Alcohol policies

Alcohol policies aim at preventing the harm done by alcohol consumption

Population-based interventions are the most effective measures

The most effective measures, in terms of preventing harm caused by alcohol to public health, are population-based interventions. Therefore, this EUphact focuses mainly on this type of intervention and not on treatment programmes. For more information on treatment see Alcohol consumption >> Interventions.

Alcohol policies are valued differently by stakeholders

Alcohol policies are valued differently by different stakeholders. Representatives of the alcohol industry, compared to representatives of governmental organisations and NGOs, are more in favour of educational measures than of regulatory measures such as tax and price measures. Additionally, while industry stakeholders view their involvement in the policy development process as important, NGOs see industry lobbying as a major barrier to effective policy to reduce alcohol-related harm (Anderson & Baumberg, 2005). In this EUphact different opinions are not elaborated further, except in relation to the opposition to the EU Alcohol Harm Reduction Strategy (see EU policies and strategies). Instead, the focus is placed on existing alcohol policies and on the evidence for effective alcohol policies. For more on existing policies see EU policies and strategies and National policies and strategies. For more information on the effectiveness of policies see Evidence: effective policy measures.

In the EU, alcohol is primarily treated as an economic commodity

In EU policies, alcoholic beverages are primarily treated as economic commodities. For example: the production of wine receives €1.5 billion worth of support yearly through the Common Agricultural Policy (CAP) (Anderson & Baumberg, 2006).

Alcohol consumption is a growing public health issue in the EU

First EU Alcohol Harm Reduction Strategy adopted in 2006

In October 2006, the European Commission adopted the first Alcohol Harm Reduction Strategy (COM(2006) 625). It identifies good practices which have led to 'positive results' and areas where further progress could be made. Among other outcomes, it led to the establishment of the Alcohol and Health Forum in June 2007 (EU press release IP/07/774). Both NGO’s, and commercial interest parties, such as breweries can participate in the Forum. The European Parliament adopted a resolution in which it welcomes the strategy, but calls upon the Commission to formulate 'ambitious general objectives for the Member States with a view to curbing hazardous and harmful alcohol consumption' (EP, 2007). See EU priorities in the Strategy on alcohol for the priorities that are identified in the Strategy.

The EU Alcohol Harm Reduction Strategy faced a lot of resistance

The EU Alcohol Harm Reduction Strategy faced a lot of resistance as it was being prepared. Especially alcohol industry organizations were opposed to it and argued that EU Member States should only have national policies (Kubosova, 2005). The Brewers of Europe sponsored a report on alcohol consumption in Europe, and used it to support this claim (Weinberg Group, 2006). This report was published almost at the same time as the EU funded Alcohol in Europe report, which the EU Strategy is partly based upon.

WHO is the most active international body on alcohol issues

The World Health Organization (WHO) has been the most active international body on alcohol. In 1979 the WHO World Assembly already spoke about the problems related to alcohol (Anderson & Baumberg, 2006). The first WHO regional office to launch an action plan on alcohol was the Regional Office for Europe in 1992. Another action plan, a charter and a Declaration on Young People and Alcohol followed, offering guidance for the development and implementation of alcohol policies in European countries (WHO, 2006c). The 1995 European Charter on Alcohol was based on 5 principles that still form the basis of the WHO alcohol policy (WHO, 1995e) .

The Framework for Alcohol Policy in the WHO European Region, of 2006, is the most recent WHO-Europe communication on alcohol policy. It states that there is a need for concerted action at a supra-national level, especially because national policy initiatives are being increasingly hampered by trade agreements, common markets and increased globalisation, despite society’s growing recognition of alcohol related problems and the growing awareness of available cost-effective measures (WHO, 2006c). The framework also identifies the need for coordinated and strategic national efforts. See Core areas and instruments for national action for more information on the latter.

