CONFERENCE REPORT

ORGANISED BY CO-SPONSORED BY

WITH THE SUPPORT OF FOREWORD

The European Alcohol Policy Alliance had the pleasure to host the 6th European Alcohol Policy Conference, 27th and 28th November 2014 in Brussels. The conference brought together over 300 participants from 36 countries, which ensured a broad representation of stakeholders concerned with alcohol related-harm, with participation from policy and decision makers, civil society, scientists and alcohol and health experts.

The 6th European Alcohol Policy Conference intended to raise awareness among the key policy and decision makers about the current burden of alcohol in Europe, and the multiple health and social problems it creates. It is for this reason that we encourage you to support our Call for a Comprehensive Alcohol Policy Strategy in the European Union. In addition, the conference had the intention to strengthen networks, build capacity and stimulate action to prevent and reduce alcohol related problems at all levels.

Topics covered at the conference were the need for a new EU Alcohol Strategy, price and taxation, health and inequalities, advertisement, information to consumers and the Joint Action on Reducing Alcohol Related Harm (RARHA).

At the conference, Eurocare presented its report Eurocare Recommendations for a Future EU Alcohol Strategy, which gives clear policy recommendations on key priority areas for action from the EU on alcohol policies. Eurocare hopes the conference together with the recommendations presented will create a foundation for upcoming discussions in the EU on topics such regulation of marketing, consumer information, price and taxation and road safety.

Tiziana Codenotti Mariann Skar Eurocare President Secretary General

Page | 2 OPENING AND INTRODUCTION

Tiziana Codenotti, Eurocare President, started by introducing the 6th European Alcohol Policy Conference, and welcoming delegates to the event. She noted that Eurocare are proud to host this conference of over 300 public health experts, civil society organisations and policymakers, and made special mention of the attendance of 45 ministers of health, WHO and European Commission who had collaborated on the event.

She noted that the purpose of the conference was to stimulate action into alcohol policies at all levels and should inspire actions by all actors, in a continent that “is still the highest alcohol drinking region of the world”. It aimed to facilitate network and coalition building between and within European countries, to present co-financed projects by the European Commission and finally to call for an updated EU Alcohol Strategy. “It is the right moment to update the European Alcohol Strategy, building on recommendations from the WHO”

She gave special thanks to the funders of the conference, who had made it possible, including the European Health Programme, Actis from Norway, The Norwegian Health Ministry, ANPAA from France, The Scottish Ministry of Health, EHYT from Finland, IOGT Sweden and Visit Mexico.

Martin Seychell, is Deputy Director General for Health and Consumers at the European Commission, started by thanking Eurocare for creating this opportunity to meet and discuss alcohol and health policy in Europe. “I am confident that this conference hosted by Eurocare will bring the debate further.”

Page | 3 He noted that alcohol is a societal problem, therefore it is essential that all parts of society at all levels, realise that they have a role and indeed a responsibility to contribute to reducing alcohol related harm. He also noted that we should not limit alcohol harm to just health effects because alcohol has social impacts, such as violence and on social behaviour. In the EU, he added that if we translate the harms of alcohol to economic term, it equates to 160 billion euros and that these harms fall disproportionally on certain groups in society. Not only those who are heavy drinkers but light and moderate drinkers also make up a significant proportion of the harm.

He concluded “it is clear that a one size fits all approach is not a valid answer and all EU institutions, ministers, civil society organisations have a role to play.” The Commission cannot, however, substitute for action or inaction in member states and our work so far is based on supporting member states and to mobilise action on reducing alcohol related harm. Responsibility for public health remains with the member states and they are responsible for deciding on what actions they want to take and the European Commission will continue to support member states in their actions.

Evelin Ilves, WHO spokesperson and the Estonian First Lady, noted the effort of Eurocare to reduce alcohol related harm in Europe. The European continent remains to consume twice as much as the world average and our overconsumption costs 186 billion euros in sickness and lost activity. “Alcohol overconsumption is often driven by the supply and availability of alcohol“

We are sometimes made to believe that changing our attitude to alcohol in society is impossible. We must see through the PR and see how we can reconsider the role of alcohol in society and it is the governments of Europe and the European Commission who can control the availability and promotion. “Let us continue with the work that has brought us here today”

Gauden Galea, from the WHO Regional Office in Europe, noted how over time the industry has someone managed to constrain us to a language but we should admit that alcohol is harmful and not just speak about harmful use of alcohol but more broadly about the harm caused by all types of alcohol use.

He went on to demonstrate how alcohol use is one of the top causes of disease burden in Europe – “The question in Europe is far from being resolved” – and that in Europe we have high exposure and high mortality and disease. For men, between 15 and 64, 1 in 7 deaths caused by alcohol and 1 in 13 women, also noting the large variation between Turkey at one end of the scale and Belarus at the other.

Mr Galea noted how we should not just count harm by the cases of liver cirrhosis. The point is that it is not just health that is the issue, it is the whole impact on society including absenteeism, accidents and unemployment. “We have agreed globally that something needs to be done”

Page | 4 ALCOHOL IN ALL POLICIES: COST-EFFECTIVE INTERVENTIONS TO PREVENT AND REDUCE ALCOHOL-RELATED HARM

Franco Sassi, Senior Health Economist at the Economics of Prevention Programme at the OECD, opened by emphasising his organisation’s productive relationship with Eurocare in the OECD work on prevention, and hoping that it will continue into the future.

Mr Sassi displayed alcohol consumption trends in Europe, demonstrating an overall slow decline but a very mixed picture for individual countries. For example, in Italy has consistently decreased but Finland has risen to the OCED average, after starting from a lower level. This follows a general trend that in most southern countries consumption has decreased, while in most northern countries it has increased. However, even in countries which have seen dramatic declines in alcohol consumption, the picture is not comforting. We increasingly see that hazardous drinking in some groups, such as in young women. We also see an increase in binge drinking among young people, apart from in the UK and Ireland, which already had a high level in the past and remains high.

