What lessons can be learned from alcohol control for combating the growing prevalence of obesity?
Professor I Gilmore, Royal College of Physicians, 11 St. Andrews Place, Regent’s Park, London NW1 4LE, UK. E-mail: email@example.com
Alcohol is an accepted part of our society. Like food, it is associated with pleasure, relaxation and celebration. Although for a proportion of the population, consumption carries some health benefits in reducing the risk of coronary heart disease, there is increasing evidence of harm from alcohol misuse.
The consumption of alcohol has risen by 50% since 1970 and is a major determinant of ill health in the UK. A recent Academy of Medical Sciences report (1) on which this review is based concludes that there are strong links, underpinned by substantial evidence, between per capita alcohol consumption and the burden of alcohol-related harm.
There are many similarities between the cross-departmental public health measures required to reduce alcohol-related problems and those required to tackle obesities, but also some important differences, the principal one being that, in common with smoking, alcohol is not essential to life, while food is.
The extent of the problem
Per capita consumption of alcohol in Britain has increased by 50% since 1970. Although wine, beer and spirits have all contributed to the trend, consumption of wine shows the strongest growth. Consumption figures are likely to be an underestimate as they take no account of unrecorded consumption such as cross-border imports (including the more recent phenomenon of ‘booze cruises’), smuggling and home production, which may together add a further (20% to the official UK reported consumption (2).
Alcohol-related costs of crime and disorder are put at £7.3 billion, and some 47% of victims of violence say that their assailant was under the influence of alcohol at the time of their attack. Health costs are estimated at an additional £1.7 billion a year. By contrast, the current cost of obesity to the National Health Service stands at £1 billion (3), with costs to the UK economy predicted to rise to £3.6 billion by 2010.
Some 2.9 million of the population are estimated to be alcohol-dependent, and acute or chronic alcohol use is responsible for up to 150 000 hospital admissions a year. One-third of all casualty attendances may have alcohol causally implicated and, although the number of alcohol-related road fatalities is in decline, the total number of casualties from alcohol-related road traffic accidents rose by a fifth between 1993 and 2001 (2).
Alcohol is responsible for about 70% of deaths from cirrhosis of the liver. In the 30 years from 1970 to 2000, deaths from chronic liver disease, a prime indicator of chronic alcohol-related health, harm has escalated over 450% across the population. Not only is the death rate rising but it is also peaking at a younger age.
Thus, the cost of alcohol misuse is enormous, with the adverse consequences of misuse very broadly experienced across a wide number of areas besides health. While alcohol can confer some health benefits – for instance, in men over 40 years and post-menopausal women, moderate consumption leads to decreased risk of myocardial infarction and ischaemic stroke – overall, alcohol is still responsible for many more years lost than gained.
There is compelling evidence from many different populations that as per capita consumption of alcohol rises, so does the level of alcohol-related harm.
Access to drink
The consumption data would indicate that there has been increased access to drink and this is true across all three major elements related to access: its real price, its ease of physical availability and the social acceptability of drinking.
Alcohol has become substantially more affordable, with a decrease in price relative to income. This decrease is matched by an increase in consumption. There is a large literature confirming that price influences consumption (4).
In 1953, there were approximately 61 000 on-licensed premises. According to the report of the Prime Minister’s Strategy Unit (2), that figure now stands at 78 500. Premizes with an off-license have increased from 24 000 in 1953 to more than 40 000 today. There is also a wider range of premises selling alcohol following the Licensing Act of 1961, which made alcohol available in supermarkets. Coupled with this is less strict regulation of hours and days of sale, meaning that it is possible to purchase alcohol at almost any hour on any day.
Coupled with the above developments is increased social access, which is heavily influenced by advertising and branding campaigns. Concerning the effect on children, a recent World Health Organization review (5) concluded that: ‘The promotion of alcohol is an enormously well funded, ingenious and pervasive aspect of modern life . . . Exposure to repeated high-level alcohol promotion initiates pro-drinking attitudes and increases the likelihood of heavier drinking’. UK expenditure on alcohol advertising rose from £150 million to £250 million annually in the period 1989–2000. The parallels with the advertising and promotion of energy-dense foods are striking.
There are a number of ways that alcohol misuse damages both society and the individual and these need to be understood in terms of the three main mechanisms in which it does so: toxicity, dependence and intoxication (5). Heavy drinking over a long period of time results in toxicity to many organs and to problems in the family and workplace. Over time, heavy drinking may cause alcohol dependence, which means that the drinking is maintained despite the evident harms. Intoxication relates to the amount and mode of drinking on a specific occasion. While this can occur in both heavy and dependent drinkers, it also occurs widely in the population, and among younger drinkers in particular. Intoxicated teenagers and young adults are a substantial preventable burden on accident and emergency departments and a major cause of social unrest in town and city centres.
Strategies to reduce alcohol-related problems are divided into those that target high-risk drinkers and the more general population. In fact, the distinction is not always as clear cut. For instance, increasing price affects all drinkers, but the heaviest drinkers will feel the effects most.
Preventing chronic health problems means ensuring a reduction in consumption, but this may be complicated by dependence. Preventing harms from intoxication presents more opportunities for intervention, from measures to control the time and pace of drinking, providing shatterproof glasses and extending the hours of public transport.
Effectiveness of different strategies of prevention
The effectiveness of various alcohol prevention strategies are the subject of an extensive literature (5).
Little or no effectiveness
Educational and public information approaches have little effect. This may be because they tend to operate within political restraints and have tended to be short-term, and are, by comparison to advertising provided by the alcohol industry, much less intense. Education tends to be schools-based and is unlikely to succeed if adults are not also engaged.
Mobilizing public support for prevention approaches – for example, limiting the availability of alcohol, drink–driving countermeasures, and so on – rather than seeking to change individual behaviour can be more effective.
