By Andy Stonard, Consultation Event Alcohol Panel Chair is the CEO of Esprit du Bois and the Former CEO of Rugby House – Drug & Alcohol Treatment Services. He is author of A Glass Half Full: Drinking - Reducing The Harm

Professor Philippe de Witte, Head of the Laboratory of Behavioural Biology at the Université Catholique de Louvain (UCL), Belgium. He is Editor-in-Chief of Alcohol and Alcoholism and Chairman of the Advisory Board of the European Foundation for Alcohol Research. He is a former Fulbright Scholar, specialising in brain research at the US National Institutes of Health.

Boys and girls are binge-drinking, creating problems in their daily lives

Alcohol is a major cause of harm on a global basis, increasingly for our youth, but health policy and treatment responses have been inconsistent and ineffective. What is needed is a complete overhaul of our current thinking. It is time to go much further in actually listening to, and applying, what the latest brain research is telling us.

There appears to be a significant amount of information about the level and incidence of drinking by young people. It is increasing. This information becomes a key platform for concern and thinking in relation to what the brain science tells us about brain maturation during a human being’s second decade and how levels of alcohol can delay or interfere with this key period of development. Not surprisingly, in such a controversial area there also exists a great deal of data interpretation and sensationalism.

Two major studies can be taken at face value to better our understanding of youth consumption of alcohol. One is American, the other European, and both arrive at the same upwards trend conclusion, yet interestingly, neither present any clear evidence of patterns of conformity across Nations.

Study #1: Monitoring the Future – National Results on Drug Use: 2012 Overview Key Findings on Adolescent Drug Use (The University of Michigan Institute for Social Research).

It states that alcohol has been widely used by American young people for a long time. In 2012, the proportions of 8th, 10th, and 12th graders who reported drinking an alcoholic beverage in the 30-day period prior to the survey were 11%, 28%, and 42%, respectively. In 2011, however, all measures of alcohol use – lifetime, annual, 30-day, and binge drinking – reached historic lows over the life of the study in all three grades.

Among 12th graders, binge drinking peaked with overall illicit drug use in 1979. Binge drinking then declined substantially from 41% in 1983 to a low of 28% in 1992, a drop of almost one third (also the low point of any illicit drug use). However, in 2012 binge-drinking rose significantly among 12th graders, from 22% to 24%.

Study #2: Substance Use Among Students in 36 European Countries (2011, The European School Survey Project on Alcohol and Other Drugs).

It reported that in all 36 countries apart from Iceland, at least 70% of students have drunk alcohol at least once during their lifetime, with an average of 87% in the 2011 survey. The corresponding average figures for use in the past 12 months and the past 30 days are 79% and 57%, respectively. For all three time frames, there were small decreases from 2003 through 2007 to 2011. Of course, these averages are based on highly divergent country figures. For example, alcohol use during the past 30 days was reported by more than 75% of the students in the Czech Republic and Denmark, but only by 17% in Iceland and 32% in Albania.

Of the students who reported the amounts of various beverages that they consumed during the most recent day on which they drank alcohol, the estimated average consumption differed between the sexes, with boys drinking one-third more than girls (2011 averages of 5.8 versus 4.3 centilitres of 100% alcohol).

A significant difference in this direction can be found in nearly all countries. In a large majority of the countries, beer is the dominant beverage among boys. Spirits is the most important beverage among girls in just over half of the countries. On average, these two beverages together account for about 70% of the students’ total consumption.

Again, there are huge differences between countries. On their most recent drinking day, Danish students, on average, drunk more than three times as much as students in Albania, Moldova, Montenegro and Romania. Large quantities are mainly found among students in the Nordic and British Isles countries, while countries with smaller quantities often are located in South Eastern Europe. The average quantities consumed on the latest drinking day were about the same in 2011 as in 2007. At the national level, however, they increased significantly in 2011 in ten countries but dropped in only four.

This measure of ‘heavy episodic drinking’ (five drinks or more on the same occasion during the last 30 days) has undergone one of the most striking changes among girls. The aggregate-level average increased from 29% in 1995 to 41% in 2007. In the 2011 survey, however, this figure has dropped to 38%. Among boys, the figure is also slightly lower in 2011 (43%) than it was in 2007 (45%) and thus also relatively close to the 1995 figure (41%).

Two Nordic countries are at opposite ends of the scale when it comes to heavy episodic drinking. The proportion of students in Iceland who reported in 2011 that they had engaged in this behaviour during the past 30 days was 13%, while it was more than four times higher in Denmark (56%).

