all three areas.

An interest in international law is not what makes most people passionate about alcohol and addiction issues. It only becomes important when it stops health policy makers adopting effective policies – which it does, but not as often as is sometimes insinuated. The world trade law of the WTO sets certain conditions for health policies, for example, but the WTO have also demonstrated that they will prioritise health over trade when these conditions are met. Similarly, the European Court of Justice has upheld trade-distorting alcohol advertising restrictions, because “it is in fact undeniable that advertising acts as an encouragement to consumption” (in their words) and that Member States can decide on how much they want to protect human health.

More importantly, the treaties signed by nationally elected leaders – which make up ‘EU law’ – do not give the EU the powers to make policies for health unless they are a by product of creating an efficient EU market. While this means that an EU strategy can only ever encourage certain policies (such as sensible licensing restrictions), there are other areas where EU legislation can help the smooth runnings of the market, such as for drinks health warnings or advertising.

While not the only essential information, reviewing what works in reducing alcoholrelated harm is perhaps the most important basis for action –otherwise all our goodwill and efforts will be wasted. This is sensitive, however, as finding that a policy ‘does not work’ suggests that those of us working in that area have been wasting our time…which is why we must be clear that school-based education is neither an effective single policy nor a futile effort. Reviews of educational programmes show that the overall effect is either small or zero – but given that education on alcohol is both a human right and potentially lays the ground for other interventions, we have no excuse for not trying to make that small effect as large as possible (see page 257 of the report for a guide to improving alcohol education).

Other policies that generally work well include unrestricted breat testing, lowered blood alcohol concentration levels for drivers (and even lower ones for young drivers), regulating the market (e.g. licences, taxes) and brief advice to heavy drinkers (e.g. by GPs). Policies that generally don’t work well include designated driver campaigns and advertising self regulation. Some policies have research suggesting that they will have some effect, even if the evidence isn’t conclusive – such as for advertising restrictions. And finally, we must remember that policies are not ‘magic buttons’ to be pressed and forgotten about… their effectiveness depends on what happens around them – mass media campaigns work well if they support specific interventions, for example, while raising the minimum age for buying alcohol will not work if it is not properly enforced.

No researcher should fool themself that policy makers will simply adopt the most effective policies – and nor should they, given the number of considerations that matter for making and implementing any policy in a democracy. But each of these other considerations can be better understood from the research, including the economic costs of public health policies. Alcohol is clearly an important economic commodity, with the EU playing a central role in the global alcohol market, and several hundred thousand jobs linked to it at the very least. However, most discussions of this miss an obvious point – if people spend less money on alcohol, they have more money to spend on other goods. This means that for every job lost producing or selling alcohol – and the evidence suggests the link with consumption levels may not be as strong as might be thought – others will be generated elsewhere in the economy. More sophisticated modelling in the tobacco field suggests that public health policies could even lead to an increased number of jobs, depending on exactly how people spend the money they save from less alcohol. In otherwords, public health policies on alcohol are unlikely to have any significant impact on the European economy – and may even slightly help it, given the reduction in the considerable social costs of alcohol.

So what happens now?
Put in the starkest possible terms, the report shows that alcohol is a major public health problem, but that we know what to do to reduce this level of harm. This in itself is unlikely to be surprising to most readers of Alcohol Alert; but for the process of making policy in the EU it is a crucial basis from which to proceed. What is now left to do is the messy businessof policy debate – which is less amatter of evidence than one ofargument, persuasion and passion. We are now at a stage rich in potential; what remains to be seen is whether we look back at this moment with regret at how much difference we failed to make, or whether we look back with pride that the first EU strategy on alcohol genuinely changed Europe for the better.

Reference
1 Defined as 5+ ‘standard drinks’ on a single occasion. The problems of defining binge-drinking are discussed further in chapters 1 and 4 of the report.