Creating the evidence base
At the time that the European Commission has been preparing its own strategy on alcohol to cover the full range of activity that takes place at a European level, it has called for an analysis of the health, social and economic impact of alcohol in Europe. This is the present report, which is an expert synthesis of published reviews, systematic reviews, meta-analyses and individual papers, as well as an analysis of data made available by the European Commission and the World Health Organization. The report views alcohol policy as “serving the interests of public health and social well-being through its impact on health and social determinants.” This is embedded in a public health framework, a process to “mobilize local, state, national and international resources to ensure the conditions in which people can be healthy”. A standardized terminology has been proposed throughout the report based on that of the World Health Organization, the specialized United Nations agency on health matters.
Alcohol has been produced and drunk in Europe for thousands of years, usually made out of whatever materials were locally available. Laws on alcohol did exist, but normally for reasons of public order or to regulate the market rather than for public health. However, this picture changed with a series of developments in medieval and early modern Europe, including industrialization, improved communication links, and the discovery of stronger, distilled beverages. Large ‘temperance’ movements spread across much of Europe in the nineteenth and early twentieth centuries, driven by concerns over spirits before often moving on to an opposition to all alcoholic drinks. In most, but not all, countries the temperance movement faded to a position of little significance at the end of the twentieth century. The idea of ‘alcoholism’ as a disease also grew during the nineteenth century, with many European countries developing homes or asylums to treat ‘alcoholics’. In recent years, the ‘new public health movement’ has become the dominant paradigm for discussing alcoholrelated problems, allowing a broader discussion than a focus on a small subset of ‘alcoholics’.
Today’s Europe includes a wide range of uses and meanings of alcohol, ranging from an accompaniment to family meals to a major part of rites of passage. Drinking behaviour is often used to communicate the formality of an event or the division between work and leisure. Drunkenness is equally symbolic, with ‘drunken comportment’ – how people act under the influence of alcohol – varying across Europe.
Alcohol and the economy of Europe
Europe plays a central role in the global alcohol market, acting as the source of a quarter of the world’s alcohol and over half of the world’s wine production. Trade is even more centred on Europe, with 70% of alcohol exports and just under half of the world’s imports involving the European Union (EU). Although the majority of this trade is between EU countries, the trade in alcohol contributes around 9billion Euros to the goods account balance for the EU as a whole.
It is hard to place a value on the amount of smuggling in the EU, although the European High Level Group on Fraud estimated that 1.5bn Euros were lost to alcohol fraud in 1996. Price differences play more of a role in the level of legitimate cross-border shopping, where individuals legally bring back alcohol with them from cheaper countries. At least 1 in 6 tourists returns from trips abroad with alcoholic drinks, carrying an average of over 2 litres of pure alcohol per person in several countries.
The economic role of the alcoholic drinks industry is considerable in many European countries. Alcohol excise duties in the EU151 countries amounted to 25 billion Euros in 2001, excluding sales taxes and other taxes paid within the supply chain – although 1.5 billion Euros is given back to the supply chain through the Common Agricultural Policy. Due to the relative inelasticity of the demand for alcohol, the average tax rates are a much better predictor of a government’s tax revenue than the level of consumption in a country.
Alcohol is also associated with a number of jobs, including over three-quarters of a million in drinks production (mainly wine). Further jobs are also related to alcohol elsewhere in the supply chain, e.g. in pubs or shops. However, the size of the industry is not necessarily a good guide to the economic impact of alcohol policies – for example, trends in alcohol consumption show no crude correlation with trends in the number of jobs in associated areas such as hotels, restaurants, and bars, suggesting that the effect of changes in consumption may be relatively weak.
Based on a review of existing studies, the total tangible cost of alcohol to EU society in 2003 was estimated to be 125bn Euros (1.3% GDP), which is roughly the same value as that found recently for tobacco. The intangible costs show the value people place on pain, suffering and lost life that occurs due to the criminal, social and health harms caused by alcohol. In 2003 these were estimated to be 270bn Euros, with other ways of valuing the same harms producing estimates between 150bn Euros and 760bn Euros. Although these estimates are subject to a wide margin of error, they are likely to be an underestimate of the true gross social cost of alcohol (excluding benefits) given the number of areas where it has been impossible to obtain data. Similarly, while the estimates take into account the benefits of alcohol to health systems and loss of life (valued intangibly), there is no research that would enable the other social benefits to be evaluated.