Between the two most recent surveys, the figures for heavy episodic drinking increased significantly in four countries (Cyprus, Greece, Hungary and Serbia), while a significant fall can be seen in nine countries with comparable data, including the four Nordic countries of the Faroe Islands, Iceland, Norway and Sweden. The largest increases, of about 10 percentage points, happened in Cyprus and Hungary, while the largest decreases, of 9 percentage points, took place in the Faroe Islands and Iceland.

On average, nearly six in ten students had consumed at least one glass of alcohol at the age of 13 or younger and 12% had been drunk at that age. This reply was given, on average, by more boys than girls, and that tendency was the same in almost all countries.

A number of students reported having had problems during the past 12 months linked to their alcohol consumption. The types of problem most commonly reported were “performed poorly at school or work” (13%) and having had serious problems with friends or parents (12% each). Countries where many students reported problems related to their alcohol consumption include Bulgaria, the Czech Republic, Latvia and Slovakia.

A closer look at how this youth drinking impacts their brain

While there is a decline in drinking among young people, a significant percentage of young people engage in risky behaviour by repeated episodic heavy drinking. Substantial evidence indicates that the initiation of risky drinking is higher during adolescence than at other times in life. Risky drinking is often part of an overall profile of high-risk behaviours in adolescents, but the availability and role of alcohol consumption in society demands a thorough understanding of youth drinking.

The second decade of life is a time of physical maturation and continuing development of the brain. Emotions and motivations are thought to originate in the midbrain, whereas the frontal region of the brain exerts executive function and limitation of impulsive behaviour. Recognising that different regions of the brain develop at different times may help us to understand some of the impact of alcohol consumption during the second decade of life.

Understanding that the midbrain regions develop earlier and faster than the frontal regions helps explain why adolescents may experience more dramatic emotional responses following ingestion of alcohol yet not have sufficient ability to limit impulsivity. As a consequence of having inadequately developed executive functions, adolescents are very vulnerable to the feeling of invincibility when drinking alcoholic beverages.

Both animal and human studies have shown that heavy drinking can cause cognitive deficits, which further impair decision making, problem solving, planning, attention and learning. Thus, early heavy drinking can interfere with school performance and create behavioural difficulties for young people. For example, heavy drinking by young people can result in a wide range of costly health and social consequences, including fatal and nonfatal accidents, all types of interpersonal violence, risky sexual behaviour, academic problems, and alcohol poisoning.

The policy-maker and health community’s focus must primarily be on modifiable risk factors since these factors represent potential targets for prevention. Unfortunately, the problem is complex and a single solution or policy to prevent youth drinking does not exist. Nevertheless, a number of strategies are effective in some circumstances and warrant further study in different populations.

Preventing risky drinking requires understanding of the important influence of family and peers. As young people develop independence and freedom from their parents, they learn behaviours related to drinking and other aspects of life from both family and peers. Genetic traits like impulsivity, anxiety, sensation seeking and emotional dysregulation can also contribute to harmful drinking. The expression of genetic traits and early learning is further influenced by the cultural and environmental milieu.

Social networking and digital media have developed rapidly over the last five years. However, they remain a largely unexplored domain both for exacerbating and alleviating problems related to alcohol use in young people. Equally, alcohol advertising across the board needs closer examination and tightening up. For example, youth are highly influenced by sports and it is this domain that many alcohol producers target. Where tobacco companies have been removed, one now sees a preponderance of alcohol and gambling companies presenting an image that alcohol and betting is good for you.

Much of the previous work regarding the effectiveness of public policies on harm associated with alcohol consumption has examined the impact on the population as a whole. An exception is the growing body of knowledge regarding the vulnerability of the developing brain in adolescents to the harmful effects of alcohol. This issue may have relevance for public policy regarding the age of purchase or consumption of alcoholic beverages which varies dramatically from 16 years in Europe to 21 years in America and even younger elsewhere.

Some risk and protective factors are common to all cultures. These include biological and temperamental traits that predispose an individual to drink or not to drink and to experience greater reinforcement from drinking. On the other hand, other risk and protective factors are culturally determined, such as expectancies about alcohol and parental influence. It is expected that the former types are consistent across countries, whereas the latter may differ.

What is clear from SciCom’s high-level gathering of experts and the growing body of scientific evidence being produced is that further work in this area should examine the impact of public policies on adolescents, who may be “at-risk” for harm associated with heavy drinking through no fault of their own.

