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Alcohol pricing – could it improve men’s health?

CORDELIA E.M. COLTART AND IAN T. GILMORE

The authors give an overview of the rationale for using alcohol pricing as a public health tool. They outline the background to government alcohol strategies, review recent moves by the government to acknowledge the problem, and contrast their proposed policy to the evidence base that underpins the advice of health professionals advocating for an urgent minimum pricing policy for alcohol.

ou only have to go into an accident and Yemergency department on a Friday night to see the scale of the alcohol problem in the UK. The statistics are striking, with recent data reporting 30000–40000 deaths attributable to alcohol,1 more than one million alcohol- related hospital admissions in England each year,2 and the economic costs of alcohol-related health harms at something in the order of £20–55 billion.1 Figure 1. Making alcohol more expensive and less available would help reduce alcohol-related problems The evidence highlighting the scale of the problem is accumulating, as is evidence Cordelia E.M. Coltart, MB BS, MRCP, MPH, Clinical Advisor to the to support the association between President, Royal College of Physicians; Ian T. Gilmore, MD, FRCP, affordability of alcohol and increased 3 Consultant Physician and Gastroenterologist, Royal Liverpool consumption (Figure 1). The consequences University Hospitals; Honorary Professor of Medicine, University of of alcohol-associated harm are largely Liverpool; Chair, Alcohol Health Alliance preventable, or at least would be with effective and enforceable alcohol policies.

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However, as we all know, alcohol policies have been increasing markedly over recent In the face of failing government policies, rarely feature highly on any health agenda. decades. These findings are particularly in 2009 the CMO recommended tougher alarming when compared to countries with policies to reduce the harmful effects of THE PROBLEM similar cultures, genetic background and alcohol, such as a minimum unit price Harmful and hazardous use of alcohol is drinking cultures (eg Australia, New Zealand, (MUP) for alcohol,10 although the related to both the volume of alcohol Netherlands, Sweden and Norway).5 government quickly rejected this last consumed and the pattern of drinking. proposal.11 Further calls for action have Britain has the highest binge-drinking However, the most recent statistics suggest been made by the Academy of Medical culture worldwide (men more than a small overall reduction in harm Sciences in their document ‘Calling time: women). The problems associated with associated with alcohol, with a 6 per cent the nation’s drinking as a major health alcohol consumption are well documented, decline in alcohol-related deaths and 6 per issue’;12 the World Health Organization in with alcohol being shown to cause more cent reduction in consumption in 2009 the recently ratified Global Alcohol than 60 medical problems (Box 1), in (Figure 2).6,7 While this may be a genuine Strategy;13 and the House of Commons addition to the consequences of ‘passive effect of the current recession, these Health Committee, who in 2009 reported drinking’ (the indirect harmful effects to data represent an isolated one-year that ‘we are concerned that government a third party from alcohol use, eg the snapshot and must be viewed in the light policies are much closer to, and too effect on the drinker’s family, colleagues, of overall trends, which have increased influenced by, that of the drinks’ industry victims of violence and traffic injuries). overwhelmingly since the 1990s. and the supermarkets, than those of expert Furthermore, domestic violence is strongly health professionals such as the Royal related to alcohol use, with some regions Much of the information available on College of Physicians (RCP) or the CMO’.1 reporting 53 per cent of cases linked to alcohol does not distinguish between men perpetrators ‘under the influence’.4 and women, but the data highlight that in Alcohol pricing policies all societies studied, men consistently drink Alcohol price can be regulated in two One way to monitor the impact of alcohol more than women in both frequency and ways: increased duty (including absolute burden and the success/failure of alcohol quantity.8 This leads to higher rates of increases in alcohol duty linked to taxation policies is to measure one of these well- adverse drinking consequences – men according to inflation, linking levels of recognised health consequences. For are twice as likely as women to die of taxation to alcohol strength including instance, death rates from liver disease is a alcoholic .8 Furthermore, alcohol introduction of tax incentives for low- good surrogate marker of the damage to affects testicular and sexual function in alcohol alternatives) and minimum unit society by alcohol (liver disease accounts males, although it is unclear whether pricing. Both of these approaches would for 80 per cent of the mortality attributed this alters reproductive outcomes or impact upon and decrease price-based to alcohol).5 The liver death rate trends infant development.8 alcohol promotions.