The use of alcohol in Europe
The EU is the heaviest drinking region of the world, although the 11 litres of pure alcohol drunk per adult each year is still a substantial fall from a recent peak of 15 litres in the mid-1970s. The last 40 years has also seen a harmonization in consumption levels in the EU15, with rises in central and northern Europe between 1960 and 1980, met by a consistent fall in southern Europe. Average consumption in the EU102 is also closer to the EU15 than ever before, although substantial variation remains within the EU10. Most Europeans drink alcohol, but 55 million adults (15%) abstain; taking this and unrecorded consumption into account, the consumption per drinker reaches 15 litres per year.
Just under half of this alcohol is consumed in the form of beer, with the rest divided between wine (1/3) and spirits (1/4), with a harmonization visible over the past 40 years in the EU15. Around 40% of drinking occasions in most of the EU15 are consumed with the afternoon/evening meal, although those in southern Europe are much more likely to drink with lunch than elsewhere. While the level of daily drinking also shows a north—south gradient, non-daily frequent consumption seems to be more common in central Europe, and there is evidence for a recent harmonization within the EU15.
Drinking to drunkenness varies across Europe, with fewer southern Europeans than others reporting getting drunk each month. This pattern is attenuated when ‘bingedrinking’, a measure of drinking beyond a certain number of drinks in a single occasion, is instead investigated, suggesting that there are systematic differences in either/both people’s willingness to report being intoxicated or the length of a ‘single occasion’.
The studies of binge-drinking also show occasional exceptions to the north-south pattern, in particular suggesting that Sweden has one of the lowest rates of binge-drinking in the EU15. Summing up across the EU15, adults report getting drunk 5 times per year on average but bingedrink 17 times. This is equivalent to 40m EU15 citizens ‘drinking too much’ monthly and 100m (1 in 3) binge-drinking at least once per month. Much fewer data are available for the EU10, but that which exists suggests that some of the wine-drinking is replaced by spirits, the frequency of drinking islower, and the frequency of binge drinking higher than in the EU15.
The heaviest drinkers account for a substantial amount of the alcohol drunk in a country, with the top 10% of the population consuming one-third to one-half of all the alcohol drunk. While 266 million adults drink alcohol, but up to 20g (women) or 40g (men) per day, over 58 million adults (15%) consume at harmful levels above this, with 20 million of these (6%) drinking at over 40g (women) or 60g per day (men). Unlike abstinence, heavy drinking is linked to collective changes in drinking, so that changes in consumption tend to be seen across the drinking spectrum. Looking at addiction rather than drinking levels, we can also estimate that 23 million Europeans (5% of men, 1% of women) are dependent on alcohol in any one year.
In every culture ever studied, men are more likely than women to drink at all and to drink more when they do, with the gap greater for riskier behaviour. Although many women give up alcohol when pregnant, a significant number (25%-50%) continue to drink, and some continue to drink to harmful levels. Patterns in drinking behaviour can also be seen forsocio-economic status (SES), wherethose with low SES are less likely to drink alcohol at all. Despite a complex picture for some aspects ofdrinking (with some measures showing opposite trends for menand women), getting drunk and becoming dependent on alcohol are both more likely among drinkers oflower SES.
Nearly all 15-16 year old students (>90%) have drunk alcohol at some point in their life, on average beginning to drink at 12 years of age, and getting drunk for the first time at 14 years. The average amount drunk on a single occasion by 15-16 year olds is over 60g of alcohol, and reaches nearly 40g even in the lower-consuming (for 15-16 year olds) south of Europe. Over 1 in 8 (13%) of 15-16 year olds have been drunk more than 20 times in their life, and more than 1 in 6 (18%) have ‘binged’ (5+ drinks on a single occasion) three or more times in the last month.