Mr Sassi presented the J-Curve of the health effects of alcohol, based on mortality, but argued that this is not the only outcome to consider. Harms to others and quality of life are not included in the J- Curve, nor are other impacts on quality of life, so we should be careful about how we interpret it as a model.

He then looked at the health outcomes of various alcohol policy measures such as tax increases and advertising regulation, according to a new study being undertaken by the OECD. Brief interventions and treatment of dependence also had significant health gains in DALYS, as well as measures such as opening hours regulation and drink drive interventions.

Page | 5 MIND THE GAP: HEALTH AND INEQUALITIES

Witold Zatonski, project leader for the EU funded “Closing the Gap” project, argued that we have “three-speed Europe” in terms of adult health if we divided it into Western Europe, Central Europe and former USSR states.

He noted that women in Western Europe have had fantastic progress with life expectancy in particular. He noted that smoking and alcohol consumption were key factors in reduced life years and early mortality. He presented findings of liver cirrhosis mortality from 1950s until the present day.

He then went on to look at all-cause mortality and how this was correlated with the price of alcohol in Poland and how through the decline of vodka prices, there was a decline in health gain in Poland from around the year 2002.

He then looked at whether the health gap between the regions of Europe were increasing or decreasing, in which he showed data on the risks of dying from 1990 to 2010, rates remained high for Czech Republic, Slovakia, Slovenia, Estonia and Poland for men and high for women in Estonia, Czech Republic, Denmark, Hungary, Ireland, Slovakia and Poland. The speed of closing the gap is closing but he concluded that this gap is closing too slowly.

He concluded that as alcohol is carcinogenic that we cannot treat it in any way like a normal commodity and that for this reason, it needs regulation, including price negotiation.

Page | 6 WHY DOES THE EU NEED AN ALCOHOL STRATEGY?

Maria Renström, seconded expert to the WHO in Geneva and previously working for the European Commission, opened the session by looking back on alcohol policy. Over the last 20 years, alcohol has grown as a topic in Europe, and we should be positive about the steps that we have managed to take. She noted that its important to maintain a responsibility with the governments, whether there is a formal strategy or not.

Jürgen Rehm, a prominent public health researcher, set the scene. We have had a ten percent reduction in consumption in the last decade overall but not in all areas, so have seen some increase in East and Central East and in the Nordic countries. However, the rates of consumption are going down but it is not nature-given, it has been resulted from policies, by action of citizens and it can be changed by us.

The risk of dying is increasing steadily after 10g (average drinking amount). 20g is less than two drinks. Overall, in a lifetime, alcohol kills 2 out of 100 people if they were to drink only 20g and that is a risk that we would never except from any other behaviour risk factor.

So when does alcohol kill? Alcohol is the 5th highest risk factor in Western Europe but it is the number one of cause of death and disease in Eastern Europe. Overall, it kills way too many, it kills way too early and parts of Europe have the highest alcohol attributable disease rate in the world.

Page | 7 The last point he wanted to make was if we applied the risks of environmental health risks, like for air pollution, which have a rate of risk of 1 in 1 million people but alcohol kills others, non-drinkers and children to a way higher rate than 1 in 1 million, so if we look at just from a harm to others perspectives, we would have to take more action, so why do we treat it so differently? Alcohol is not included in any normal food regulation and is the only psychoactive substance without a binding international treaty. “We need an EU Strategy to inform the actions of EU Member States and this is inline with the international strategy”. The harm is still high and it can and should be reduced. Harm is not restricted to the health or to the drinker.

Fernando Leal da Costa, Health Secretary of State in Portugal, noted that when we think about alcohol abuse, we should look at psychiatric co-morbidity, safe sex and look at all social dimensions that surround alcohol use.

This is the key to success, any strategy should be international and regional, not only local. Portugal is committed to tackling alcohol through effective policies and we are working on a scoping paper on the need for a new alcohol strategy. “Portugal believes that the harms that led to the previous EU Alcohol Strategy still hold true today”

In Portugal, the government approved the national plan to address addictive behaviours in 2013 in quantifiable targets and it is a multi-ministry plan which addresses addiction and dependencies, as well as equally demand and supply.

We envisage and shall apply an individual approach and put citizens in the centre of our policy and look at alcohol use through the lifecycle. This new social perspective as well as NCDs Alcohol is a strong, addictive substance and we must never forget that fact. Yes, we have a problem of young people drinking but we also have a problem with a growing number of people drinking heavily in old age, sometimes linked to loneliness and unemployment. “One must compare loss of jobs to loss of lives”.

Portugal is supporting a Joint Action and Portugal has accepted the challenge of being the co- ordinating partner.

Philippe Roux, Head of the Health Determinants Unit in DG SANCO, argued that there is no need to repeat that there is a need for a new Alcohol Strategy but you need to know who owns the decision. The strategy allows a real exchange between the national health authorities and we made a lot of progress.

Crispin Acton, Programme Manager of the Alcohol Misuse Unit in the UK, noted that in terms of the achievements of the current Alcohol Strategy, we would largely take the official results of the evaluation which summarised the achievements and our take on that is that there have been achievements on drink driving and more commonality on underage drinking, databases as well as commonalities between alcohol levels. I re-read the current strategy and Committee on National Alcohol Policy and Action (CNAPA) is not mentioned in the EU strategy and from the point of view of CNAPA, perhaps lip service is being paid to member service but the importance of CNAPA and Member States needs to be recognised more and right now, we have been asked in CNAPA to write

Page | 8 a paper to the new commissioner about what we would like in a new strategy. We would specifically like to see a focus on Alcohol in all policies and we would want this to be included as well at the EU level and we should remember that there are EU rules that constrain what we can do at a member state levels, such as labelling. We also think its important that the EU shares the results of what policies have been effective and I think the current EU strategy is out of date because it is looking a little on the primitive stage right now and we do see the need for a new EU Alcohol Strategy and we have asked for this since late 2011. There are benefits at the EU level, particularly with cross-border issues and EU wide research on this topic. The EU could really use its influence on health and we would question whether it is really using that.

Fernando Leal da Costa: It is true that the EU does not have specific competency on health but we are all bound by the treaties to look after our citizens and we should never forget this. Tobacco has benefited by an EU Directive and there are lots of things that could be included into a European approach on alcohol. Anything that we do in relation to a health determinant must be seen in a context of health in all policies. If we do involve our citizens in our quest, we will never solve the problems of alcohol related harm.

Eric Carlin, Director of Scottish Health Action on Alcohol Problems, wanted to speak positively about the achievements that have been made. One of the problems has been that through various forums such as the Alcohol and Health Forum, is that we have given legitimacy to industry activities within the EU and within the Forum and we do not feel confident that health interests are being balanced against industry interests.

Jürgen Rehm noted that what strikes science here is that a lot of velocity from the EU is that it has been too slow. From a scientific point of view, we think that the EU is behind with science in the field, it is behind developments in the WHO and we would like to see more. One of the main problems in the research field is the social balance of alcohol related mortality. There is of course a health inequity issues, the poor die before the rich, however what has been found is that alcohol interacting with that and the alcohol deaths are way more unequal than what you would even expect. What we do not know is how do these policies actually reduce the inequities in Europe and all policies should be checked if they are actually possible of reducing the health gap between poor and rich.

Philippe Roux: Someone said they see that things are slow on the European level. We need to really think about what is desirable, what is doable and what in the context, do we need to change to make the desirable and doable?

Maria Renström, ended the panel by highlighting that in drug policy, we talk about shared responsibility not just member state responsibility so why should we not talk about shared responsibility when it comes to alcohol action?

Page | 9 WILL EU LEGISLATION ENABLE CONSUMERS TO MAKE INFORMED CHOICES?

Emanuele Scafato, from the Istituto Superioire di Sanita in Italy, welcomed everybody to the session and said that it was an honour to chair. He said that the issue of labelling is a really relevant issue for the European Union, and emphasised that there is much discussion surrounding the utility of different types of labelling, before introducing the speakers to the panel.

Lars Møller, Programme Manager for Alcohol, Illicit Drugs and Prison Health Programmes at WHO Europe, opened the presentations by talking about the levels of alcohol consumption across the world.

Mr Møller discussed the WHO’s Alcohol and Health Report, which included data on alcohol attributable standardised death rates (SDRs) per 1000 people. From data of this kind, he demonstrated the East- West divide that exists in terms of alcohol inequities in Europe. He explained that when it comes such health inequities, there are both socio-economic inequities as and gender inequities prevalent.

The WHO Action Plan from 2012-2020 has recently been updated with a progress report, which showed that product information and health warnings are still not being properly implemented across Europe. Mr Møller posed the questions about whether consumers where interested in labelling information on alcoholic beverages, and noted that a WHO infographic posted on

Page | 10 Facebook, about calories and young women, attracted attention from over 30,000 people – a surprisingly high result.

In 2013, a review on “Enhanced labelling on alcohol drinks” was produced, and here the authors recommended a host of information on the labels including ingredients, calories and nutritional information.

Mr Møller then discussed the example of Moldova, which has had the highest alcohol consumption globally. They drafted a national plan, which was partly funded by the European Commission, for awareness campaigns across the country. One survey conducted in 2010 asked people whether alcohol consumption during pregnancy could cause harm to the baby, where 40% of people said no, but this dropped to almost 0 by 2014 – indicating a big shift in awareness. Mr Møller noted such that simple information can at least change the knowledge that the public has, but we do not know yet if it significantly changes behaviour.

Mr Møller concluded by discussing the WHO reports titled “Alcohol in the European Union”, and “Status Report on Alcohol and Health in 35 European Countries”, a topics that will be continued and followed in the future.

Pierre-Yves Bello, from the French Ministry of Health, discussed the introduction of the Loi Evin in France, which introduced that no drinking during pregnancy message on all alcoholic beverages.

He noted that it was unfortunate that during the legal decree, there was no minimum size specified, so it is often very small on the container. For this, he provided some advice to other states. Mr Bello also argued that the colour was an important aspect in terms of visibility, which should have gained attention in the legal process.

Over recent years in France, he demonstrated an improvement in attitudes towards not drinking during pregnancy, but insisted that there were still efforts that needed to be made. He noted that by 2012 over 60% of women were aware of the pregnancy warning, and of those the logo was understood by 98.6% of women.

Mariann Skar, the Secretary General of Eurocare, introduced the concept of labelling more broadly. She noted the plethora of warning signs applied to roads, chemicals and goods, but highlighted that there was not one single piece of legislation for ingredients on alcohol.

She noted that there had been a missed opportunity in the EU, regarding Regulation 1169/2011, to introduce alcohol into the EU regulation on ingredient listing. However she noted that there has been a shift in perspective, and that now “we see a difference, we see a change.” Now, we have information on alcohol in the EU action plan. There has been little research on the impact of labelling, and Ms Skar urges for in the future.

Ms Skar showed a video of a small experiment taken in the UK to demonstrate how behaviour may be altered with greater consumer information, on aspects such as calories. Elements which should

Page | 11 be included in labelling are nutritional information, allergic effects, calorie information and carcinogenic effects. She added that there is also strong public support for information, and furthermore, “we all have a right to know this information.”

Ms Skar pointed out that now some producers have got voluntary agreements, some of which are working, but this is not the case across the board. Much of this important information is still only found on websites, where the public do not see it, and should instead be visible on the product itself. She pressed the Commission to move forward on this, claiming that “this is a typical cross- border issue” and certainly possible if there is political will.

WORKSHOPS DAY ONE

ALCOHOL IN ALL POLICIES: A ROADMAP FOR ACTION AT THE EU LEVEL

Sven-Olov Carlsson, IOGT International and Eurocare Board Member, welcomed the panellists and the audience, and noted that the theme for the conference was “Alcohol in All Policies”. The Aspect Report in 2004 outlined the history of tobacco control effort at the EU level, and provided a road map for EU institutions on the future regulatory and fiscal measures. This facilitated continued progression of tobacco control – alcohol is no ordinary commodity – an effective alcohol strategy needs to look at all aspects of alcohol policy – but these are managed by many different EU agencies. Too often, individuals or organisations are mobilised too late and opportunities are lost.