BOX 1. Key health harms associated UK ALCOHOL POLICY Minimum unit pricing will differentially with alcohol The first move to acknowledge alcohol as a affect supermarket alcohol sales, where health concern in the UK came in 2001, the trend in alcohol purchasing and ACUTE INTOXICATION when the Chief Medical Officer (CMO) consumption is growing as home drinking l Injuries/trauma (unintentional and reported that UK deaths from cirrhosis trends increase.14 In contrast, duty and tax intentional) were rising disproportionately and set to policies will differentially impact on alcohol l Consequences of ‘passive drinking’ overtake the European Union mean sales in pubs and clubs, as alcohol duty average.9 In 2004 the government set out strategies can be, and often are, avoided by CHRONIC DISEASES an alcohol harm-reduction strategy, retail discount offers on alcohol, to offset l Neuropsychiatric disorders centred on increased education and public the duty increase. There is international (particularly depression) information on alcohol harm and increased evidence to support the effectiveness of l Cardiovascular disease voluntary partnerships with the drinks pricing strategies, reinforced by modelling l Cancer (including oesophageal and industry. However, these approaches were data, to substantially reduce alcohol liver) not successful and, in contrast, policy consumption and associated harms. l decisions driving alcohol use to rise were l Associated with infections such as implemented (eg increasing alcohol Lessons should be learnt from international HIV/AIDS, tuberculosis and pneumonia availability by removing restrictions on strategies demonstrating the clear sales and reduced relative price). association between affordability and

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per week.17 For example, supermarkets 22 could transfer the discounted bargains 20 Males from alcohol to fruit and vegetables, 18 thereby preventing moderate drinkers subsiding alcohol purchases for the 16 harmful and hazardous drinkers, while 14 increasing the health of the supermarket 12 shoppers and balancing the modest 10 Females increase in alcohol purchases such that the 8 result is the same overall spend per week. 6 4 Several other recent policy developments 2 have been proposed, such as approval

Age-standardised rates per 100 000 population 0 to sell reduced measures of alcohol, 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 eg wine in measures of under 75ml and Year a ‘schooner’ of beer (two-thirds of a pint).18 Furthermore, the government will Figure 2. Alcohol-related death rates, UK 2000–096 introduce a new duty on ‘strong’ beers over 7.5 per cent alcohol by volume, aimed to consumption. For example, in 2004, the Recent UK estimates have shown that a decrease the consumption of cheap, Finnish government reduced alcohol excise £0.50 MUP would decrease alcohol ‘super-strength’ lagers, usually associated duty (to reduce the tax on alcohol sold consumption by 6.9 per cent, leading to with hazardous drinking behaviours.19 within Finland and prevent excessive 3393 fewer deaths, 97900 fewer hospital However, once again, this will affect only a imports resulting in internal losses in admissions, 45800 fewer crimes, 296900 tiny proportion of beer sales. alcohol tax revenues) by an average of 33 fewer sick days and a total saving of per cent. This led to an immediate 17 per £15 billion over ten years.16 75–80% of Finally, the government hopes to achieve cent increase in sudden deaths involving alcohol is consumed by 20–25 per cent of positive societal change through alcohol (equivalent to eight additional people, who misuse it. Any pricing policy that ‘responsibility deals’ by incorporating alcohol-related deaths per week).15 targets the cheapest alcohol will target heavy businesses into public health strategy drinkers, who buy 15 times more alcohol decisions (including alcohol). While ‘nudging’ Current policy than the moderate drinker, spend 10 times may have a role to play, it will most In January 2011, UK ministers proposed as much per year and pay 40 per cent less effectively alter the behaviour of the already plans to control alcohol pricing in England per litre of pure alcohol due to cheaper health-conscious audience, who do not and Wales, by imposing a ban on selling preferences (eg discounted, multi-buy, comprise the bulk of the alcohol problem. alcohol for less than the combined tax and super-strength alcohol).16 The drinks industry has not traditionally duty paid on it. This would result in prices shown commitment to public health and a from 21p per unit of beer and 28p per unit The Scottish Parliament last year rejected conflict of interest is inevitable. for spirits, which equates to 38p for a can plans for an MUP, as the Scottish National of weak lager, £2.03 for a bottle of wine Party (SNP) could not secure the support CONCLUSION and £10.71 for a litre of spirits. This move of coalition partners. However, as of May Medical professionals have a key role to play may have been intended to demonstrate 2011, the SNP have a working majority and in advocating for the implementation of that the government is doing something are committed to pursuing an MUP. They alcohol policies to protect the health of the tangible about this stark public health will first have to overcome anxieties about population. General practitioners are pivotal problem, but in reality, the proposals do breaches of European competition law. in this process, as the frontline interface of not begin to tackle the problem, affecting a the profession, seeing patients on a daily tiny proportion of drinks currently sold Opposition parties will claim that an MUP basis. The UK has a strong track record in (estimated by the Guardian newspaper at would penalise responsible moderate successfully campaigning for public health less than 1 in 4000 sales). Therefore, this drinkers, but studies have shown this not policy, most notably around the tobacco first move by the government sets an to be the case and that an MUP in the campaign. The success of this campaign, in ineffectual floor to minimum price and range of £0.50 would not increase the part, was a consequence of strong medical disregards the evidence. average British family’s supermarket bill pressure, both epidemiologically and on a

