By Andy Stonard, CEO, Esprit du Bois; Former CEO Rugby House – Drug & Alcohol Treatment Services; Author: A Glass Half Full: Drinking - Reducing the Harm

Alcohol is a major cause of harm on a global basis. But health policy and treatment responses have been inconsistent and ineffective, says Mr. Stonard. What is needed, he argues, is a complete overhaul in our thinking and a move away from the moral and economic approach which has dominated in the past. It is time, he says, to go much further in applying the increasing understanding that science is giving us.

Alcohol is a drug. Available - legally or illegally - in 90% of the world, it is produced and distributed via an industry network that includes farming, production, distribution, retail, entertainment and leisure, advertising and sponsorship. According to the World Health Organisation (WHO) and the International Centre for Alcohol Policy, between 30% and 50% of the world’s alcohol output is privately produced and consumed. As a global phenomenon, alcohol requires interventions that are flexible and appropriate to widely differing regions and countries.

What does not vary, however, is the damage alcohol can cause, as the WHO reports: “The harmful use of alcohol is a serious health burden, and it affects virtually all individuals on an international scale. Health problems from dangerous alcohol use arise in the form of acute and chronic conditions, and adverse social consequences are common when they are associated with alcohol consumption”.

Every year, the harmful use of alcohol kills 2.5 million people, including 320 000 young people between 15 and 29 years of age. It is the third leading risk factor for poor health globally, and harmful use of alcohol was responsible for almost 4% of all deaths in the world, according to the introduction of the WHO International strategy on alcohol harm reduction 2012 – 2020.

What is even more worrying is the fact that these figures do not include the much larger numbers of people who are drinking alcohol at levels that begin to put their lives at risk or who are engaged in alcohol-related behaviour that can put them at risk of accident, injury or infection.

How we drink and how we produce alcoholic beverages is different from Country to Country and how we try to tackle the harms associated with drinking alcohol is just as different, with the inconsistencies and differences highlighting a poor application of the science and knowledge that we do have.

The Economist online from the 14th February 2011 highlights this perfectly: ‘The world drank the equivalent of 6.1 litres of pure alcohol per person in 2005, according to a report from the World Health Organisation published on February 11th. The biggest boozers are mostly found in Europe and in the former Soviet states. Moldovans are the most bibulous, getting through 18.2 litres each, nearly 2 litres more than the Czechs in second place. Over 10 litres of a 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.’

How to reduce these figures should represent key policy drivers. However, these figures are produced from a much larger Global pool of people who are drinking alcohol at levels that begin to put their lives at risk or are engaged in alcohol related behaviour and lifestyles that can put their lives at risk from related accident, injury or infection.

A good example of this can be found in the UK - The 2012 Government Alcohol Strategy details this breakdown in the following way.

We estimate 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 11-15 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; and
• Over 500 will be moderately or severely dependent on alcohol.

These figures are built on the Alcohol Harm Reduction Strategy for England and Wales from 2008 that states that there are over 8 million adults drinking over 28 units per week. The publication 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 A&E at certain key times are alcohol related.

Analysis of data from Ireland’s Hospital In-Patient Enquiry (HIPE) scheme has revealed a “considerable increase” in alcohol liver disease (ALD) morbidity and mortality between 1995 and 2007. Rates of alcoholic liver disease per 100,000 adults increased by 190% from 28.3 in 1995 to 82.2 in 2007, according to figures published in the journal, Alcohol and Alcoholism.

The figures also reveal “considerable increases” of alcohol liver disease among younger age groups. Among 15-34 years olds, the rate of ALD discharges increased by 247%, while for the 35-49 age group, the rate increased by 224% which did not surprise the researchers as 18-29-year-old drinkers have the highest level of alcohol consumption among Irish drinkers and two-fifths binge drink weekly.

However, the figures show that the majority of ALD discharges are still among the 35 to 64 age groups. Over two-fifths (43%) of all discharges were aged 50-64 years; 35% were 35-49 years old, 16% were aged over 65 years, while 6% were 15-34 years old.

The report found that while the majority of ALD discharges were male (70%), there was a higher proportion of young females. This too was “unsurprising” according to researchers, as young Irish women “drink in a manner similar to males with harmful drinking patterns, including weekly binge drinking common among this group”.

The study found that increases in Alcoholic Liver Disease are consistent with the increase in alcohol consumption and harmful drinking patterns.

