(Updated with additional references)
The past 50 years have seen the worst epidemic of public harm from a legal drug since the introduction of cheap gin in the 1700s (1, 2). Although alcohol intake has doubled in this period (3), alcohol related harms have increased many times more on account of the culture of heavy and, particularly, binge drinking that has developed.  There are a number of reasons for this epidemic. The major ones have been the last government’s policies of reducing the real price of alcohol (4) and increasing drinking hours (5), plus the massive increase in the marketing of alcohol in supermarkets, often as a loss-leader (6).  There has also been a marked growth in strong lagers and ciders of up to 8% alcohol content that appear designed to facilitate rapid intoxication rather than to satisfy palates (7).

Attempts to rectify this situation, such as the report by the Chief Medical Officer last year (8) and NICE this month that recommended pricing per unit of alcohol in drinks (9), and the Royal College of Physicians report the year before (10), were dismissed by government and the drinks industry as soon as they were published on spurious and intellectually dishonest grounds (see previous post Alcohol: the new opium of the masses?).  Thankfully we have a new government and one that in the run up to the election pointed out the issues especially of high strength ciders that have never been near an apple; some are a purely synthetic mixture of malic acid and alcohol! (11)  So what should the coalition do to reduce the harms of alcohol?  Here are my top twenty suggestions:

1.    Make alcohol a national health priority:  current estimates are that the damage from alcohol costs the NHS the order of £20bn per year and the violence it induces cost £7billion in police time.

2.    Tax according to alcohol content since alcohol is the dangerous drug in drinks. Everyone accepts the rationality of this between alcohol classes – e.g. sherry is taxed more than beer and less than spirits, so there is a precedent that could easily be brought into action. A can of 8% lager should cost twice that of a 4% one and 4 times that of a 2% one. This was planned by the last Labour government and the coalition missed a real opportunity to make a statement about alcohol harms by not increasing the tax in this way despite their manifesto commitment (12).

3.    Increase alcohol tax to bring the cost of alcohol in real terms back to where it was in the 1950s before the progressive rise in consumption started, i.e. gradually, say over 5 years, triple the price.  All available evidence shows that the price of alcohol determines use for almost everyone with the only possible exceptions being severely dependent drinker (13)s. The increased health burden of alcohol is largely driven by non-dependent drinkers so would be significantly reduced by an increase in price. I have estimated that the average taxpayer would save the order of £2,000 per year by the reduced costs of alcohol-related harms if we increased the price as suggested.  In the case of wine drinkers, only those consuming more than several hundred bottles a year would be worse off with this scheme, and they are drinking at a dangerous level anyway.

4.    Stop selling strong alcohol in supermarkets; use the Swedish model where only alcoholic drinks of less than 3% can be sold outside licensed shops that have more limited opening times than supermarkets (14). Supermarket alcohol sales are not only destroying lives but also public houses and other alcohol outlets where drinking is conducted in a social manner and where intoxication can be monitored and young people can learn to drink socially and more sensibly.

5.    Ban special discounting of alcohol in bars e.g. happy hours, all you can drink for £10 etc.

6.    Stop selling wine in larger 250 ml glasses that have crept up on use in recent years – we should go back to smaller glasses again.  For a medium size female, 5 large glasses of wine in one hour will lead to  a blood alcohol level of 300mg/% which is that needed to produce coma.

7.    Repeal the 24 hr licensing law so bars close at 11pm.

8.    Ban organisations such as Carnage UK that promote dangerous levels of drinking as entertainment (15).

9.    Make it a law that all alcohol outlets must sell non-alcoholic beers and lagers so that those who like the taste of ales can get it without the risk on intoxication.  Make these drinks be sold at below the cost of equivalent alcohol-containing ones and make it obvious that they are available.

10.    Enforce the law that makes serving drunk customers illegal in bars: have breathalysers in bars and clubs so that seemingly intoxicated people can be tested and denied more alcohol if they are above 150mg/%.

11.    Add warning notices to all drinks warning of the damage alcohol does, as with those on cigarette packets.

12.    Reduce the drink driving limit to 40mg/% to deter drink driving and hence reduce drinking. And if caught, get people properly assessed and repeal their licences if they flout DVLA guidance.  Encourage the wider use of alcohol detectors in cars.