Zoltan Massay-Kosubek, from the European Public Health Alliance (EPHA), stated that alcohol is a priority area for EPHA. It has a large impact on liver deaths in the EU, 75% of which are attributable to alcohol, and exacerbates health inequalities. Mr Massay-Kosubek argued that the EU has an obligation to support Member States through various instruments. The EU Alcohol Strategy, in particular, should focus on prevention and health promotion, and not simply binge drinking and young people as it does in the current Action Plan. He argued that a change in mind-set is needed – from a demand-side approach to a supply-side approach – as evidence shows that these measures are more effective.

Graziella Jost, from the European Transport Safety Council, noted that 26,025 people are killed in the EU28 in 2013 as a consequence of road collisions, but that there are almost 200,000 injuries – this is the equivalent of one air crash every week happening on our roads, but it does not get the same coverage in the media. She presented the blood alcohol content (BAC) limits across the EU, noting that that lower levels were being applied to professional drivers and that there should be a

Page | 12 zero tolerance approach. She also noted the variation in enforcement action by the police between different Member States.

Kate O’Regan, from the European Cancer Leagues, discussed the different types of cancer that can be caused by alcohol. She also summarised alcohol’s prevalent role as an impact for non- communicable diseases (NCDs) and its social costs. She emphasised that people need an increased awareness about the health risks of alcohol, as the connection between alcohol and cancer is too often overlooked. She referred to the European Code Against Cancer, which states that “If you drink alcohol, limit your intake. Not drinking alcohol is better for cancer prevention.”

Joanne Vincenten, from Eurochild, discussed alcohol policies supporting child injury prevention. She highlighted that alcohol is the leading cause of death in children aged 0-19 years in the EU27. This includes violence, neglect and abuse, road incidents, drowning, falls, burns and poisonings. New research in Northern Ireland shows that impairment due to alcohol is a factor in 80% of fatal house fires.

She noted that only 14 countries out of 31 had a national policy that included support to children whose parents have substance abuse problems. She noted that compared to drink driving, which is very visible, issues hidden in the home often do not have national actions or support.

HEALTH AND RESEARCH

Patrizia Burra, from the University of Padua and the European Association for the Study of the Liver (EASL), presented evidence of mortality from major liver diseases. At the example of chronic liver disease, liver cancer and acute liver failure, she emphasised that alcohol intake continues to be a major contributor to premature death for both men and women throughout Europe. Although the overall alcohol- related health burden is falling, there are still wide inequalities among Member States, with some Members attributing greater attention to alcohol policy than others. Ms Burra stressed the need for public health systems to give a stronger focus and more funding to treating alcohol disorders, which is directly correlated with lower mortality rates. Moreover, although the liver is commonly considered being done most damage to, alcohol abuse must be viewed holistically, affecting other systems such the digestive, nervous, or skeletal systems.

Stephan Haas from the Karolinska Institutet highlighted the impact of alcohol on the gastrointestinal (GI) system. He underlined cancer as a major alcohol-induced disease, of which GI cancers form an important part, as these organs are the ones in direct contact with alcohol. The risk of developing GI cancers increases exponentially with the amount of alcohol consumed, an effect further amplified by

Page | 13 smoking. While the pathogenesis of cancer in the bowel is well-established, there is little knowledge about the effects of alcohol on pancreatic cancer. More research in this field is needed, for which the EU needs to devote more funding to biomedical research through EU-wide research networks.

Jürgen Rehm from Dresden University of Technology presented the effects of alcohol on neurological and mental health. This burden is frequently underestimated as such disorders are usually not lethal and do hence not draw much attention. Future research should give increasing attention to the dual causality of alcohol abuse and mental diseases, as existing neurological dysfunctions does not only stem from, but can be a precondition of, alcohol abuse. A dysfunctional brain contributes to developing an alcohol addiction. Treating alcohol dependence through pharmacotherapy, i.e., the development of new drugs influencing a person’s neurobiology is therefore crucial. At the same time, biological mechanisms themselves do not explain higher drinking in certain social classes. Government regulators should therefore also develop mechanisms targeting the social determinants of alcohol abuse.

OPEN DIALOGUE: IMPLEMENTATION, COST-EFFECTIVENESS, AND ASSESSMENT OF BI’S PROGRAMS

This workshop shared results from the ODHIN (Optimizing delivery of health care interventions) project especially relevant for health policy representatives and health practice managers. In addition, the workshop also promoted a frank dialogue between the audience and the scientists responsible for the researh.

Antoni Gual chaired the workshop. Mr Gual is a psychiatrist, with long experience in Addictions research, including both the clinical and the public health fields. He conducts the Addictions Unit at the Clinic Hospital of Barcelona, Spain; and also acts as Alcohol Consultant at the Health Department of Catalonia.

Other speakers in the workshop: Myrna Keurhorst, Colin Angus and Emanuele Scafato (Istituto Superiore di Sanità).

Page | 14 THE UNINTENDED CONSEQUENCES OF THE TRANSATLANTIC TRADE AND INVESTMNET PARTNERSHIP (TTIP)

Michel Craplet, Honorary President of Eurocare and ANPAA France, introduced the Transatlantic Trade and Investment Partnership (TTIP). Proponents of TTIP say the agreement would result in multilateral economic growth, while critics say it would increase corporate power and make it more difficult for governments to regulate markets for public benefit.

Usman Khan, founder of Modus Europe, posed the question as to whether TTIP poses a present or substantial risk to health. He explained that TTIP is being set within a framework where they have gone from tariff reduction to regulatory reform, from BITS to WTO and back again. He noted that 80% of the gains from TTIP are going to come from non-tariff issues (alcohol not being one) but most of the growth ambition will come from non-tariff reform. What the benefits will be is a matter of contested space.