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case-by-case consultation basis, where www.publications.parliament.uk/pa/cm200910/ mar/16/gordon-brown-alcohol-pricing smoking was/is highlighted in virtually cmselect/cmhealth/151/15102.htm 12 Academy of Medical Sciences. Calling time: every medical encounter. 2 NHS Information Centre. Statistics on alcohol: the nation’s drinking as a major health issue. England, 2011. www.ic.nhs.uk/pubs/alcohol11 2004. www.acmedsci.ac.uk/p48prid16.html We should learn from these successes and 3 Anderson P, Chisholm D, Fuhr DC. 13 World Health Organization. Global alcohol every consultation should additionally Effectiveness and cost-effectiveness of policies strategy: strategies to reduce the harmful use of include a discussion about alcohol usage, and programmes to reduce the harm caused by alcohol. Report of the World Health Assembly, highlighting the harms associated with it. alcohol. Lancet 2009;373:2234–57. 2010. www.who.int/mediacentre/news/releases/ The former CMO (England) highlighted the 4 Koenig MA, Lutalo T, Zhao F, et al. Domestic 2010/alcohol_20100521/en/index.html urgent need for effective alcohol policy violence in rural Uganda: evidence from a 14 British Beer and Pub Association. Statistical and professional support is crucial. It will community-based study. Bull WHO 2003; handbook 2004. be interesting to see if Scotland leads the 81:53–60. 15 Koski A, Siren R, Vuori E, Poikolainen K. Alcohol way in introducing evidence-based policy 5 Sheron N, Hawkey C, Gilmore I. Projections of tax cuts and increase in alcohol-positive sudden into the UK, as they did with the ban on alcohol deaths – a wake-up call. Lancet 2011; deaths – a time-series intervention analysis. smoking in public places. In addition, a 377:1297–9. Addiction 2007;102:362–8. cultural change is needed to alter the 6 Office for National Statistics. Alcohol-related 16 Meier P, Brennan A, Purshouse R, et al. acceptability and perception of drinking to deaths in the United Kingdom, 2011. www.ons. Independent review of the effects of alcohol excess. This will take time and is harder to gov.uk/ons/rel/subnational-health4/alcohol- pricing and promotion. Part B. Modelling the achieve, particularly given the limited related-deaths-in-the-united-kingdom/2009/ potential impact of pricing and promotion government budget for , index.html policies for alcohol in England: results from the which is swamped in comparison to the 7 British Beer and Pub Association. Statistical Sheffield alcohol policy model version 2008(1-1). drinks industry budget (45 times higher at handbook 2010. University of Sheffield, 2008. www.dh.gov.uk/en/ £600–800 million/year). 8 Nolen-Hoeksema S. Gender differences in risk Publichealth/Healthimprovement/Alcoholmisuse/ factors and consequences for alcohol use and DH_4001740 As a profession we have a duty to advocate problems. Clin Psychol Rev 2004;24:981–1010. 17 Record C, Day C. Britain’s alcohol market: how for responsible, sensible and evidence- 9 Department of Health. On the state of the minimum alcohol prices could stop moderate based national action with a call for a public health: annual report of the Chief drinkers subsidising those drinking at £0.50 MUP for alcohol to reduce the Medical Officer, 2001. London: Department of hazardous and harmful levels. Clin Med preventable, but rising statistics of alcohol Health, 2001. 2009;9:421–5. health harms in the UK. 10 Donaldson L. 150 years of the annual report 18 Department for Business, Innovation and of the Chief Medical Officer: on the state of Skills. More freedom to buy and sell bread and Declaration of interests: none declared. public health 2008. London: Department of wine. 2011. http://nds.coi.gov.uk/content/ Health, 2009. detail.aspx?NewsAreaId=2&ReleaseID=417278 REFERENCES 11 Hencke D, Sparrow A. Gordon Brown rejects call 19 HM Treasury. Review of alcohol taxation. 2010. 1 House of Commons Health Committee. to set minimum prices for alcohol. Guardian 16 www.hm-treasury.gov.uk/d/alcohol_tax_review Alcohol: first report of session 2009–10. March 2009. www.guardian.co.uk/politics/2009/ 301110.pdf

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