Reducing the harms of alcohol in the UKBMJ 2007; 335 doi: http://dx.doi.org/10.1136/bmj.39426.523715.80 (Published 20 December 2007) Cite this as: BMJ 2007;335:1271
- Ian Gilmore, president of the Royal College of Physicians,
- Nick Sheron, hepatologist
Alcohol causes major health problems—the Cabinet Office reported up to 150 000 hospital admissions and 15 000-22 000 deaths overall in 2003.1 Between 1991 and 2005, deaths directly attributed to alcohol almost doubled.2 More people are dying from alcohol related causes than from breast cancer, cervical cancer, and infection with methicillin resistant Staphylococcus aureus combined. Furthermore, the recent report from the World Cancer Research fund confirmed that even drinking alcohol within so called “safe limits” increases the risk of cancer of the breast and upper gastrointestinal tract.3
The cultural and sociological factors that determine our patterns of drinking may date back thousands of years.4 As such, the Licensing Act 2005 was always unlikely to transform the culture of feast drinking to that of a Mediterranean society. Similarly, other options to reduce harm favoured by government and the alcohol industry—education and public information—don’t seem to change drinking behaviour or to reduce alcohol related harm.5 6 So, can we justify trying tougher measures to reduce alcohol related harm—particularly to health—and is there any evidence to show they would work?
The turning point in a similar debate over tobacco control was the effect of passive smoking, yet damage to third parties from exposure to alcohol misuse is far greater. Drinking alcohol is a factor in more than half of violent crimes and a third of domestic violence. Between 780 000 and 1.3 million children are affected by their parents’ use of alcohol—30-60% of child protection cases and 23% of calls to the National Society for the Prevention of Cruelty to Children about child abuse or child neglect involved drunken adults.1 This seems justification enough for society to debate what reasonable and evidence based means could reduce the harm caused by alcohol.
Evidence on alcohol policy has been expertly reviewed for the Academy of Medical Sciences,7 the European Commission,8 and the World Health Organization (WHO).9 The findings were similar in each case—effective measures included increasing prices, controlling alcohol advertising, increasing the minimum age for buying alcohol, and restricting opportunities to buy alcohol. Others were specific measures to reduce drink driving, including lowering maximum blood alcohol concentrations to 0.5 g/l and increasing enforcement with random breath testing of drivers. Some of these specific measures have knock-on effects; French campaigns to enforce drink driving laws reduced wine consumption in restaurants by around 15%,7 and a combination of lower alcohol limits for drivers and vigorous enforcement in Australia showed wider health benefits.8
Modelling of these measures by WHO has shown that increasing the price of alcohol is the most effective and cost effective measure.9 Like any commodity the purchase of alcohol is price sensitive. Increasing prices has the biggest effect on the heaviest consumers and on young people, who spend a relatively high proportion of their income on alcohol.7 Between 1980 and 2003 the price of alcohol increased 24% more than prices generally, but disposable income increased by 91%, making alcohol 54% more affordable in 2003 than in 1980.10 Models from the UK treasury show that up to 50% more tax on spirits would increase government income even though cross border smuggling would probably increase, and taxation could be increased even more for wine and beer before income to the treasury would be reduced.11 To suggest, as producers and retailers do, that increasing the price of alcohol would not reduce alcohol related harm goes against the evidence and the fundamental principles of marketing—product, price, promotion, and place.
Early detection and intervention are almost as effective at reducing harm to health but require specific funding.9 The Department of Health in England has funded a large ongoing study of early detection and brief intervention in three settings—primary care, emergency departments, and prisons. If this confirms the results of previous studies,12 early intervention should be implemented more widely and funded properly. Banning advertising of alcohol and reducing its availability are also effective, although less so than increasing taxation and early intervention, as has been the case with smoking.13
Perhaps the most striking and convincing recent evidence that reducing harmful drinking saves lives comes from Russia. After Mikhail Gorbachev introduced his polices on alcohol control, deaths (half of which were caused by accidents, violence, and poisoning) dropped dramatically, and 1.2 million lives were saved.14 How many more lives will be damaged by alcohol in the UK before our governments decide to tackle the problem with measures that are likely to work?
Competing interests: IG is a member of the Alcohol Research and Education Council and chairman of the Alcohol Health Alliance UK. NS is a trustee of Alcohol Concern, the Drinkaware Trust, and honorary secretary of the Alcohol Health Alliance UK.
Provenance and peer review: Commissioned; not externally peer reviewed.