Advertising controls can be moderately effective (6). Hard-hitting counter-advertising can also be effective, as it is for smoking. Overall, advertising increases consumption (7). Exposure to alcohol advertising, especially among young people, increases positive beliefs about drinking, reduces perception of risk and shapes other perceptions, including acceptable levels of alcohol intake.
Limiting availability through taxes and other influences on price
Tax increases have been shown to impact on rates of cirrhosis mortality, drink–driving deaths and violent crime (8). A 2003 HM Customs and Excise study (9) calculated the influence of price on consumption. For example, a 1% increase in price would lead to a 0.48% decrease in beer consumption. On the basis of these estimates, a 10% rise in the price of alcoholic beverages should produce a drop of 7% in male and 8.3% in female cirrhosis mortality and a drop of 28.8% in male and 37.4% in female deaths from explicitly alcohol-involved causes (alcohol dependence, poisoning, etc.).
Low alcohol taxes in other European Union member states and the very generous traveller’s cross-border allowance has caused a substantial increase in consumption that is not included in official statistics. The growth of alcohol-related mortality in the period 1993–1997 implies a rise in unrecorded consumption by almost half in the UK in that period (10). The current ‘personal supply’ rules expressed in terms of the recommended UK weekly limit (21 units for men, 14 for women) amount to a 2-year supply for a male drinking at sensible levels and a 3-year supply for a woman. Here, if the UK and other relatively high-tax jurisdictions were to push for an increase in minimum European tax levels on alcoholic beverages, substantial reductions in consumption might be made.
Minimum purchase age laws
Reducing purchase age is among the best-supported findings in alcohol policy research, much of which comes from the United States, where there is a relatively high minimum age of 21 years. Establishing a uniform minimum purchase age of 21 years in the UK would be expected to have a beneficial public health effect.
Alcohol-specific sales outlets
There is clear evidence on the effects of changing the number and type of off-licenses to include grocery retailers. For instance, there was a 16% increase in wine consumption in New Zealand when grocery stores and supermarkets were added as sales outlets for wine. Restricting off-premises alcohol sales to alcohol-specific outlets would provide better control of alcohol sales and be especially effective at reducing supply for under-age buyers.
Enforcing legislation with regard to licensing and sales offences is currently low on the list of police priorities, but international experience strongly suggests that regulation and surveillance greatly increase the compliance with regulations. In the Netherlands, a dedicated alcohol control service was set up with about 70 inspectors, and this has had a significant effect on reducing the rate of violent crimes between 10 pm and 6 am (11).
Limiting hours and days of sale
There is strong evidence in the research literature that increasing opening hours in the late evening is associated with increased overall consumption (5).
In most of Europe, the maximum blood-alcohol level (BAL) is 0.05%. Sweden, however, has a BAL of 0.02% and offers a clear message: if you have had anything to drink, you should not drive. Evaluation of the effects of moving from a BAL of 0.05% to 0.02% in Sweden showed that, in combination with other measures, it had a significant effect on drink–driving fatalities (12).
Random breath-testing that is implemented with a substantial and sustained level of effort, such that each driver is stopped at least once every 2 years, would have a lasting effect.
Regulation in drinking environments
Recent years have seen the transformation of the night-time economy of British city centres. One feature is the way small pubs have been replaced by much larger premises that are often part of a branded chain. In Manchester city centre, for example, the capacity of licensed premises increased by 240% between 1998 and 2001, while the number of assaults reported to the police increased by 225% between 1997 and 2001 (13).
Measures to combat the problem of drunkenness in city centres has tended towards banning orders on individual drinkers. Another approach has been a call for more diversified leisure provision. Neither is a particularly successful strategy and regulatory controls follow rather than precede failures in planning.
Server training, regulation and liability
International literature shows that server training and refusing service to those already intoxicated is effective in reducing drink–driving casualties (5). Making servers and their establishments liable for damage caused by those they serve has also proved effective.
Drinking is regarded as normal and enjoyable. As with smoking, alcohol is addictive, so heavy drinkers may become dependent drinkers, undermining their intentions not to drink. Although it is clear that the public understands that smoking kills, the link between excess alcohol and subsequent mortality and morbidity is less apparent. At best, those seen to have a serious ‘drink problem’ are seen to be at risk of health problems. A point of commonality with smoking, obesity and alcohol is that there is a significant timelag between cause and effect.
In the absence of effective measures, consumption will continue to rise over the next 5 years. Cirrhosis rates tend to lag 5–10 years behind consumption rises but can be anticipated to be even more substantial by 2040.
The Academy of Medical Sciences report (1) concluded that the two key mechanisms likely to lead to a reduction in alcohol consumption are price and availability. How does this translate into policies for obesity?
Increasing the price of a popular item like energy-dense foods is likely to be politically very unattractive, particularly while the nation does not yet appreciate the level of harm resulting from obesity. Only when alcohol-related disorder – such as levels of violence in city centres – becomes great enough for the public to demand action, might there be a call for political action that will empower Government to act more decisively on the price of alcohol. It is difficult to see a similar tipping point for obesity, where the public appreciates no immediate harms and where the availability of energy-dense foods would be an issue. For the poorest in society, such foods are a major component of their diet and a price rise might serve to increase, rather than decrease, inequalities. As with alcohol, we know that misuse affects the disadvantaged in society most. And, like alcohol, tackling availability of unhealthy foods would be not only fraught with political difficulties but also resisted by manufacturers and retailers alike.
Meanwhile, it is likely that fragmented attempts at education within schools will be made, despite the evidence of lack of effectiveness. Restricting advertising of unhealthy foods would, from the example of alcohol, have only moderate effects.
Conflict of Interest Statement
No conflict of interest was declared.