Alcohol policy in the Nordic countriesBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7088.1142 (Published 19 April 1997) Cite this as: BMJ 1997;314:1142
Why competition law must have a public health dimension
- Laurent Chenet, Research fellowa,
- Martin McKee, Professor of European public healtha,
- Merete Osler, Lecturerb,
- Allan Krasnik, Professor of social medicineb
- a European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London WC1E 7HT
- b Institute of Public Health, 2200 Copenhagen N, Denmark
Last month the European Court dealt a potentially fatal blow to alcohol policy in much of Scandinavia.1 A preliminary ruling held that Sweden's retail alcohol monopoly, which has the effect of controlling access to spirits, was illegal under European competition law. If upheld, this policy seems likely also to apply to Finland and, possibly, Norway and Iceland due to their obligations as members of the European Economic Area. All of these countries operate this system, which has been effective–death rates from cirrhosis in Sweden are less than half those in Denmark, where there is no such policy.2
Indeed, in February the Danish daily newspaper Politiken reported new evidence that deaths from alcohol related diseases in Denmark have risen by 120% since 1970,3 contributing to the failure of Denmark to match improvements in life expectancy seen in neighbouring countries.4 The death rate from liver cirrhosis in Denmark is now as high as in France,2 a country where drinking has historically been at a higher level. These findings are consistent with evidence from sales figures. These underestimate consumption, as they exclude alcohol bought in duty free shops or elsewhere in the European Union, but they show that consumption in Denmark has risen by 36% between 1970 and 1993.
The situation in Denmark deserves close attention. The Danish government, while recognising the adverse health consequences of excess alcohol consumption, has avoided regulatory approaches such as the controls on access used in other parts of Scandinavia and instead relies on taxation. Taxation does reduce demand,5 but this should be part of a comprehensive strategy including a range of policy instruments. Furthermore, the effect of a policy should be monitored and, if it is not working, changed. It is now clear that this policy has failed and there is an urgent need for a new approach.
Unfortunately, even before the court's decision, there was evidence that things could become worse. Denmark was one of the first countries to introduce a safe drinking campaign, based on new evidence that moderate consumption of alcohol may confer some protection against cardiovascular diseases. There are several reasons why this may be inappropriate in general and in the Danish context in particular. The first relates to the distribution of alcohol consumption in the population. When there is already evidence of substantial alcohol consumption, with many people drinking at levels that damage their health, relaxing “official” guidelines may move the entire distribution so as to increase the population at risk of adverse consequences.6 Further evidence of this comes from the paper by Colhoun and others in this week's issue (see p 1164).7
Secondly, the size of the overall beneficial effect of moderate drinking is not the same for all age groups, and, for some conditions such as strokes,8 9 it is not seen. Although Denmark has had low death rates for cerebrovascular diseases, virtually no improvement occurred in the past few decades.10 There is clear evidence that Denmark is now losing its advantage, with many other countries reaching lower levels of mortality.
Although there seems a clear need for action, evidence from other countries suggests that key decisions often reflect considerations other than the impact on health.11 For example, the recent relaxation of alcohol consumption guidelines by the British government has been heavily criticised because of the influence exerted by the alcohol industry.12 It is less clear how much this is the case in Denmark, although we cannot ignore the prominent part played by the industry in the Danish economy and in social and cultural life. It is a major employer and contributes directly–through taxes and provision of some homes for elderly people–and indirectly–through the contribution of exports and employment–to the broader economy. It thus has considerable lobbying power, and it is difficult to see any government wishing to alienate it.
The European Court's decision is consistent with the tremendous pressure by some countries in the European Union, most notably Britain, to promote deregulation and further liberalisation in many areas of public life and highlights the dangers to public health posed by competition law unconstrained by adequate public health safeguards–not only at a European level but also, potentially more importantly, through the World Trade Organisation. The Danish experience of the past two decades adds to the evidence13 that this road is a dangerous one and one that must be addressed at the forthcoming inter-governmental conference on the future development of the European Union.