What policy-makers are saying but not doing

With such clear implications for alcohol on brain development, the lack of policy clarity has to be seen as alarming. Most Nations may well have regulatory controls in place around supply and sale, but it is obvious from the statistics that their application is far from effective.

The WHO estimates that the world drank the equivalent of 6.1 litres of pure alcohol per person in 2005. The biggest boozers are in Europe and the former Soviet States. Moldovans are the most bibulous, getting through 18.2 litres each and nearly 2 litres more than the Czechs in second place. Over 10 litres of the Moldovan’s annual intake is reckoned to be ‘unrecorded’ home-brewed liquor, making it particularly harmful to health. Such moonshine accounts for almost 30% of the world’s drinking. More importantly, harm reduction strategies fail to recognise the strong links between alcohol-related harm and low income. It is referenced in many studies around the world, but it is mainly anecdotal. An accepted figure is that 80% of overall alcohol harms are associated with the poorest 10% of the population.

In the UK, the Chief Medical Officer, Sir Liam Donaldson, issued in 2009 a five-point guide on the consumption of alcohol by children and young people. His advice is:

• An alcohol-free childhood is the healthiest and best option – if children drink alcohol, it shouldn’t be before they reach 15 years old;
• For those aged 15 - 17 years old, all alcohol consumption should be with the guidance of a parent or carer or in a supervised environment;
• Parents and young people should be aware that drinking, even at age 15 or older, can be hazardous to health and not drinking is the healthiest option for young people. If children aged 15 - 17 consume alcohol, they should do so infrequently and certainly on no more than one day a week;
• The importance of parental influences on children’s alcohol use should be communicated to parents, carers and professionals. Parents and carers need advice on how to respond to alcohol use and misuse by children; &
• Support services must be available for children and young people who have alcohol related problems, and their parents.

However, this is guidance. What the law states is the following:

It is against the law:

• To sell alcohol to someone under 18 anywhere;
• For an adult to buy or attempt to buy alcohol on behalf of someone under 18. (Retailers can reserve the right to refuse the sale of alcohol to an adult if they’re accompanied by a child and think the alcohol is being bought for the child.);
• For someone under 18 to buy alcohol, attempt to buy alcohol or to be sold alcohol;
• For someone under 18 to drink alcohol in licensed premises, except where the child is 16 or 17 years old and accompanied by an adult. In this case it is legal for them to drink, but not buy, beer, wine and cider with a table meal; &
• For an adult to buy alcohol for someone under 18 for consumption on licensed premises, except as above.

It is not illegal:

• For someone over 18 to buy a child over 16 beer, wine or cider if they are eating a table meal together in licensed premises; &
• For a child aged 5 to 16 to drink alcohol at home or on other private premises.

This example perfectly reflects the inconsistencies between the law on one hand, and the guidance being given by health experts and groups on the other, often in good faith, as a step to try to deal with a growing crisis of youth consumption of alcohol. As a measure to relieve some pressure on the ‘troubled alcohol industry’ and after a lengthy lobbying campaign, the UK’s March 2013 budget stated that the price of a pint would be cut by a penny, in a surprise reversal of the chancellor’s commitments to annually increase beer duty by two percentage points above inflation until 2015.

Chief Medical Officers worldwide are increasingly aware that the harmful use of alcohol is killing 2.5 million people, including 320,000 young people between 15 and 29 years of age. The harmful use of alcohol is especially fatal for younger age groups and alcohol is the world’s leading risk factor for death among males aged 15-59, according to the World Health Organisation (WHO).

To make this more relative, the UK Government’s 2012 Alcohol Strategy estimates that in a community of 100,000 people, each year:

• 2,000 people will be admitted to hospital with an alcohol-related condition;
• 1,000 people will be a victim of alcohol-related violent crime;
• Over 400 11 to 15 year olds will be drinking weekly;
• Over 13,000 people will binge-drink;
• Over 21,500 people will be regularly drinking above the lower-risk levels;
• Over 3,000 will be showing some signs of alcohol dependence; &
• Over 500 will be moderately or severely dependent on alcohol.

These figures are built into the Alcohol Harm Reduction Strategy for England and Wales which estimate that over 8 million adults there are drinking more than 28 units per week. The 2012 Alcohol Strategy also acknowledges that 50% of stranger violence is alcohol-related, 30% of child abuse involves alcohol, 50% of domestic violence and up to 80% of admissions at Accident & Emergency hospital services at certain times are alcohol related. We can pick any OECD country and find similarly high statistics.