Although two countries saw more drunkenness on some measures in girls than boys for the first time in 2003, boys continue to drink more and get drunk more often than girls, with little reduction in the absolute gap between them. Most countries show a rise in binge-drinking for boys from 1995/9 to 2003, and nearly all countries show this for girls (similar results are found for non-ESPAD countries using other data). This is due to a rise in binge drinking and drunkenness across most of the EU 1995-9, followed by a much more ambivalent trend since (1999-2003).The impact of alcohol on individuals
Generally the higher the level of alcohol consumption, the more serious is the crime or injury. The volume of alcohol consumption, the frequency of drinking and the frequency and volume of episodic heavy drinking all independently increase the risk of violence, with often, but not always, episodic heavy drinking mediating the impact of volume of consumption on harm.
Apart from being a drug of dependence, alcohol is a cause of some 60 different types of diseases and conditions, including injuries, mental and behavioural disorders, gastrointestinal conditions, cancers, cardiovascular diseases, immunological disorders, lung diseases, skeletal and muscular diseases, reproductive disorders and pre-natal harm, including an increased risk of prematurity and low birth weight. For most conditions, alcohol increases the risk in a dose dependent manner, with the higher the alcohol consumption, the greater the risk.
The frequency and volume of episodic heavy drinking are of particular importance for increasingthe risk of injuries and certain cardiovascular diseases (coronary heart disease and stroke).
A small dose of alcohol consumption reduces the risk of heart disease, although the exact size of the reduction in risk and the level of alcohol consumption at which the greatest reduction occursare still debated. Better quality studies that account for other influences find less of a risk and find that the reduced risk occurs at a lower level of alcohol consumption. Most of the reduction in risk can be achieved by an average of 10g of alcohol (one drink) every other day.
Beyond 20g of alcohol (two drinks)a day - the level of alcohol consumption with the lowest risk - the risk of coronary heart disease increases. In very old age, the reduction in risk disappears. It is alcohol that mainly reduces the risk of heart disease rather than any specific beverage type. There is evidence that alcohol in low doses might reduce the risk of vascular caused dementia, gall stones and diabetes, although these findings are not consistent across all studies.
The risk of death from alcohol is a balance between the risk of diseases and injuries that alcohol increases and the risk of heart disease (which mostly occurs at older age) that, in small amounts, alcohol decreases. This balance shows that, at least in the United Kingdom, the level of alcohol consumption with the lowest risk of death is zero or near zero for women under the age of 65 years,and less than 5g of alcohol a day for women aged 65 years or older. For men, the level of alcohol consumption with the lowest risk of death is zero under 35 years of age, about 5g a day in middle age, and less than 10g a day when aged 65 years or older, (and probably returning to zero in very old age). There are health benefits to the heavier drinker from reducing or stopping alcohol consumption. Even for chronic diseases, such as liver cirrhosis and depression, reducing or stopping alcohol consumption are associated with rapid improvements in health.
The impact of alcohol on Europe
Alcohol places a significant burdenon several aspects of human life in Europe, which can broadly be described as ‘health harms’ and ‘social harms’. Seven million adults report being in fights when drinking over the past year and (based on a review of a small number of national costing studies) the economic cost of alcohol attributable crime has been estimated to be 33bn Euros in the EU for 2003. This cost is, split between police, courts and prisons (15bn Euros), crime prevention expenditure and insurance administration (12bn Euros) and property damage (7bn Euros). Property damage due to drink driving has also been estimated at 10bn Euros, while the intangible cost of the physical and psychological effects of crime has been valued at 9bn-37bn Euros(52bn Euros for the cost of alcohol-related crime).
Alcohol also impacts on the family, with 16% of child abuse and neglect attributed to alcohol use and 4.7m- 9.1m children (6%-12%) living in families adversely affected by alcohol. An estimated 23 million Europeans are dependent on alcohol in any one year, with the pain and suffering this causes for family members leading to an estimated intangible impact of 68bn Euros. Estimates of the scale of harm in the workplace are more difficult, although nearly 5% of drinking men and 2% of drinking women in the EU15 report a negative impact of alcohol on their work or studies. Based on a review of national costing studies, lost productivity due to alcohol attributable absenteeism and unemployment has been estimated to cost 9bn-19bn Euros and 6bn- 23bn Euros respectively.