National health policies are influenced by international treaties

Health policies of EU member states are influenced by international trade treaties, established by the World Trade Organisation (WTO). Treaties dealing with goods (GATT), and treaties dealing with services (GATS) are the most prominent international legal obligations. Common practice shows that the WTO will prioritise health over trade in some circumstances, but for this to be the case the health policies concerned must pass a series of strict tests. For example there needs to be proof that they serve a legitimate purpose and that no alternative measure is available that is less commercially restrictive (Anderson & Baumberg, 2006; Grieshaber-Otto, 2004). The impact that WTO treaties will have on health in the long run is unpredictable. Negotiations are ongoing and the economic and political values in relation to free trade do not always prove to be compatible with public health values (Anderson & Baumberg, 2006; Babor, 2002).

Policies reducing supply and availability are the most effective

Effective policy focuses both on total consumption and on risky drinking

Alcohol policy measures should combine both policies directed at the whole drinking population and measures directed at more risky drinkers with more detrimental drinking patterns (Babor, 2002; Edwards, 2001; Allamani et al., 2001). This is because many alcohol-related harms stem mainly from alcohol consumption in the general population, rather than from alcohol consumption by a specific group of risky drinkers. Therefore, reducing the total alcohol consumption will result in a reduction in alcohol-related public health problems, while implementing interventions focused on high-risk drinking, like interventions to reduce drink-driving, will result in a reduction of specific types of harm, such as accidents. Interventions directed at drinkers in general will however also affect heavy and risky drinkers (Edwards, 2001; Babor, 2002; Farrell et al., 2003; Cooke & Moore, 2002). For more information on average volumes of consumption, drinking patterns and their consequences see Alcohol use >> Consequences for individuals and society.

Community prevention programmes have potential

Community prevention programmes have the potential to effectively reduce alcohol-related harm. In community prevention programmes several partners work together, and different types of prevention measures are combined in one programme within a community (e.g. a city). Results of experiments vary. Some show substantial reductions in high-risk drinking and related harm, while others show minimal results (Stafström, 2007; Sweet & Moynihan, 2007 2007; Stafström et al., 2006; NIAAA, 2006; Holder et al., 2000; Holder, 1998). The European project Building Capacity has as one of it goals to develop knowledge on community alcohol action.The fact that community prevention can have big effects, confirms that a comprehensive approach is best for alcohol prevention policies. Experts have concluded this for local as well as regional and international levels (Edwards, 2001; Horlings & Scoggins, 2006).

The evidence-base for effective alcohol policy is geographically limited

The evidence base for effective alcohol policy is still largely dominated by studies from North America, Northern Europe, Australia and New Zealand. However, this evidence is also of significance for Europe as a whole (Anderson & Baumberg, 2006). Categories of policies that have been researched are mentioned in Alcohol use >> Interventions.

Alcohol policies are important in preventing socio-economic health differences

Alcohol consumption is an important entry point for policies and interventions to reduce socio-economic inequalities in health. This is because the level of alcohol consumption varies between different socio-economic groups. In some European countries, socio-economic differences in alcohol-related mortality have a great contribution to socio-economic differences in total mortality, while in other European countries the impact is less pronounced. Possibly drinking pattern differences within populations are partly responsible for these socio-economic differences (Eurothine, 2007). Regarding specific alcohol policies: price policies seem to have a greater impact on the lower socio-economic classes than on other classes. For more information on the socio-economic differences in alcohol consumption see Alcohol use >> Causes and risk factors and the EUphocus Health inequalities.

National alcohol policies: low comprehensiveness and strictness

On average, European countries have fewer alcohol policy measures in place than the rest of the world (Anderson & Baumberg, 2006). The policies in European countries are also generally less strict. For example, in a number of EU countries the minimum age for buying alcohol is 16 (though age limits may be graduated in relation to the type of beverage), while outside Europe a higher age limit of 18 is more popular.

There is growing similarity between national alcohol policies within Europe

Over the last five decades the alcohol policies of the different European countries have become increasingly similar. About 50 years ago, crudely speaking, low-consumption (Nordic) countries had a high level of alcohol control; the medium-drinking (Central European) countries had a medium level of alcohol control; and high-consumption (Southern European) countries had a low level of alcohol control (Leifman, 2002b; Österberg & Karlsson, 2002). See Occurrence of alcohol use for more information on the north-south gradient of drinking levels and drinking patterns.

Since 50 years ago things have changed: in 2000, national alcohol policies showed more similarities. The comprehensiveness and strictness of national alcohol policies had converged, although differences remained (Österberg & Karlsson, 2002). The converging trend is the result of two developments:

• Policies affecting availability were used to a lesser extent. For example, Swedish policies were weakened because of EU regulations (Crombie et al., 2007). Countries that have become increasingly interested in alcohol policy, have not focused on controlling the availability of alcohol, but on education instead.
• Alcohol control measures that were in place have become increasingly similar: such as BAC levels for drink-driving and legal age limits (Anderson & Baumberg, 2006).

Differences remain between countries

Despite converging trends, differences remain between countries in the comprehensiveness and strictness of alcohol policies. Not all the EU-25 countries have an action plan or coordinating body for alcohol, but most of them do have programmes for at least one aspect of alcohol policy. For more information see National alcohol policies in European countries. In general the least strict policies are in Southern Europe and parts of Central and Eastern Europe. Most of the strict policies can be found in Northern European countries. Countries that have stricter policies also tend to have high taxation levels. Exceptions to this rule are France (strict policy, low tax), Ireland and the UK (both low policy, high tax) (Anderson & Baumberg, 2006).

Cultures, economics and global trends affect alcohol consumption

Besides alcohol policies, factors such as culture, economics and global trends also contribute to alcohol consumption and changes in alcohol use (Leifman, 2002b). Especially qualitative features of drinking patterns, like binge drinking and beverage preferences are subject to cultural influences: they change slowly and are difficult to alter through policy measures (Simpura et al., 2002). Thus policy action is not the only factor responsible for changes in alcohol consumption. Over the last few decades alcohol consumption has, however, risen in European countries that have weakened their alcohol policies, such as Sweden and Finland, and declined in countries that are showing an increasing interest in alcohol policy: Occurrence of alcohol use (Leifman, 2002b).

The five priorities in the EU Strategy on alcohol

The first EU Strategy on alcohol was adopted by the European Commission in October 2006 (EC, 2006a). It identifies five priorities, which are to:

• protect young people, children and the unborn child;
• reduce injuries and deaths from alcohol-related road accidents;
• prevent alcohol-related harm among adults and reduce the negative impact on the workplace;
• inform, educate and raise awareness on the impact of harmful and hazardous alcohol consumption, and on appropriate consumption patterns; and
• develop, support and maintain a common evidence base.

WHO: ethical principles and goals for alcohol policy

The WHO adopted the European Charter on Alcohol on the 1995 European Conference on Health, Society and Alcohol in Paris, France. Next to ten strategies for action, it states 5 ethical principles and goals for alcohol policies. They still form the basis of the WHO alcohol policy strategy:

1. All people have the right to a family, community and working life protected from accidents, violence and other negative consequences of alcohol consumption.

2. All people have the right to valid impartial information and education, starting early in life, on the consequences of alcohol consumption on health, the family and society.

3. All children and adolescents have the right to grow up in an environment protected from the negative consequences of alcohol consumption and, to the extent possible, from the promotion of alcoholic beverages.

4. All people with hazardous or harmful alcohol consumption and members of their families have the right to accessible treatment and care.

5. All people who do not wish to consume alcohol, or who cannot do so for health or other reasons, have the right to be safeguarded from pressures to drink and be supported in their non-drinking behaviour.

Core areas and instruments for national action in the Framework for alcohol policy

• there is a need for supporting local communities in the development and implementation of effective measures in order to effectively prevent or reduce alcohol-related harm;
• a strong case can be made for restricting availability;
• availability plays a particularly important role in youth drinking, with social availability of alcohol, through parents and friends, calling for wider action;
• education and information should be combined with other measures in a comprehensive strategy;
• local regulation and enforcement can effectively reduce rates of alcohol-related problems like drink-driving accidents, violence and public disturbance;
• the efficacy of screening and brief intervention for hazardous drinking in primary health care is supported by a large body of international research literature; and that
• alcohol policies in the workplace need to be adopted to reach hazardous drinkers through workplace interventions.

The above table should be interpreted using the following criteria.

Effectiveness

This criterion refers to the scientific evidence demonstrating whether a particular strategy is effective in reducing alcohol consumption, alcohol-related problems or their costs to society. The following rating scale was used:

? No studies have been undertaken or there is insufficient evidence upon which to make a judgment.

Breadth of research support

The highest rating was influenced by the availability of integrative reviews and meta analyses. Breadth of research support was evaluated independent of the rating of effectiveness (i.e., it is possible for a strategy to be rated low in effectiveness but to also have a high rating on the breadth of research supporting this evaluation). The following scale was used:

Cost Efficiency

This criterion seeks to estimate the relative monetary cost to the state to implement, operate and sustain this strategy, regardless of effectiveness. For instance, increasing alcohol excise duties does not cost much to the state but may be costly to alcohol consumers. In this criterion, the lowest possible cost is the highest standard. Therefore, the higher the rating, the lower the relative cost to implement and sustain this strategy. The following scale was used:

National alcohol policies in European countries

The way in which alcohol policies have been implemented in the different European countries varies. A selection of policy actions is summerised and similarities and differences between countries are mentioned below (Anderson & Baumberg, 2006).

• Education and public awareness: Most countries have a minimum of school-based education programmes.
• Drink-driving countermeasures: All countries have some form of drink-driving restrictions. The Maximum BAL is 0,5g/L in all EU-25 countries, except in the UK, Ireland and Luxembourg. However, such restrictions are not optimaly enforced in all EU countries.
• Restrictions on the availability of alcohol: Most EU countries have restrictions on the sale of alcohol: in a few cases (Nordic countries) through retail monopolies, more often though through licences. All European countries have legal age limits for the sale of alcohol in bars and pubs, but not all have such age limits for shops. The actual age limit also varies between countries, with it being 18 years in most northern European countries and 16 in most southern European countries.

• Advertising controls: Alcohol marketing is controlled in different ways across Europe. The control measures employed varies for different types of marketing. For example: TV marketing restrictions are more common than billboard marketing restrictions. The EU-10 countries mostly have uncontrolled advertising environments, while the EU-15 countries mostly have voluntary agreements in place. In France and Sweden, as well as in the non-EU country of Norway, a total legal ban on TV advertising of alcohol has been implemented.
• Pricing and taxation: Taxation is a commonly employed policy that has been implemented in a wide range of different ways across Europe. The highest average effective tax rate on alcohol has largely been implemented in northern Europe, and the lowest in southern and parts of central and eastern Europe. Five countries, namely Denmark, France, Germany, Ireland and Luxembourg, started introducing a tax on alcopops from 2004 onwards (EC, 2006a) .

Breast cancer

Suicide (attempt)

Infant mortality

Life expectancy

Alcohol use

Diabetes

Healthy life expectancy

Mental Health in the EU

Health inequalities

Food, Nutrition, Physical Activity and Cancer

WHO Alcohol Control Database

WHO health for all database (HFA-DB)

WHO Global Alcohol Database

HP-Source.net European alcohol policy and alcohol prevention database

Health-EU Portal, alcohol

Health-EU Portal, EC Health Indicators

WHO lexicon of alcohol and drug terms

WHO-CHOICE project, CHOosing Interventions that are Cost Effective

EUROCARE European Alcohol Policy Alliance

World NGO Network on Alcohol and Public Health

Building Capacity, implementing coordinated alcohol policy in Europe

ELSA Enforcement of nat. laws and self-regulation on advertising & marketing of alcohol

PHP Pathways for Health Project on drink driving, binge drinking, health warnings and labelling for alcoholic beverages

Bridging the Gap, Alcohol Policy Network in the Context of a Larger Europe

ECAT To Empower the Community in response to Alcohol Threats

ECAS European Comparative Alcohol Study

EDAP Evidence for Drugs and Alcohol Policy: Cochrane Systematic Reviews

Informations- und Kommunikationsnetzwerk über Gesundheutsbezogene - Präventionsprojekte für Jugendlische in der Europäischen Union

Drive Clean! PEER-education-project for young drivers to prevent alcohol and drugs in connection with road use