The long-awaited Green Paper on Prevention was published, without fanfare, in the last days of Theresa May’s Government. The Paper’s discussion on alcohol veers towards non-existent: the most significant contribution was to make alcohol free beers easier to produce by, ironically, allowing them to be more alcoholic. The Alcohol Health Alliance firmly believes in prevention, at the population level, because it works, is fair, and is sorely needed.
“Prevention is better than cure”, is an aging, bordering on ancient, cliché. However, its triteness makes it no less true. A systematic review found that, across a range of measures, the median return on investment for public health services (which focus on prevention) was ~£14:1, an absurdly good investment. Prevention measures can be considered on a spectrum, ranging from the population-level measures to targeted approaches (see image below). The sugar levy introduced last year is an example of the former. It affects the price of sugary drinks, with the aim of changing the behaviour of everyone who drinks them, to reduce the risk of them developing negative/life-impacting outcomes such as type II diabetes. In contrast, a targeted prevention measure focuses on those most at risk. For example, a GP could test their patients for pre-diabetes, and then provide dietary and lifestyle advice. So what population level approaches are available to reduce alcohol harm?
Prevention policies and alcohol-harm
Central to our thinking are the WHO ‘best buys’. These interventions, all with a high cost-benefit ratio, are: increasing alcohol taxes; bans or comprehensive restrictions on alcohol advertising across multiple media; and reducing the availability of alcohol through restrictions on hours of sale. We conceptualise them as: ‘price, promotion, and availability.’ All three of these are population-based preventative measures: they impact the entire population of people who drink alcohol with the aim of reducing the myriad of bad health and social outcomes which are related to alcohol. Currently, the Alcohol Health Alliance is engaged in a campaign to increase alcohol duty (alcohol tax) and to introduce a minimum unit price in England (a floor price below which alcohol cannot be sold, which exists in Scotland and will soon be introduced in Wales). We also firmly support restrictions on alcohol marketing (to tackle promotion), and reformation of licensing regulations (to reduce availability). I will be mainly looking at price interventions.
A complex history
Regulating the price of alcohol has a long, and not always noble, history (I highly recommend this article for a thorough analysis, some of which is summarised below). The original price controls in the 13th century were to set a maximum price, a somewhat odd proposition when viewed with the lens of today. Arguably this too had ‘prevention’ at its heart: ale was a staple thus if it became too expensive there could be disastrous consequences. The first of the harm-minimising alcohol taxes in the UK were the Gin Acts in the early- to mid-18th century. These responded to concerns about gin consumption, and, to quote one of the acts, the ‘…immoderate drinking of distilled spirituous liquors by persons of the meanest and lowest sort…’. William Hogarth’s ‘Beer Street’ and ‘Gin Lane’ is a colourful and enduring image of the time. Genuine concerns, mixed with a splash of hyperbole, led to substantial restrictions and heavy levies on gin sellers.
How we could do it
In the current social landscape, increasing the price of alcohol is one of the most effective options for reducing alcohol-related harm. To take one example, a 50p minimum unit price is predicted to save 525 lives a year in England and many-fold more hospital admissions. Similarly, an increase in alcohol duty by 10% over 5 years, at full effect, would save 730 lives annually in England. Duty would also raise revenue for the Government to spend on prevention and treatment services. For the cost of a pint of beer to be changed by a 50p minimum unit price it would have to sell for less than £1, and a 10% rise in alcohol duty (far higher than we are calling for) represents only around 4-5 pence on the same drink. The change is small but across the entire population it makes a huge difference.
The reason population measures work are varied and complex, but I will consider two. Firstly, despite being population-wide, they tend to affect those with the riskiest behaviours most, and secondly, alcohol harm is a population-wide problem. Increasing the price of alcohol through duty or minimum pricing will impact the cheapest products most, as these are currently sold below the minimum price and a larger proportion of their cost is tax. Those who experience the most harm from alcohol tend to be, although far from exclusively, those drinking larger amounts. Because they are consuming more they tend to both spend a greater portion of their income on alcohol, and consume cheaper alcohol. The net effect of the above is that they are more responsive to the price changes.
Underlying people’s objections to population-wide measures is often the ugly assumption that problems with alcohol only occur to a very few people: ‘the problem drinkers’. They are not like the rest of us, so why should we be ‘punished’ to help them? This is simply untrue. More than a quarter of the total adult population regularly drink over 14 units per week (the recommended low risk level). More than one in four people who drink alcohol had been binge-drinking in the last week. More than one in a hundred adults in England have an alcohol dependency which could benefit from specialist treatment. Alcohol causes cancer: 11,800 cases of cancer of the throat, mouth, liver, breast, colon, oesophagus, and larynx every year. It is linked crime, violence, road deaths, and injuries. The net effect is that you will almost certainly know someone who has been harmed by their own, or another’s, drinking. This problem is a problem for all of us and needs a population-wide response.
Population-wide prevention is a difficult sell, and, as evidenced by the recent Green Paper, politicians are often loath to rise to the challenge. However, population-wide policies are overwhelmingly the most effective way of reducing alcohol harm. When lives can be saved, and trauma to children, partners, and families can be prevented, we should all play a part in doing so. We need to face this problem head-on: alcohol harm affects our whole society. Only by owning that, can we get serious about preventing it.
Written by Kieran Bunn, Policy and Advocacy Assistant at the Institute of Alcohol Studies