Looking from a health perspective, alcohol is responsible for about 195,000 deaths each year in the EU, although it is also estimated to delay 160,000 deaths in older people mainly through its cardioprotective effect for women who die after the age of 70 years (although due to methodological problems, this is likely to be a considerable overestimate of the number of deaths delayed).
These figures are also relative to a situation of no alcohol use, and the net effect would be much greater looking at the lowest-risk level of drinking. Measuring the impact of alcohol through Disability-Adjusted Life Years (DALYs) lessens this problem, and shows that alcohol is responsible for 12% of male and 2% of female premature death and disability, after accounting for health benefits. This makes alcohol the third highest of twenty-six risk factors for ill-health in the EU, ahead of overweight/obesity and behind only tobacco and high blood pressure.
This health impact is seen across a wide range of conditions, including 17,000 deaths per year due to road traffic accidents (1 in 3 of all road traffic fatalities), 27,000 accidental deaths, 2,000 homicides (4 in 10 of all murders) 10,000 suicides (1 in 6 of all suicides), 45,000 deaths from liver cirrhosis, 50,000 cancer deaths, of which 11,000 are female breast cancer deaths, and 17,000 deaths due to neuropsychiatric conditions as well as 200,000 episodes of depression (which also account for 2.5 million DALYs). The cost of treating this ill-health is estimated to be 17bn Euros, together with 5bn Euros spent on treatment and prevention of harmful alcohol use and alcohol dependence. Lost life can either be valued as lost productive potential (36bn Euros excluding health benefits), or in terms of the intangible value of life itself (150bn-710bn Euros after accounting for health benefits).
Young people shoulder a disproportionate amount of this burden, with over 10% of youth female mortality and around 25% of youth male mortality being due to alcohol. Little information exists on the extent of social harm in young people, although a third of a million (6%) 15-16 year old students in the EU report fights and 200,000 (4%) report unprotected sex due to their own drinking.
Between countries, alcohol plays a considerable role in the lowered life expectancy in the EU10 compared to the EU15, with the alcohol attributable gap in crude death rates estimated at 100 (men) and 60 (women) per 100,000 population. Within countries, many of the conditions underlying health inequalities are associated with alcohol, although the exact condition may vary (e.g. cirrhosis in France, violent deaths in Finland). Worse health in deprived areas also appears to be linked to alcohol, with research suggesting that directly alcohol-attributable mortality is worse in deprived areas beyond that which can be explained by individual-level inequalities.
Many of the harms caused by alcohol are borne by people other than the drinker responsible. This includes 60,000 underweight births, as well as 16% of child abuse and neglect, and 5-9 million children in families adversely affected by alcohol. Alcohol also affects other adults, including an estimated 10,000 deaths in drink-driving accidents for people other than the drink-driver, with a substantial share of alcohol-attributable crime also likely to occur to others. Parts of the economic cost are also paid by other people or institutions, including much of the estimated 33bn Euros due to crime, 17bn Euros for healthcare systems, and 9bn-19bn Euros of absenteeism.
Natural experiments and time series analyses both show that the health burden from alcohol is related to changes in consumption. The impact of a onelitre change in consumption is highest in the low-consuming countries of the EU15 (northern Europe), but still significant for cirrhosis, homicide (men only), accidents, and overall mortality (men only) in southern Europe. While some have argued that the greater change in northern Europe reflects the ‘explosive’ drinking culture there, this may also reflect the greater proportional size of a one-litre change in the low consuming northern European countries. Overall, it has been estimated that a one litre decrease in consumption would decrease total mortality in men by 1% in southern and central Europe, and 3% in northern Europe.