There is therefore a need to consider a twin track approach: one that is effective in reducing numbers at the chronic/severe end, and another which seeks to reduce the numbers at risk of harm (30 to 40% of the population) not only through alcohol-related ill health but also through accidents and injury, or violence by third parties under the influence of alcohol. Estimates vary, but around 40 to 50% of violent incidents involve the consumption of alcohol - with anecdotal evidence that the figure is higher still.

Addressing the reduction of harm in relation to alcohol needs to be at an individual, a national and an international level.

On an individual level, we are trying to bring about change in consumption patterns and in behaviour. In order to achieve this, individuals need access to good information so they can understand how to assess risk and how alcohol interacts on a chemical level at both a brain and motor neurone functional level. This requires the dissemination of simple science relevant to the individual, while issues of lifestyle and associated health, economic and social considerations also need to be addressed.

To support this, governments need to provide the right information to help individuals understand the science. Government and public health also need to work in cooperation with industry rather than in opposition to it, through sensible regulation.

Most importantly, harm reduction strategies have to recognise the strong link between alcohol-related harm and low income. It is referenced in many studies around the World, but in all honesty, is mainly anecdotal. In the UK, Alcohol Concern, a national alcohol NGO stated in the 1990’s that around 80% of overall alcohol harms are associated with the poorest 10% of the population. What studies this was based on were never quoted but have gained acknowledgement and acceptance at many conferences. This figure cannot be supported by any one single piece of evidence but has never been challenged over 20 years.

What we require is nothing less than a complete overhaul of our thinking on the issue of alcohol and alcohol-associated harm. This paper describes the present approach – one which is based on economic and moral thinking rather than on the knowledge and understanding being generated by science and on a recognition of the clear role played by poverty.

Pricing and Supply

The use of taxation and duty to control alcohol consumption has been a principal tool for the last 5,000 years, along with supply control. Many governments refer to this as harm reduction at an economic level.

It is a reality that increasing price does reduce overall alcohol consumption. What it achieves is a reduction by the majority who already drink in moderation. For those already drinking heavily or who are addicted it makes matters worse. It raises their biggest cost (drinking), with the result that other basic needs are neglected in order to maintain their level of drinking.

The economic and political argument is that this approach will affect future consumption levels. But what it completely fails to address are the behavioural aspects of drinking-related harm. Nor has it ever considered the effect of alcohol pricing on other drug markets. Our health based approaches are focused on the substance rather than on the people, who as consumers have an alarming tendency to change behaviour and habits when faced with market forces and policy and regulatory change.

What cannot be ignored is the fact that ‘economic harm reduction’ initiatives earn governments huge sources of revenue.

The international response

Under the auspices of the WHO, the key international strategy on alcohol harm reduction (running from 2012 to 2020) identifies ten key areas of policy options and interventions at the national level and four priority areas for global action.

The ten areas for national action are:

1. Leadership, awareness and commitment;
2. Health services’ response;
3. Community action;
4. Drink-driving policies and countermeasures;
5. Availability of alcohol;
6. Marketing of alcoholic beverages;
7. Pricing policies;
8. Reducing the negative consequences of drinking and alcohol intoxication;
9. Reducing the public health impact of illicit alcohol and informally produced alcohol; &
10. Monitoring and surveillance.

The four priority areas for global action are:

1. Public health advocacy and partnership;
2. Technical support and capacity building;
3. Production and dissemination of knowledge; &
4. Resource mobilisation.

In the words of the WHO: “The implementation of the global strategy will require active collaboration with Member States, with appropriate engagement of international development partners, civil society, the private sector, as well as public health and research institutions. WHO and its Member States are dedicated to work together to address the key areas of policy options and interventions, to interact with relevant stakeholder and to ensure that the strategy is implemented both nationally and globally. The progress of the strategy will be assessed at the Sixty-sixth World Health Assembly in 2013.”

Like many of these documents it is finely worded and based on clear common sense. The resources required for its successful implementation will be enormous, both financially and more importantly politically. But even at the most basic level it faces huge difficulties, as is demonstrated by the way in which different countries approach the issues of safe drinking levels and drink-driving regulations – two examples of the most fundamental application of the science we do know:

On safe drinking levels, a review appearing in Drug and Alcohol Today (2013) which looked at 57 countries (including the 27 EU member states), showed that 27 countries had official low-risk drinking guidelines that could be expressed as grams of ethanol while many others did not have guidelines that could be expressed in this way. (They encouraged moderate consumption and/or abstinence in certain circumstances - but did not define what this is.) Some countries did not have readily accessible alcohol guidelines at all - including eight EU member states.