However, TTIP presents a “regulatory risk” for issues such as availability, advertising, pricing and taxation, which is why it has raised concern. Mr Khan highlighted that TTIP is one of only many international trade agreements, but the fact that this free trade agreement goes across all of Europe is why it has gained attention and alerted civil society organisations. He argued that “there are already a whole host of trade agreements and multi- lateral agreements in place, so it may not represent anything fundamentally different. What is different is that it will do it on a pan-European level rather than with individual member states”.

One issue to be aware of is the investor-state dispute settlement (ISDS) factor, where companies could claim that their company is being treated unequally. People are aware of the high-profile case of Philip Morris taking the Australian

Page | 15 government to court and how this creates regulatory chill, because other countries are worried about taking action until they see what happens in Australia. Mr Khan concluded that while there were certain risks, TTIP is not a “game changer” and that further engagement is essential.

Ivone Kaizeler, from the “tariff and non-tariff negotiations” unit in DG TRADE, explained the fundamental pillars of TTIP. She explained that the TTIP structure had three pillars, the first being market access, then regulatory component and then rules. There is a chapter being discussed on pharmaceuticals, medical devices, textiles for example. In terms of who the negotiators are, there is co-leadership between DG Trade and the regulators (DG Sanco, DG Growth, DG Agri, DG Taxud, Compet etc).

The audience expressed concern of the creation of a new regulatory vehicle to reduce the ability of Member States to take action, and asked whether there could be clear and explicit text exempting proportionate public health measures. Ms Kaizeler responded to the idea that TTIP will prevent regulation by saying “our view is that it will not”. She did not see how it could severely disrupt the normal regulatory process and stating that “the precautionary principle guides almost all of our legislation”.

Page | 16 PRICE AND TAXATION OF ALCOHOL

Peter Rice, Eurocare Board Member and Chair of Scottish Health Action on Alcohol Problems, welcomed everybody to the second day of the 6th European Alcohol Policy Conference. He introduced the Scottish case to implement a minimum unit price for alcohol, which has wide support from the public health community, national brewers and representatives for the small pubs.

Donald Henderson, from the Scottish Government, spoke about how drinking is often thought of as culture and, that to this end, people often think that you are taking action on something inevitable or unchangeable. However, he drew reference to the changing alcohol consumption rates already seen in history, showing that consumption is a changeable phenomenon that we should not think of alcohol consumption as “immutable”. He noted how harmful consumption of alcohol is concentrated in lower income groups, and that the heaviest drinkers progressively chase the strongest or the cheapest drinks. He outlined that broadly, “excise can only address the strength of a product”. He continued that “what we need is a progressive impact but starting from the point of the strongest and cheapest drinks, therefore we needed a different mechanism”. This, he claimed, was a minimum unit price: “It will do a job that tax cannot do”.

Mr Henderson noted that there was continuous public support for the measure, that approximately 45% are supportive of the measure and 40% against. The Scottish government is now in the process of going through courts to pursue the measure, where it now sits with the European Court of Justice, who is looking at how they should address of issues linked to the Treaty of Lisbon. He noted that whilst Article 34 made clear reference to free trade within the EU, Article 36 allows for limitations on this for the purpose of public health and it is not for trade protection reasons.

Page | 17 He noted specifically that a lot of the cheapest products sold in Scotland actually come from Scotland and the rest of the UK themselves, so minimum pricing is not being pursued for trade protection reasons. It does not discriminate in relation to origin or class of alcohol and it will be effective, in saving lives and reducing alcohol harm. The Scottish government representative was confident enough to say that if the law is not effective, it would be removed after only five years – he was simply requesting the opportunity. Mr Henderson noted that this is not the answer for alcohol harm everywhere, but he noted that it is the answer to a lot of alcohol harm in Scotland, and he hopes that the courts will agree.

Anna Puchacz Koziol, from PARPA in Poland, noted that the legal act of the Act on Upbringing in Sobriety and Counteracting Alcoholism in Poland accounted for the introduction of measures to tackle alcohol use, which minimum unit pricing could fit within. Data from Canada showed that after the minimum prices was implemented, the consumption dropped by 8.4%. Other research from British Columbia found a 10% increase in minimum prices reduces consumption of spirits by 6.8%, wine by 8.9%, cider by 13.9%, beer by 1.5% and all alcoholic drinks by 3.4%. As a result, she felt that “minimum unit pricing is a well-oriented and effective strategy” to deal with alcohol related harm.

Ms Puchacz Koziol described the development of consumption and harm in Poland. She noted that the price of alcohol had not risen at the same rate of other commodities since 2000 in Poland and that the economic availability of alcohol had increased steadily since 2001. For several years, more than half of the total alcohol consumption in Poland has been beer, one third is spirits and the rest wine. In 2009, Poland increased the excise duty for alcohol and saw an immediate drop in consumption, but in general it is still rising.

Heather Jones (European Commission), a seconded national expert to DG TAXUD, noted the two tax directives which were applicable to the issue of alcohol minimum pricing. The first is the Directive 92/83/EEC and the second is the Directive 92/84/EEC and that changes to these two directives is very difficult because they require unanimity and a request in 2006 was unsuccessful. However, there was some support for classification of intermediate products, own consumption and the area of exemptions.

DG TAXUD has a new regulation published in July 2013 which launched a Euro CDA formulation (Commission Regulation 162/2013). Two recommendations have just been adopted which bans the use of methanol in the use of cosmetics, perfumes and personal hygiene sector and the use of chemical markers in these products – both of which have been adopted under soft law – which was a quicker, more efficient vehicle for change. Ms Jones explained that DG TAXUD is looking into denatured alcohol and has analysed some of these products, which found that spirits were being sold with fruit flavouring at a very low price – for as little as 72p per bottle. These can then be turned into counterfeit products which have methanol in them. Surrogate alcohol is now thought to represent 30% of global unrecorded alcohol and denatured alcohol is included in the COM Anti- Fraud Action plan.