Evaluating alcohol policy options
The drinking-driving policies that are highly effective include unrestricted (random) breath testing, lowered blood alcohol concentration (BAC) levels, administrative license suspension, and lower BAC levels for young drivers. The limited evidence does not find an impact from designated driver and safe drive programmes. Alcohol locks can be effective as a preventive measure, but as a measure with drink driving offenders only work as long as they are fitted to a vehicle. The World Health Organization has modelled the impact and cost of unrestricted breath testing compared with no testing; applying this to the Union finds an estimated 111,000 years of disability and premature death avoided at an estimated cost of 233 million Euros each year.
The impact of policies that support education, communication, training and public awareness is low. Although the reach of school-based educational programs can be high because of the availability of captive audiences in schools, thepopulation impact of these programs is small due to their current limited or lack of effectiveness. Recommendations exist as to how the effectiveness of school-based programmes might be improved. On the other hand, mass media programmes have a particular role to play in reinforcing community awareness of the problems created by alcohol use and to prepare the ground for specific interventions.
There is very strong evidence for the effectiveness of policies that regulate the alcohol market in reducing the harm done by alcohol. Alcohol taxes are particularly important in targeting young people and the harms done by alcohol in all countries. If alcohol taxes were used to raise the price of alcohol in the EU15 by 10%, over 9,000 deaths would be prevented during the following year and an estimate suggests that approximately 13bn Euros of additional excise duty revenues would also be gained. The evidence shows that if opening hours for thesale of alcohol are extended moreviolent harm results. The WorldHealth Organization has modelled the impact of alcohol being less available from retail outlets by a 24hour period each week; applyingthis to the Union finds an estimated 123,000 years of disability and premature death avoided at an estimated implementation cost of98 million Euros each year.
Restricting the volume and contentof commercial communications of alcohol products is likely to reduce harm. Advertisements have a particular impact in promoting amore positive attitude to drinking amongst young people. Self regulation of commercial communications by the beverage alcohol industry does not have a good track record for being effective. The World Health Organization has modelled the impact of an advertising ban; applying this to the Union, finds an estimated 202,000 years of disability and premature death avoided, at an estimated implementation cost of 95 million Euros each year.
There is growing evidence for the impact of strategies that alter the drinking context in reducing the harm done by alcohol. However, these strategies are primarily applicable to drinking in bars and restaurants, and their effectiveness relies on adequate enforcement. Passing a minimum drinking age law, for instance, will have little effect if it is not backed up with a credible threat to remove the licenses of outlets that repeatedly sell to the under-aged. Such strategies are also more effective when backed up by community based prevention programmes. There is extensive evidence for the impact of brief interventions, particularly in primary care settings, in reducing harmful alcohol consumption. The World Health Organization has modelled the impact and cost of providing primary care-based brief interventions to 25% of the at-risk population; applying this to the Union finds an estimated 408,000years of disability and premature death avoided at an estimated cost of 740 million Euros each year.
Using the World Health Organization’s models, and compared to no policies at all, a comprehensive European Union wide package of effective policies and programmes that included random breath testing, taxation, restricted access, an advertising ban and brief physician advice, is estimated to cost European governments 1.3 billion Euros to implement (about 1% of the total tangible costs of alcohol to society and only about 10% of the estimated income gained from a 10% rise in the price of alcohol due to taxes in the EU15 countries), and is estimated to avoid 1.4 million years of disability and premature death a year, 2.3% of all disability and premature death facing the European Union.
European and global alcohol policy
The most prominent international legal obligations that affect alcohol policy are the General Agreement on Tariffs and Trade (GATT) dealing with goods, and the General Agreement on Trade in Services (GATS). Past cases on these have shown that the World Trade Organization (WTO) will prioritize health over trade in some circumstances (for example, a ban on asbestos imports), although policies must pass a series of strict tests in order to be maintained.
However, by far the greater effect on alcohol policy in practice has come from the trade law of the European Union (EU). Most of the cases relating to alcohol stem from the‘national treatment’ rule ontaxation, which means that states are forbidden from discriminating –either directly or indirectly – in favour of domestic goods against those from elsewhere in the EU. No exceptions can be made to this on health grounds, with the result that countries face certain restrictions in the design of their tax policy. In contrast, the increasingly influential European Court of Justice (ECJ) has unambiguously supported advertising bans in Catalonia and France, accepting that “it is in fact undeniable that advertising acts as an encouragement to consumption”.
