Alcohol as an issue for public health

Robin Room

School of Population Health, University of Melbourne;

Centre for Alcohol Policy Research, Turning Point Alcohol &

Drug Centre, Fitzroy, Victoria

robinr@turningpoint.org.au

Master class, Alcohol Forum National Conference, Dublin, Ireland, 2 April,

2014

The cultural position of alcohol

Alcoholic beverages are intertwined with recorded

history in most parts of the world

Though not Oceania, Australia, northern America until

European colonisation

In Ireland, as in many other societies, there have

been deep political and social conflicts and

divisions over alcohol

The position of alcohol in the culture and in history

needs to be taken into account in public health

planning and programming.

The history: there have been enormous changes within cultures

in European societies and their offshoots

Before 1600: a rough equilibrium of cottage production

from crop surpluses

• Industrialization of beer and then of spirits as early stages

in the industrial revolution

– Large-scale production relatively easy

– Psychoactivity: alcohol creates its own demand

– Profitable a means of capital accumulation

• Imperialism and colonization

– Introducing alcohol or new beverages

– Spirits as a trade good, as an exchange for labour, as a “glue of empire”

– Alcohol excise taxes as financing empires

The “gin epidemic” and its equivalents

• Britain in the 1700s:

– Industrial production of spirits falling price

– Rising standard of living

– Landowners who controlled government saw gin as a market for their grain, kept availability high

• Similar periods of very high consumption in other European countries and colonies at different times in the 1700s and 1800s

• Higher consumption than in those societies in modern times

The temperance movements

In UK and its settler societies, in Ireland, in northern

Europe, to some extent in central Europe

Second largest and longest-lasting social movements

(after the labour/worker’s movements)

Bottom-up movements, 1830s – 1930s

With a strong base among working-class men

The seedbed for the feminist movements of the late 1800s

Produced real change in consumption levels, the place of

alcohol in society

Alcohol consumption in the UK, 1684-1975: twice as high in the 1700s as anytime in the 1900s (Spring & Buss, Nature 270:567-572, 1977)

Alcohol consumption in the US 1830s-1970s (indirect measures during Prohibition)

(Moore & Gerstein, eds., Alcohol & Public Policy, National Academy Press, 1981)

Australia as a “temperance culture” (i.e., a strong temperance history)

– e.g., 6 o’clock closing, Sunday closing

-- then a long reaction against the “wowser”, and a

steep postwar rise in consumption

• Public drinking becomes respectable for women – The second women’s movement: women men’s haunts and habits

• Southern/Central European migrations: the advent of table

wine

• General trends: commercialisation of leisure, deregulation,

market fundamentalism, consumer sovereignty

• Counter-influence: the attack on drink driving

Consumption and availability:

U-shapes through the 20th century

Consumption levels:

1880s/90s: 5.8 litres alcohol per capita (NSW & Vic.)

1932: <2.5

1975: 9.5

2000: 7.8

Liquor licenses

In Victoria

A few words on drinking in Ireland

Irish consumption limited by poverty, temperance

movements, licensing restrictions

Meanwhile, Irish overseas (e.g. U.S., Australia) had

among the highest alcohol problem rates in comparisons

of ethnicities

Why were problem rates so high overseas but

relatively low in Ireland?

Various theories -- e.g., Richard Stivers, A Hair of the Dog:

Irish Drinking and American Stereotype, 1976)

But then came the Celtic Tiger and the deregulation of

alcohol licensing & controls ...

As Irish consumption levels rose,

cirrhosis mortality followed along

Alcohol across the globe

Drinking at all, vs. abstention

Level of drinking

Hazardous drinking

essentially, the proportion of drinking that is to

intoxication

Alcohol as a risk factor in the Global Burden of

Disease

total Disability-Adjusted Life-Years lost

Where Ireland stands, globally

Over half the adults in the world do not drink at all;

about 80% of Irish adults do

Medium high on per capita consumption

Upper-middle rank on how hazardous the

consumption is (what proportion of drinking is to

intoxication)

Highest consumption is in and around Russia

Highest hazard scores there and in much of

developing world

Rates of abstention, 2006

Prevalence of abstention

in World 2005 0.00 - 0.20

0.20 - 0.40

0.40 - 0.60

0.60 - 0.80

0.80 - 1.00

Lighter and greener = more abstainers

Globally, there are more abstainers than drinkers among adults

Per-drinker consumption varies much less than abstainer rates

Total consumption in litres

pure alcohol 2005 0 - 3

3 - 6

6 - 9

9 - 12

12 - 15

15 - 21

Total consumption, recorded &

unrecorded, 2005

Darker = higher

Highest in Russia & Europe, high in Latin

America, growing in middle-income countries

1: Least hazardous; Regular drinking, often with meals and without heavy drinking bouts