Page | 18 JOINT ACTION ON REDUCING ALCOHOL-RELATED HARM (RARHA)

Bernt Bull, from the Norwegian Ministry of Health and Care Services, introduced the Joint Action on Reducing Alcohol Related Harm (RARHA). He explained that it was an invention in the European Union, with the idea of having a closer relationship between research efforts and national governments, in order to provide a shorter route to implementation. He explained that this exists in many health fields and is based on the idea of Member States taking a special responsibility. Portugal is leading this project, and Manuel Cardoso is leading this project.

Manuel Ribeiro Cardoso, the Deputy General Director of SICAD and Executive Coordinator of RARHA, introduced the Joint Action initiative which was established with Member States, and is supported by NGOs such as Eurocare.

He outlined the expected outcomes from the programme including, for example, good practice tool- kits, which would comprise of transferable interventions which are based on substantial evidence. Of course, such programmes have got a dissemination strategy together with organisations such as Eurocare, as well as website and newsletters to which people can subscribe.

Page | 19 Iva Pejnović Franelić, from the Croatian National Institute of Public Health and member of the CNAPA, noted that Croatians drink slightly more than the EU average and says that there is reason to be concerned about the drinking patterns in Croatia. She noted that noted that Croatia has joined the Joint Action programme along with some collaborating partners, in relation to Working Packages 4 (Monitoring) and 5 (Guidelines).

As part of Work Package 4, Croatia sees a big opportunity because a comprehensive population survey specifically on alcohol has never been done before in Croatia. It also provides the chance to bring together already existing data from other population surveys on drugs, and to bring them together into a common European data set. Work Package 5 is very interesting, and also very challenging. She noted that this harmonisation could help on national, as well as EU level, in order to translate research into effective public health messages. She noted that Croatia sees a big opportunity in taking part in this project to bring data together into a common dataset and talked about the challenges of not having standardised drinking guidelines.

Most important about being a partner in this Joint Action, is that it has opened new doors and opportunities to talk about alcohol issues on a national level. Highly motivated – see a good response and need for this kind of work. Hope that this joint action and can bring together more closely, research, policy and practice.

Sandra Radoš Krnel, from the National Institute of Public Health in Slovenia and head of Work Package 5, noted that the Joint Action is different to other initiatives in the European Union because it comes from Member States. They seek support from the Commission, and Slovenia is very happy about this Joint Action and having it.

Data collection is an important component of RARHA, an important tool for further policy developments. This gives not just benchmarking, but will also be easy to see the results of the particular policies. Slovenia is most involved in is Work Package 6 – Good practice tool kit. We want to share knowledge and use what has been done in other countries. We also like to share our own best practices. Learn better about how to evaluate good practices.

Slovenia is the leader of the Work Package 5, which will collect and disseminate a tool kit for best practice from different Member States.

Marjatta Montonen¸ THL Finland, started by noting that this Joint Action is more than just another EU-funded project, because it is a Joint Action under the Ministries of Health. Although the challenge of alcohol-related harm is common to all of our countries, our alcohol policy frameworks and particular cause for concern are different – therefore there is not a one size fits all. Work on the knowledge base is something is an area where we all have something to gain.

The work package that Finland is coordinating with Italy (WP 5) brings together researchers and decision-makers in work on drinking guidelines.

Page | 20 Monika Rueegg, from the Federal Office of Public Health in Switzerland and is a collaborating partner to the RARHA, mainly active on work package 5 (guidelines). Switzerland is trying to revise its guidelines.

The benefit of the common project is that we can have a common exchange of experiences. Switzerland has a national programme on alcohol policy, and decisions of good-practice, how to design and how to communicate.

WORKSHOPS DAY TWO

SOCIAL MARKETING: INFORMATION CAMPAIGNS

Anna Raninen, from the Swedish Council for Information on Alcohol and Other Drugs (CAN) introduced the concept of the social marketing, and explained how these differed from information campaigns. Rather than just raising awareness, social marketing is predominantly focused on behavior change. It is important to be aware of this distinction when discussing health campaigns via social marketing.

Triin Vihalemm, from Tartu University in Estonia, discussed the potential of information campaigns. She gave a comprehensive overview of the theory underpinning such campaigns and also talked about public support for policy measures. She went on to give concrete examples of this from various Estonian campaigns.

Marta Zin-Zedek, from PARPA in Poland, discussed campaigns that had been taken in Poland, specifically on drink driving. One of these which showed to be effective was called “Stop Drunk Driver”, and was targeted at people who observe people attempting to drive after drinking, and encouraging them to intervene.

A presentation was shown by Marko Vuorensola, from a campaign previously launched by the Finnish organisation Fragile Childhood, and specifically two videos titled “Monsters” and “Orphanage”. The intention of this campaign was the raise awareness to parents about how children

Page | 21 see their drinking. This campaign was very successful in reaching many people through social media networks such as Facebook, and making it into the mainstream news media.

ADVOCACY: LESSONS LEARNED

Katherine Brown, Eurocare Board Member and Director at Institute for Alcohol Studies, UK and Eurocare Board Member, opened the session by introducing the topic and the speakers. The workshop will showcase best practice in the field of alcohol advocacy.

Maja Stojanovska, from Active, discussed a project on advocacy titled “Democracy Dialogue” targeted at young people. She argued that it is important to include young people when talking about alcohol related harm, and her organisation is looking to recruit more young people interested in alcohol policy. Young people have been part of initiatives to see how easy it is to get alcohol when you are underage, but can also be part of non-youth policy.

Anne Babb, Secretary General from International Federation of the Blue Cross (IFBC), explained how that since 2009 the IFBC has been active in alcohol policy. In Africa they produced two manuals on reducing alcohol related harm and 43 countries received training. European member organisations are taking joint actions. Published different reports and summaries, what members have been done in these countries together with EUCAM.

Page | 22 Ms Babb focused on the impact of the work, for example attitudes towards alcohol advertisement has changed; increased community safety; different stakeholders are working more closely together; increased visibility in media; networking with global networks; specific results for various countries; draft policies are being developed. Another important point is the shift from health education to advocacy as a result of the work.