Standardized excise duties are a longstanding goal of the EU in order to reduce market distortions, where large differences in tax rates between nearby countries lead to large amounts of shopping abroad. This leads to lost revenue for the high-tax government, as well as creating pressure to lower taxation rates, as has occurred in some of the Nordic countries.
The production of alcoholic drinks in the form of wine receives 1.5 billion Euros worth of support each year through the Common Agricultural Policy (CAP), including the co-financing of sales promotion campaigns on “the health benefits of moderate wine consumption”. The economic and political importance of these subsidies, and. in particular the problems of wine producers, makes it hard to progress from a public health perspective.
The international body most active on alcohol has been the World Health Organization (WHO), whose European office has undertaken several initiatives to reduce alcohol related harm in its 52 Member States. These include the Framework for Alcohol Policy in theEuropean Region, the European Charter on Alcohol and two ministerial conferences, which confirmed the need for alcohol policy (and public health more broadly) to be developed without any interference from commercial or economic interests.
Although the EU itself cannot pass laws simply to protect human health (Member States have not conferred this power on the European institutions), some policies dealing with the internal market can incorporate substantial health concerns, such as the alcohol advertising clause within the Television Without Frontiers Directive. Otherwise, the EU’s action on alcohol has come through ‘soft law’, in the form of nonbinding resolutions and recommendations urging Member States to act in a certain way.
Member State alcohol policy
Every country in the European Union (EU) has a number of laws and other policies that set alcohol apart from other goods traded in its territory, often for reasons of public health. Despite the ubiquity of alcohol policies, just under half the EU countries still do not have an action plan or coordinating body for alcohol. Even so, most countries have programmes for one aspect of alcohol policy, of which schoolbased education programmes are the most common throughout Europe. All countries also have some form of drink-driving restrictions, with everywhere except the UK, Ireland and Luxembourg having a maximum blood alcohol limit for drivers at the level recommended by the European Commission (0.5g/L).
Sales of alcohol are generally subject to restrictions in most EUcountries, in a few cases through retail monopolies but more often through licences, while the places that alcohol can be sold are frequently restricted. Over one-third of countries (and some regions)also limit the hours of sale, while restrictions on the days of sale or the density of off-premise retailers exist in a small number of countries.
All countries prohibit the sale of alcohol to young people beneath a certain age in bars and pubs, although four countries have no policy on the sale of alcohol to children in shops. The cut-off point for allowing sales to young people also varies across Europe, tending to be 18 years in northern Europe and 16 years in southern Europe. Alcohol marketing is controlled to different degrees depending on the type of marketing activity. Television beer adverts are subject to legal restrictions (beyond content restrictions) in over half of Europe, including complete bans in five countries; this rises to 14 countries for bans on spirits adverts. Billboards and print media are subject to less regulation though, with one in three countries (mainly in the EU10) having no controls. Sports sponsorship is subject to the weakest restrictions, with only seven countries having any legal restrictions at all.
The taxation of alcoholic beverages is another consistent feature of European countries, although the rates themselves vary considerably between countries. This can be seen clearly for wine, where nearly half the countries have no tax at all, but one in five countries has a tax rate above PPP1,000. In general, the average effective tax rate is highest in northern Europe, and weakest in southern and parts of central and eastern Europe. Four countries have also introduced a targeted tax on alcopops since 2004, which appears to have reduced alcopops consumption since.
When the different policy areas are combined into a single scale, the overall strictness of alcohol policy ranges from 5.5 (Greece) to 17.7 (Norway) out of a possible maximum of 20, with an average of 10.8. The least strict policies are in southern and parts of central and eastern Europe, and the highest in northern Europe – but the scores do not all decrease from north to south, as seen in the high score in France. This picture of alcohol policy is very different from the one visible fifty years ago, with the overall levels of policy now much closer together, largely due to the increased level of policy in many countries, particular in the area of drink-driving where all countries have a legal limit. Marketing controls, minimum ages to buy alcohol, and public policy structures to deliver alcohol policy are also much more common in 2005 than in 1950.