Moreover, there was variation in what was considered a ‘standard drink’ or ‘unit of alcohol’, ranging from 8g of ethanol in the UK to 14g in Slovakia. More guidelines expressed limits in terms of daily amounts than weekly amounts, and recommended maximum limits ranged from:

• 20g to 56g ethanol daily for men
• 10g to 42g ethanol daily for women
• 160g to 280g ethanol weekly for men
• 80g to 140g ethanol weekly for women

The ratio of recommended maximum limits for men and women also varied, with women’s limits ranging from the same as men’s to half men’s limits. Where both a daily and a weekly limit were given for a country, the weekly limit was between three and seven times the daily limit. Some countries recommended having some alcohol-free days, or reducing daily consumption if drinking every day of the week.

Looking at the issue of drink driving rules, meanwhile, of 145 Countries reported on by the WHO, 14% (21 countries) allow no blood alcohol content (BAC). The countries which do allow some BAC vary as much as tenfold in what they allow.

In other words, despite the increasing understanding and knowledge provided by science and research, we still have a far from adequate approach. We work within a framework of units of alcohol which focuses on amounts rather than understanding behaviour and the range of individual factors which can influence harm, from physical or psychological/emotional characteristics to cultural, genetic, age or income-related issues.

Complicating factors

To make matters worse, not only might a ‘unit’ vary from country to country, it is also the case that within each country the established unit is then applied to every person from 18 to 80; from 60 kilos to 260 kilos, from someone in good health to someone else in poor health, on medication or not, on 100 euros a week or 1000 euros a week.

Then we have the issue of what constitutes harm in relation to drinking, or - more pointedly - what constitutes a problem that requires some form of recovery. What makes harm reduction a difficult concept across all substances is the fact that the overriding moral and political imperative is abstinence, based on the notion ‘once an addict, always an addict’ and its accompanying idea that the addiction (or illness or disease) is only held in abeyance through abstinence. For many people this has of course been a successful path. Unfortunately, it also suits those politicians and others involved in health policy who cannot submit to the idea that, in drugs, substitute prescribing and needle exchange save lives and stop horrible infections. They are seen as being ‘soft’ on drugs, and the view is that someone wanting to cut down on their smoking or transfer to a less harmful practice is not as good as someone quitting. Cutting down or reducing the harm just does not have the same ring to it.

Then comes the industry versus public health debate, where the industry is always portrayed as somehow the bad guy, no matter what they say, do or change. This has an interesting parallel with the ‘addict’ who, even after 20 years clean, is still referred to as ‘recovering’. For harm reduction to work, the public health sector and the wider industry (farmers, producers, retailers and services) have to work together. Like food and tobacco, alcohol is legal. The industry generates revenue for governments, its participants are regulated, are big employers and have close relationships with their customers. In Europe, our cities’ regeneration and culture are hugely dependent on cafés, restaurants, bars and clubs. The problematic dynamic for alcohol (and tobacco) is the contradiction between Treasury and Health and their inability to operate together under one government. Good public health through harm reduction is surely compromised when there is an economic reliance on the sale and consumption of alcohol, rather than a transparent and open dialogue on all aspects of the relationships.

Where is the Science in all this?

We need a world that values evidence-based policy and treatment in place of the present reliance on policy-led evidence. The approach to alcohol treatment demonstrates this dynamic.

The treatment industry for alcohol and drugs (both private and public) is based on ‘successfully’ treating drink and drug users. These programmes can last for two, six, eight or even thirteen weeks. The differing durations appear to have little scientific basis and anyway appear highly questionable in the context that breaking up and overcoming an addiction typically takes around seven years.

In addition, Project MATCH* published findings in 1999 comparing treatment outcomes from three different treatment approaches: 12 step, cognitive behavioural and motivational enhancement. What it found was very little variance between the three - but huge variations in outcomes from the same treatment depending on where the treatment was carried out. Despite this evidence, these approaches still compete with one another fourteen years on.

*Project MATCH Research Group. (1993). Project MATCH: Rationale and methods for a multisite clinical trial matching patients to alcoholism treatment. Alcoholism: Clinical and Experimental Research, 17, 1130-1145.

The established treatment and health policy approach is constructed entirely around the individual, who is seen as having an individual illness or behavioural flaw. It ignores any wider factors and is based on a set of parameters that are politically and morally constructed rather than based on the science of what we know and what works. It is time now to go further in our application of science.

The importance of factors such as how we learn to drink, or what vulnerability we have – either genetically or through social learning – to any drug such as alcohol, is becoming increasingly obvious. This is not a black or white situation. There is no specific gene that creates an addictive personality. But there is emerging evidence that our genetic construction can make some of us more susceptible or vulnerable to anything (such as alcohol), or lead to a greater impact on some aspect of our physical or emotional functioning, or contribute to organ weakness or chemical imbalance, all of which could create a string of interlinked and causal pathways.

We increasingly understand our neural pathways and understand what drug opens which receptor cells and the influences of various substances in our pleasure pathways, what triggers memories in our hippocampus and our brain reward systems. But these cannot be looked at in isolation because of the complex nature of cause and effect. For example, one the biggest impacts on drinking patterns and behaviour in Europe has, ironically, been the ban on smoking in public places. In achieving one goal, it has radically altered our drinking behaviour, with supermarkets encouraging the ‘take home’ or ’carry out’ still further.

The science of psychology and how it is applied to us as consumers, as for instance in Nudge theory (a concept in behavioural science and explained in Alberto Alemanno’s accompanying paper) gives us yet another angle on applying science to human behaviour.

Similarly, when we step outside the current ‘western’ therapeutic models of treatment and consider them more in the light of the science of anthropology and cognition and how our brains function through the senses rather than verbally, we begin to see new and potentially more effective interventions and understanding of self and behaviour through cognitive processes.

Lastly, the science of technology is harder to apply with alcohol than it is with drugs and tobacco. Clean needles, substitute prescribing and condoms in relation to drugs and infectious diseases have saved millions of lives, while of course electronic cigarettes in relation to smoking appear to have the same far reaching potential. However, for alcohol harm reduction to be effective then it cannot operate within a silo but as part of a wider harm reduction strategy, eloquently explained in Dr Delon Human’s introduction.

So what would we need to consider in any broad agreement on alcohol harm reduction?

1. What information and research do we need to be clear who are the vulnerable groups at risk in society?
2. How do we want to encourage our population to drink in a way which enhances the enjoyment and leisure aspects whilst reducing the alcohol related violence and disorder?
3. How do we encourage our population to drink in less harmful ways to their health?
4. Once we know who these groups are then how are we to help them? What tools and information and practical support can they be given?
5. What does our public health information on alcohol need to contain and where should it be available?
6. Whose job is it to deliver these messages once we know what is needed and where?
7. What do our retail outlets need to look like in the wake of this new approach to alcohol and drinking?
8. What do we need to teach our young people and young adults?
9. What terminology do we need to have to effectively help people in the future and what do we need to abandon?
10. What treatment interventions do we need to have in place?
11. What medical services do we need to have in place to back up these treatment interventions?

Recommendations:

To develop a completely new alcohol health approach based on understanding how our brain works cognitively with alcohol. This allows us to understand behaviour and risk and can be individually assessed. This will also enable us to understand that some people are at greater risk because of their health, income, employment circumstances.

That public health and industry have to work together on policy, strategy, information, regulation and marketing. There can be no other way. This also has to include an acceptance that funding from the alcohol industry is no different to funding to pharma, trusts and even tobacco. All Government funding contains a rich seam of income from all of these legally based companies and interests. It can clearly be suggested that the problem we have is between the Treasury and Health. What we need is a concord between the public (the consumer), industry, health and Government.

An open and informed public debate on alcohol, our use of alcohol and how we want to treat alcohol over the next century.

Improved funding for research and increasing what we know and what we need to know, with the EU supporting an independent body. The source of any money to provide research can and should always be non - consequential and there are good models already in existence for this. In the UK, there is an excellent model – NICE (National Institute for Clinical Excellence) – it is independent, brings in experts, reviews all the literature and creates best practice from this – there is one on tobacco harm reduction being released in June 2013 that the Tobacco Products Directive should adapt. In alcohol and drugs the guidance they have produced has been the best that there is (in this author’s opinion).

Actual implementation of what industry and government have already agreed in some countries – a good example is the agreement not to promote alcohol to under 18 years olds – sponsoring many sports events and teams must surely come under this yet is not applied. Take alcohol out of its silo and consider it alongside drugs, tobacco and diet in relation to health, alongside criminal justice agencies for criminal justice and public safety, and as a key factor to be considered across all policies and strategies.