4: Most hazardous: Infrequent but heavy drinking

Least hazardous in southern Europe, Japan; more hazardous in Russia and much of developing world

More and less hazardous patterns of

drinking

Alcohol as a risk factor for the total global

burden of disease, 2010 (Lin et al., 2012)

The politics of alcohol, globally and locally

Barriers to change

Commercial interests – the market

Free-market ideology – free competition and consumer

sovereignty

Alcohol’s cultural position

The history: temperance and then the reaction against

“wowsers”

Alcohol has come into focus late for modern

public health

The public health epidemiology paradigm – environment, host, agent – too close for comfort to temperance thinking

The strong reaction against temperance even in science e.g., epidemiologists’ denial in the 1940s/50s that alcohol causes

cirrhosis

Alcohol as “our drug” Part of everyday life or rhythm of week

Positive valuations: sociability, nutrition, “time out”

Politicians, civil servants, media quite “wet”

Protective effects for heart seen as balancing harms This is an error – net effects negative, even at individual level

No evidence of protective effect at population level

Importance of alcohol industries and retailing

Alcohol and international public health -- WHO

Geneva: 1950s – 2000 -- sporadic attention

Early 1950s Early expert committees; emphasis on alcoholism, the disease

Effort shut down by new MH chief

Mid-1970s to 1983 NIAAA support for specific studies till 1980

Nordic support for more policy-oriented program

WHA technical discussions and resolution on alcohol, 1982-83

Production & Trade study closed down by Director-General in 1983

1983-1990 – Noncontroversial small projects in MH division

1990-1998 -- separate Programme on Substance Abuse 1996: Back with MH (Division of MH & Prevention of Substance

Abuse)

2000 -- Programme abolished, resubordinated to MH

Alcohol and WHO -- 2001-2013: two more spurts of activity

2001-2002

Start on higher priority for alcohol policy

New start aborted for fear of compromising tobacco work

2003-2005

Alcohol as 4th leading risk factor in Global Burden

Nordic countries start push for new WHAssembly resolution

Language on alcohol in 2004 Health Promotion resolution

Alcohol resolution approved in WHAssembly in 2005

2006: First Expert Committee report on alcohol since 1979

2008: WHAssembly resolution for a Global Strategy on alcohol

2010: Global Strategy to Reduce the Harmful Use of Alcohol adopted

2011+: alcohol as a leading risk factor for NonCommunicable Diseases

(NCDs) – but faces the most pressure to weaken indicators and goals

2013: Resources are lacking to implement the Global Strategy

Nos. of WHO staff involved in alcohol issues

(full-time-equivalent; rough guesses)

0

0.5

1

1.5

2

2.5

3

1975-

1982

1983-

1989

1990-

1998

1998-

2000

2000-

2002

2003-

2004

c.

2005

Geneva Copenhagen Washington

Full-time

Equivalent

positions

today:

Less than 5

Why so little and late an emphasis for

alcohol? (e.g., compared to tobacco)

The effects are not confined to health

Brings in other professions and institutions;

Heavily moralised territory (e.g., violence against women, child abuse)

focus on individual responsibility and away from

environmental/population perspectives

The long shadow of the temperance era

Ambiguity arising from health-protective effects

Alcohol as a commercial product

Influence of alcohol industries (producers and retailers)

The dominance of free-market ideology --

Trade agreements internationally, in the EU

National policies – deregulation, increasing competition

What should public health emphasise as

priorities for action?

The answer in the 1950s & 1960s: alcoholism

Provide treatment for alcoholics, leave the rest of us “social

drinkers” alone

The “new public health” response, 1970s+:

The “prevention paradox”: only a minority of the problems

are caused by the heaviest-drinking tail of the distribution

approaches affecting the whole population of drinkers: availability,

taxes, limits on promotion

But this runs up against free-market ideology

The political solution 2000+: A new wave of

individualised responses: individual drinking bans

The political focus: youth and street

violence

Australia DALYs (rate per 1000) by age and sex

But harms to the drinker are as prevalent in

middle age:

And adverse effects on others from drinking

is not limited to young drinkers

Drinker that most adversely affected the respondent –

among household members, relatives, friends:

Drinker’s gender: male 71%

Drinker’s average age: 40 years

Age about 29 for those aged 18-29

Average number of standard drinks

when drinking heavily 13 drinks

Average number of days in a week that

the drinker consumes 5+ standard drinks 4 days

If there is any clear priority population, it is males

So in general, we are back to the whole working-age population

as the priority public health population

Prioritising policy strategies –

Strategies to reduce alcohol problems rates

differ in their effectiveness

• Babor et al., Alcohol – No Ordinary Commodity: Research and Public Policy, 2nd ed. (Oxford University Press, 2010)

Considering

– Evidence of effectiveness

– Breadth of support in the literature

– Extent of cross-cultural testing

– Costs to implement and sustain

Some strategies are ineffective

(though often popular)

• Voluntary industry codes, e.g. of bar practice

• Alcohol education in schools

• Warning labels

• Public service messages

• Promoting alternatives -- Alcohol-free activities

• Designated drivers and ride services

Others are effective: a list of 10 “best practices”, based on the

international evaluation literature

Alcohol control policies • Minimum legal purchase age

• Government monopoly of retail sales

• Restriction on hours or days of sale

• Outlet density restrictions

• Alcohol taxes

Drink-driving

countermeasures • Sobriety check points

• Lowered BAC limits

• Administrative license

suspension

• Graduated licensing for

novice drivers

Brief interventions for

hazardous drinkers

Cost-effectiveness of alcohol strategies in

preventing illness & death, Australia 2003

Coblac, Vos, Doran & Wallace, Addiction 104:1646-1655, 2009.

(Disability-Adjusted Life-Years)

Projected optimal sequence for combining alcohol

strategies (Coblac et al. 2009) (Disability-Adjusted Life-Years averted)

What is politically feasible is often ineffective,

what is effective is often politically difficult.

popular effective

education and persuasion +

deterrence ± +

alternatives +

insulating use from harm ± ±

availability & taxes +

treatment (as prevention) +

At our historical moment: pressure to do something, but politicians

strive not to disturb the market

But some signs of ferment: liquor licensing inquiries in 5 states &

ACT; NSW: drunken king-hits earlier closing

Building a concerted response,

based on evidence • Parallel tracks -- local, national, global

• Develop the evidence of the extent and nature of

particular alcohol-related problems

• Plan and implement policies/interventions to reduce

rates of problems

• Evaluate the effects of a policy change – Planned experiments – usually “quasi-experiments” with controls

– “Natural experiments” (= no research input on the design)

• Build provision (and funding) for evaluation into any

policy change

• Adjust policy/intervention in view of the evaluations

Example 1: reducing tobacco

deaths (the Australian experience)

– High taxes

– Advertising bans and controls

– Smoking bans: workplaces; restaurants and pubs, etc.

– Graphic warnings, media campaign

– Plain packaging

– Enforcement of age limits; regulations of sales outlets

– Nicotine replacement products

– Brief interventions by health professionals

– International Framework Convention on Tobacco Control

– 1892 cigarettes/capita in 1980; 942 in 2011

(Yet Australian efforts were critiqued by California program leaders: “a monumental paucity of funds and political will”, MJA 178:313-4, 2003.)

Example 2: driving down traffic

casualties in Victoria, Australia

• Compulsory seatbelts 1970

• Random breath-testing 1976

• Cameras for red lights 1983; speed 1986

• “Speed kills” campaign; bike helmets mandatory

1990

• Mobile radars 1996

• Lowered speed limit in residential areas; anti-speed

measures 2001-2002

• Deaths in 1970: 1061; in 2013: 242

Characterizing success

• Clear goals: reducing the harm to a minimum

– Consensus that the existing burden is unacceptable

• Professionals as advocates

• A long-term perspective– in terms of decades

• Cross-sector collaboration

– e.g. for transport safety: Transport Industry Safety Group: coroner, road & transport industry, community and regulatory bodies

• Initiatives in terms of what is possible at the time, cumulating over time

• Sometimes the unthinkable becomes possible

– e.g., a smoking ban in pubs

Joining the policy dialogue – roles for

professionals and researchers

• The limits of technocracy

• Experience-based policy advocacy

– Alcohol and drug counselors

– Emergency service & other doctors and nurses

– Mental health clinicians

– Police and community response staff

– Social workers, family counselors, clergy

• at community levels:

– Licensing decisions about on- and off-licenses

– Community planning to minimize alcohol-related harms

• at regional and national levels:

– Supporting preventive legislation

– Encouraging enforcement or laws and regulations; supporting funding for it

• at the international level:

– Pushing for exclusion of alcohol from free trade agreements

– Supporting a strong leading role for WHO in reducing alcohol problems