Wilfried Kamphausen, advisor to Eurocare, discussed “Alcohol and tobacco – legislative opportunities”. He explained how the EU public health mandate dates back to the Maastricht Treaty in 1992 but that there is no way to regulate public health measures in the EU. There is a lot of difference between laws in Member States: Cross border nature in this field are for example advertisement and sponsorship. The differences in policies at Member State level are likely to impede movement.

Mr Kamphausen explained the process on the ban of tobacco advertisement. The first Commission proposal was in the late 1980s, and then after a decade of discussion, was adopted in 1998 against opposition from Germany. After challenges, a new proposal was drafted in 2001 and adopted in 2003, banning all cross-country advertisement. Labelling on tobacco products followed later.

He then questioned why can we not transfer tobacco legislation to alcohol? It has a high addictive potential, a high risk for the user, a higher risk to third persons for alcohol, cost to economy and society is higher for alcohol, it has a stronger appeal to young people, and the social acceptance is higher for alcohol. Mr Kamphausen continued by stating that the risk of alcohol use is highly underestimated, but there is also the political issue. There are powerful lobbies against change and many Member States are producers in the alcohol industry, which was not the case for tobacco.

Mr Kamphausen highlighted that a tobacco ban was difficult at the time, and said it would be hard to answer whether it would pass now. There should be an alcohol advertising ban or strong regulation of certain aspects. The main message was to keep the pressure on.

Page | 23 EUROPEAN PROJECTS: FROM RESEARCH TO ACTION

Vesna Kerstin Petrič (Ministry of Health, Slovenia), opened the workshop by focusing on the need for research to be translated into action.

Lidia Segura (Program on Substance Abuse, Catalonia) thanked the organisers for a good cooperation, both for the conference but also for the EWA project, which she will be presenting. Ms Segura also noted that looking at the developments from research to action is important, but also possible to turn it around and see how there is lack of research. The EWA project had 25 partners from 13 countries working together over 13 months. The main aim was to raise awareness and bring organisational and individual change on the topic of alcohol policies and practices at workplace. An important component of the project was to focus on the benefits of undertaking workplace alcohol intervention, such as healthier employees and improved safety. Evaluation shows how both employers and employees were positive to the interventions introduced. A toolkit and policy recommendations were produced as deliverables from the project.

Dasa Kokole and Jan Peloza (Alcohol Policy Youth Network) started by briefly presenting the Alcohol Policy Youth Network, formally established in 2011. The Let it hAPYN project is running from 2013-2016, and is aiming for an empowerment in the youth sector with a better overview of evidence-based alcohol intervention programmes. Activities involved have been a mapping of youth organisations and their activities and interventions regarding alcohol prevention. Raising awareness, peer education and information are the main topics, together with mystery shopping. The project will now develop a toolkit for evidence based interventions, and the challenge is then how do we reach out to young people with this information.

Jennifer Curran (Alcohol Focus Scotland) presented their findings from a study they conducted in Scotland on Harm to Others. Key finding one is that 51% report one or more harms as a result of someone else’s drinking. Furthermore, key finding two shows that 37% report heavy drinkers in their lives, found in the household but also in the wider community. From the interviews conducted in the study, key themes reported was that harm to others is not well recognised and under-reported, cheap alcohol was seen as a contributing factor and there is an impact on both children, family and the wider community (e.g. workplace). On the basis of this research, Alcohol Focus Scotland made their recommendations: effective policy to reduce overall levels of harm (price, availability and marketing), better data collection and monitoring, local action plans, identification and support for people affected and last, recognition of impact of alcohol harm to others in the workplace. Alcohol Focus Scotland is now implementing pilots in two different areas in Scotland on the basis of the research and the recommendations.

Page | 24 ALCOHOL ADVERTISEMENT AND SPONSORSHIP

Kristina Hannula (EHYT Finland and Eurocare Board Member) spoke of the further restrictions on alcohol marketing which will be introduced in Finland from 1st January 2015. The new regulation will include no more alcohol advertising in public places indoor or outdoor, time restriction for TV extended and all advertising and further restrictions on gaming apps, digital games, video games, competitions, as well as no competitions and prizes in real life in social media.

Robert Madelin, Director-General for DG CONNECT and previous Director-General for DG SANCO, explained how everybody in the Brussels is anxious because it is a period of change. The treaty remains unchanged, and while the new Commissioner has lost some responsibilities, there is a window of opportunity for policy groups to regroup and think about priorities about the next five years. There will be a review of the audio-visual directive and in the context of the single market, we could be talking about responsible hosting of material online, so the idea that people who host parts of the interest should be responsible is an issue that is bubbling under. He also noted that there has been co-operation across the Commission about measuring the exposure of children to alcohol products and this will be produced by summer, which will be in time to influence the audio-media directive.

Page | 25 Lauri Beekmann, Eurocare Vice-President, executive director of the Estonian Temperance Union (AVE) and Secretary General of NordAN (Nordic Alcohol and Drug Policy Network) discussed the use of alcohol sponsorship in sport. In particular, he focused on the example of cross-country skiing and Formula One.

Mr Beekmann showed an advert of cross-country skiing in Estonia, which the alcohol industry has heavily invested in for sponsorship. Through this video he explained how sponsorship of certain sporting events could be a “Trojan horse” that surpassed different legal frameworks.

He explained the problem of this kind of message which dodges national laws on advertising: It feature on the public broadcasting channel, where normally such advertisement would not be allowed; it can be shown throughout the day, when normally alcohol advertisement may not occur before 9pm; it featured two national celebrities, one of whom was a two-time Olympic gold medallist and two-time world champion, when the law states that such promotion is illegal for alcohol advertising; and it had not accompanying health message, which is normally compulsory in every alcohol advertisement.

