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 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

Imperialism and colonization

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/workers 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 oclock 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 womens movement: women mens 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: 1932:

1975:
2000:

5.8 litres alcohol per capita (NSW & Vic.) <2.5 9.5 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, recorded & unrecorded, 2005

Total consumption in litres pure alcohol 2005

0-3 3-6 6-9 9 - 12 12 - 15 15 - 21

Darker = higher Highest in Russia & Europe, high in Latin America, growing in middle-income countries

More and less hazardous patterns of drinking

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

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 Alcohols 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)

Geneva 3 2.5 2 1.5 1 0.5 0
1975- 1983- 1990- 1998- 2000- 2003- c. 1982 1989 1998 2000 2002 2004 2005

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 prevention paradox: only a minority of the problems are caused by the heaviest-drinking tail of the distribution

The new public health response, 1970s+:

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:

Drinkers gender: male Drinkers average age:

71% 40 years

Age about 29 for those aged 18-29

Average number of standard drinks when drinking heavily Average number of days in a week that the drinker consumes 5+ standard drinks

13 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

(Disability-Adjusted Life-Years)

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

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 Licensing decisions about on- and off-licenses Community planning to minimize alcohol-related harms Supporting preventive legislation Encouraging enforcement or laws and regulations; supporting funding for it Pushing for exclusion of alcohol from free trade agreements Supporting a strong leading role for WHO in reducing alcohol problems

at community levels:

at regional and national levels:

at the international level: