Introduction

An article published in the British Medical Journal (BMJ) entitled ‘Scots lead the way on Alcohol’ states Scotland has “produced the most impressive plan of action yet seen in Britain on how to combat alcohol problems. The report recognises that this is a job not just for government or for doctors or any other single group but a job for everybody in Scotland” [1]. An accompanying editorial notes “it is sometimes argued that increasing the cost of alcohol puts an unfair burden on the innocent social drinker without altering the behaviour of the heavy drinker, but there is plenty of evidence that this is not so, and recent figures from Lothian show a fall in harmful effects among heavy drinkers after a modest price rise” [2].

The BMJ article and editorial are from 1985 and the report was by a group chaired by the late Sir John Crofton. The ‘recent figures from Lothian’ were from a study by Bob Kendall, who became Scotland’s Chief Medical Officer in the 1990s, and Bruce Ritson. Since 1985 Scotland’s alcohol problem has got far worse while the research on interventions such as the influence of price has greatly increased. Yet the same excuses are still heard about punishing the sensible drinker.

Health problems caused by binge drinking [4]

In the intervening time much research has been undertaken to explore why there is such a problem with alcohol in Scotland and to examine the effectiveness of measures that can be used to reduce the level of alcohol dependency and binge drinking. Scotland now has a very good strategy to tackle alcohol related problems at a population level. Changing Scotland's Relationship with Alcohol: a Framework for Action [3] set out the need for change and draws on research that charts the costs and impact of alcohol on Scotland and its people. Public health welcomed this Framework as it clearly took a population and evidence-based approach. Alcohol problems are not just for young binge drinkers and dependent street drinkers: given that as a population we are drinking at unsafe levels, we all need to drink less.

Alcohol Brief Interventions

“Alcohol problems are not just for young binge drinkers ... we all need to drink less.”

Alcohol Brief Interventions (ABIs) have been a big part of the NHS contribution to the strategy of lowering Scotland’s alcohol intake. Led by NHS Lothian’s Health Promotion Service, ABIs are now firmly established in primary care and maternity services and will be expanding into Accident and Emergency. While it took nearly twenty years to be introduced, it is a great example of evidence-based policy implementation. It is a pity that it was necessary to set a target and provide a ring fence of funding to mandate the incorporation of this service. Success to date has inspired other services, for example podiatry, pharmacy and sexual health services, to look at the needs of their patient populations so that more services can provide brief interventions as part of routine care. This will enable greater coverage of the population at risk. NHS Lothian has had considerable success in training over 80% of Lothian GPs in screening and delivering ABIs. This is very encouraging; however, action by the NHS alone will not solve this problem.

Figure 1

UK alcohol consumption litres of pure alcohol consumption per capita in the UK, 1900-2006 [10]

Alcohol misuse and price

Tackling alcohol misuse and its consequences are key issues for the NHS in Scotland in general and NHS Lothian in particular. Between 1998 and 2004, 15 of the 20 local authority areas in the UK with the highest alcohol-related death rates were in Scotland. This included men and women in Edinburgh and West Lothian [5]. Between 1998 and 2002 there was a 52% increase in alcoholic liver disease in Scotland and we now have one of the highest death rates from liver cirrhosis in Western Europe [6].

There is a clear and long standing relationship between the affordability of alcohol and levels of consumption. This has been established across many countries over time [7]. In the UK, alcohol is now 69% more affordable than in 1980, with consumption increasing by around 20% over the same period. The World Health Organisation (WHO) considers that tackling the affordability of alcohol is a key component of an effective alcohol strategy. To implement the rest of the Framework and ignore the price of alcohol would not make sense. Introducing a minimum price would create a price below which a unit of alcohol could not be sold. Minimum pricing would apply to all alcoholic drinks but it would not result in an increase in the cost of all drinks, only those which are currently sold below the level set. It would primarily affect low cost, high alcohol products such as ciders and own-label vodka and would impact most on harmful drinkers [8].

A study conducted in two Edinburgh hospitals compared alcohol purchasing and consumption by ill drinkers in Edinburgh with wider alcohol sales in Scotland [9]. The study looked at the last weeks or typical weekly consumption of alcohol by type, brand, units, purchase place and price. Patients consumed a mean of 198 UK units per week. The mean price paid per unit was 43p (lowest 9p per unit) which is below the 72p mean unit price paid in Scotland in 2007. Of units consumed, 70% were sold at or below 40p per unit and 83% at or below 50p per unit.

There is a short time-lag in the strong correlation between affordability of alcohol and deaths from liver cirrhosis. Based on the available evidence minimum pricing, like the smoking ban, would save lives within a year. A study undertaken in Sheffield [8] supports this: their model suggests a 40p minimum price would save about 70 lives in year one, rising to 365 lives per year by year ten.

Any minimum price should be set at a level which will have an impact on consumption and alcohol related diseases and deaths. While most attention has been paid to a minimum price of 40p this should be in tandem with a ban on promotions as together these produce an additive effect. At higher minimum prices the additive effect of a promotions ban lessens until at 60p there is little additional effect. In the end there is a choice between how many deaths might be prevented and what might be a publicly acceptable level for the minimum price.

Raising the legal age of consumption and purchase reduces consumption levels in young people (including binge drinking), and reduces the levels of alcohol-related traffic crashes, injuries and fatalities [11]. Age verification is an important aspect of this area and the Challenge 21 and Think 25 policies used by some retailers are very welcome. All licensees should be encouraged to sign-up to these initiatives [12]. It may be that the threat of a locally imposed purchase age will reinforce this voluntary measure.

Longitudinal studies consistently suggest that exposure to media and commercial communications on alcohol is associated with the likelihood that adolescents will start to drink alcohol, with increased drinking amongst baseline drinkers and drinking more if they are already consuming alcohol [13].

WHO, in their submission to the World Health Assembly, noted that it is very difficult to target young adult consumers without exposing cohorts of adolescents under the legal age to the same marketing practices. Controls or partial bans on volume, placement and content of alcohol advertising are important parts of a strategy, and research results underline the need for such controls or bans, in particular to protect adolescents and young people from pressure to start drinking. Marketing practices that appeal to children and adolescents could be seen as particular policy concerns [14].

In conclusion, we need wider societal action to complement the individual work such as ABIs. We could have acted in 1985 and introduced ABIs at the same speed and with the same systematic approach that we use for medicines but we didn’t. As a result we now have a very large problem.

Key points

Recommendations

There should be:

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