Mr Beekmann then moved on to talk about the case of Formula One. He introduced Eurocare’s open letter to Jean Todt (FIA), and showed a screenshot of a recent race which featured a lot of alcohol sponsorship across the screen. This is projected into millions and millions of homes. He then discussed if it was possible to end this form of sponsorship. He took the example of the France, and the Loi Evin – sports in France are still alive, and even in cross-country skiing.

He further discussed an initiative in Australia, where twelve leading sporting organisations have agreed to end all existing and future alcohol sponsorship agreements. In exchange, the groups will share $25 million in replacement government funding taken from new Alcopops revenues. In Ireland, the Department of Health has recently recommended that a ban on alcohol sponsorship of big sporting events should be in force by 2020.

Robert Madelin responded that this is a very strong demonstration of the problem of regulatory intervention, and the abuse of legal distinctions that allow some to circumvent the intent of society. Legislation does not always lead to the consequences that you hope for. He noted that when it comes to reviewing the audio-visual media services and advertising regulations, this is what we need to be looking at.

Gerard Hastings, Professor of Social Marketing at Stirling and the Open University and Professeur Associé, at the L’École des Hautes Etudes en Santé Publique (Rennes) opened his presentation with story designed to highlight the obvious. With respect to alcohol marketing, the problem is one of power.

He argues that there is a power imbalance when some companies spend millions of pounds on their marketing, upsetting the mutually beneficial exchange of marketing. He referred to several eminent from across Europe (such as the ECJ, UK Government Review, the Science Committee of the EU

Page | 26 Commission Alcohol Forum, and Alcohol and Alcoholism) demonstrating the problem posed by alcohol marketing.

Mr Hastings highlighted the prevalence of alcohol industry in marketing through sponsorship, digital marketing, and stakeholder marketing. He argued that tobacco control has shown what does and does not work. What does not work is content regulation, partial restrictions of specific media and voluntary measures. What does work is radical, independent and statutory action. To conclude, Mr Hastings urged people in the public health community to heed the evidence base and take radical action where it is needed.

Amandine Garde, Professor of Law at the University of Liverpool, posed the question about whether the EU could act on alcohol regulation. For her, the answer was yes. The next question is should it do so, or should it leave it to member states? When there is clear trade across borders, Ms Garde did not understand how subsidiarity could be an obstacle to EU intervention. The third question, then, is how should the EU act? She argued that where proportionality is a key principle, so a measure must be necessary and it must not exceed what is necessary and it should be read in light of EU mainstreaming obligations, so they cannot only look at the economic effects.

So what has the EU done so far and is it a proportionate response to what we are facing? She noted Article 9 (1) (e) of Directive 2010/13 on the audio visual services (AVMSD) as well as other legal provisions. Ms Garde continued by asking why we need yet more evidence when we have so much already. The Commission knows it needs to do something but it seems as if they are delaying the time when they will need to face some very difficult decisions.

She then discussed minimum harmonisation as an opportunity for Member States but noted that the freedom of Member States is limited by the “State of Establishment” principle, referring to a CJEU judgement where it had been demonstrated.

Ms Garde ended by arguing that we need to shift the paradigm of fundamental rights so that fundamental rights should be used not only as a shield to oppose industry challenges, but also as a sword to regulate food industry operators.

Irma Kilim, from IOGT-NTO, discussed the Swedish case of alcohol advertising on TV. She highlighted the cross-border issues surrounding alcohol advertising by referring to broadcasted programmes in other countries being transmitted to Sweden, circumventing national restrictions on alcohol advertising. As a response to this, IOGT-NTO filed a complaint to the Swedish government. She presented that still today, while waiting for the government to take actions, advertisements for alcohol can be found on Swedish television.

Page | 27 ROAD SAFETY

David Ward, Executive Secretary of the independent Commission for Global Road Safety, noted how there had been a global rise in road traffic injuries, with low and middle income countries accounting for 90% of global road deaths.

He referred to the UN Decade of Action from 2011-2020 which he explained was underpinned by “safe systems”, as the previous system of simply educating people was not effective, so the focus is now on a wider approach to how people use the whole transport system. In this stream, he referred to safer vehicles, safer roads and safer drivers. What they hope is that by the end of the decade is that there will be no vehicles which cannot meet the minimum UN safety standards.

He expressed concern at the creation of a private sector initiative working on road safety called “Together for Safer Roads”, being led by AB InBev. While he welcomed private sector involvement in this field, he was concerned about the creation of an alternative body and did not want to see the priorities of the UN Decade being diluted.

He also challenged the alcohol industry for a more credible commitment in the field of road safety, which currently only amounts to “chicken feed”. They should follow the approach of major philanthropists and respecting a truly independent council on road safety. This would also involve a scale of investment that is even a little bit commensurate to the kinds of challenges that they cause through the harmful effects of their product.

Page | 28 THE WAY FORWARD

Dzintars Mozgis, acting director of The Center for Disease Prevention and Control in Latvia represented the upcoming Latvian Presidency at the last session of the conference. Mr Mozgis started by stating that that alcohol policy must be based on evidence. Furthermore, we must work to acquire to necessary knowledge to provide guidance for policy in the future.

Mr Mozgis noted that he would specifically like to see more action on advertising and marketing, and the potential hazardous role that these can play with respect to alcohol. As a result, it has been agreed that marketing will be discussed at the Informal Meeting for Health Ministers in Riga next year which will provide a good opportunity for ministers to share their views and a chance to bring alcohol policy issues to a high level.

He finished by wishing everyone good success in reducing alcohol related harm and hoped that delegates would visit Riga during the Latvian EU Presidency.

Tiziana Codenotti closed the conference by requesting that organisations would join the “Call For A Comprehensive EU Alcohol Strategy”, coordinated by Eurocare. The call will be open until the end of December 2014.

Ms Codenotti thanked everyone who had helped to organise the conference, including all of the sponsoring organisations and the individuals for their dedication in organising the event. In addition, all the supporters during the days were thanked as well as the photographers and the students from Brussels Art School who had been helping to capture the event.

She ended by noted that she felt it had been an exciting conference and she hoped to see everyone in Slovenia for the next European Alcohol Policy Conference in 2016.

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