Ireland, a nation synonymous with the pleasures of the pint and the craic of its pubs, has actually the highest abstinence rate in the EU with 25% of its population never drinking. That said, alcohol-related liver disease deaths have trebled in recent years. Alcohol is now killing twice as many Irish citizens as all other drugs combined – and Ireland ranks with Denmark as having the highest illicit drug use in the EU.

On safe drinking levels, a review appearing in Drug and Alcohol Today (2013) which looked at 57 countries, showed that 8 EU member states did not have readily accessible alcohol guidelines at all. Moreover, there was confusing variation in what constituted a ‘standard drink’ or ‘unit of alcohol’. When you think about it, most countries speak of ‘daily limits’ when it comes to alcohol, encouraging the perception that it is safe to drink ‘every day’. To make matters worse, not only might a ‘unit’ vary from country to country, it makes no scientific sense to apply it to everyone aged from 18 to 80 years, or from 60 to 160 kilos. Nor can it be properly applied to somebody in good health to somebody in poor health, on medication or not, on 100 euros a week or 1000 euros a week.

What our alcohol panel concluded: Andy Stonard

The statistics on alcohol consumption speak for themselves and the implications of a growing body of scientific studies are very clear: we are sleep-walking into an alcohol epidemic that is global with devastating consequences on our youth. The latest evidence, incidentally, also shows a dramatic increase in alcohol consumption by our elderly, often city-bound and living alone.

Firstly, the most damaging impact of this process is that it remains easier to focus on the individual and to blame the individual, which of course remains the major treatment model for addiction to alcohol. Once addicted, then always addicted. It is a disease held only in abeyance by abstinence. The alcoholic is somehow different from the rest of us. They are over there and we are over here and ideally, they will stay anonymous. The industry will often play on this fact, telling policy-makers that they cannot tamper with ‘freedom of choice’ or ‘individual satisfaction’. But we cannot deny that modern day marketing laws make ‘alcohol pushers’ of us all. We are bombarded by alcohol advertising everywhere we turn. It is impossible to celebrate anything or to be a celebrity without alcohol in the equation. There are signs that this is being noted. For example, the negative reaction in Ireland to ‘Arthur’s Day’, celebrating Guinness consumption, or to the drinks industry’s widespread printing of free programme booklets for supporters during the European football Championships.

Secondly, all governments turn nice streams of revenue from the sales of this legal drug and it does create much needed jobs that, in turn, pay the taxes supporting the very governments and regulating bodies we depend upon. Even the EU receives a share of income from the sales of alcohol in its member states. Alcohol pricing in the UK today, for example, is 44% more affordable than it was in the 1980’s and the number of breweries doubled in London alone in 2013, standing at a 70 year high across the country, producing 5,200 plus types of beer. Jobs also matter. The Brewers of Europe claim to support 2.5 million jobs in Europe and their latest press release points to the role of their 4,000 brewers in ‘helping fight youth unemployment’. Their latest photo exhibition took place at the European Parliament, no less, and is a campaign to ‘show their sector’s craft and dynamism’.

Thirdly, societal problems related to drinking alcohol certainly exist – violence (stranger and domestic), public disorder, accidents and road accidents, crime, absenteeism from work etc. But alcohol production is a legal, regulated business. It is too simple to just ‘hang’ the blame for these problems on the drinks industry alone. Neither can you blame it for fighting its corner and wrapping its business in history and culture and, more recently, the joys of beer with food. But there is surely a total abdication of the ‘responsibility’ they so often quote when we know so little about their supporting science.

Why do bottles of beer, wine and spirits provide so little basic ingredient and health information, as we expect from our milk, juices and even bottled water these days? Who gives this labelling exemption and what is the logic behind it? Does the WHO have a similar Products Directive on alcohol as we do on tobacco, for example? Where are the research teams innovating these products, how much is being spent, how much is being subsidised and more importantly, how robust is the science?

What our high-level consultation event demonstrated is that there exists in alcohol a battleground between health and industry built entirely upon contradictions and a mutually beneficial stand-off. Genuine health actors are muted and do not get their suggestions heard. The focus on tobacco and other health issues like obesity or ageing provides a convenient side-show to the real story about the real and present danger of alcohol consumption. 2.5 million lives lost annually is not insignificant. We need to urgently develop a completely new alcohol health approach based on scientific understanding of how our brain works cognitively with alcohol. We’d surely all drink to that!