13.    Invigorate the treatment of alcohol dependence by making alcohol a priority for the national treatment agency; encourage the use of proven treatments that reduce drinking and stop relapse.

14.    Provide incentives to the pharmaceutical industry to develop new treatments for alcohol dependence and its consequences.

15.    Encourage research into developing an alcohol alternative that is less dangerous, intoxicating and addictive than ethanol and for which an antidote or antagonist can be made available to prevent deaths in overdose.

16.    Educate from primary school age about the dangers of alcohol.

17.    Develop public campaigns to make alcohol unfashionable just as was done for tobacco.

18.    Ban all alcohol advertising as with tobacco.

19.    Ban all government supported organisations e.g. universities from having subsidised bars. Ban drinking games and pub-crawls in public organisations such as university sports and social clubs; remove financial support from clubs that allow these.

20.    Raise the drinking age to 21. When this was done in the USA in the 1990s it was estimated that over 170,00 lives were saved in road deaths (16).

Finally, a measure that could be a powerful tool in the implementation of the above would be to reduce the use of alcohol by politicians as it could distort their objectivity in law-making in relation to the harms of alcohol. Get them to openly declare any association with the alcohol industry. The government’s wine cellar should be closed and the subsidy of alcohol in the Houses of Parliament stopped. Somehow though, it seems unlikely that MPs would call time on that particular perk…

References:

1. The cost of alcohol related harm to NHS £2.7 billion at 2006/7  prices,  cost to Society  £17.7 to £21.5 billion.  (2008) Dept of Health
http://www.direct.gov.uk/en/Nl1/newsroom/DG_170745

2.Hospital Admissions linked to alcohol 65% increase over 5 years to 2008/9 (2010)
Data Dept. of Health
http://www.nwph.net/alcohol/lape
( lape =local alcohol profile England)

3/4. Institute of Alcohol Studies (2008)  “Alcohol: Tax, Price and Public Health”.  Institute of Alcohol Studies,
http://www.ias.org.uk/resources/factsheets/tax.pdf

per capita consumption of alcohol has doubled from 6.l per year in1960s to 11.5 l a year in 2000, price  (relative to income ) halved since 1960s

5. LicencingAct  2003 HMSO  -   commenced Nov. 2005

6. Bennetts,  R (2008) Use of Alcohol as a Loss Leader.  IAS briefing.
http://www.ias.org.uk/resources/papers/occasional/lossleading.pdf

discusses “pre-loading” with alcohol ( he suggests link with reduction in  “happy hours “)

7. Doward , J  (2010) Super Strength alcohol is killing more people than “crack” or heroin. Observer 29/08/10
http://www.guardian.co.uk/society/2010/aug/29/super-strength-alcohol-killing-homeless
not referenced, interview with homelessness workers

8. Donaldson, L  On the state of the Public Health  (2009)
http://www.gov.uk/en/publicationsandstatistics/publication/annualreports/DH_096206

good overview, discusses  concept of “passive drinking” cf smoking, minimum pricing ie 50p per unit of alcohol, per capita adult intake (England)  = 120 bottles of wine per annum
he says alcohol use is up 40%  from 1970s  ( NB see ref 3  ).

9. NICE  Alcohol use disorders, preventing the development of hazardous and harmful drinking.  (June 2010)  Public Health Guidance, 24

suggests minimum price per unit alcohol, reduce availability
states between 1980 and 2008 alcohol became 70% more affordable
lists Government initiatives since 2004

10.Royal College of Physicians, (2009)  Submission to Health Select Committee Enquiring into Alcohol
http://www.rcplondon.ac.uk/professional-issues/public-health/documents/RCP-HSCl/alcohol.pdf

11.refers to James Crowden who on his blog  www james-crowden.co.uk
explainshow super strength cider is made
author and poet, “expert “ on Cider

12. Not in Conservative Manifesto per se.  ( Oct 2009) Chris Grayling  (Shadow Home Sec.) proposed  in speech 1. significant tax increase on  “alcopops”, strong beer and strong cider, 2..supermarkets banned from selling below cost price 3 amuch tougher licencing regime

13. Pursehouse, Meier,P, Brennan,A, Taylor,K, Rafia,R,  (2010) Estimated effect of alcohol pricing policies on health epidemiological model. Lancet 375 (9723), 1355-64

14.  Swedish system for licencing alcohol.

http://www.Systembolaget.se

Alcohol is sold by state monopoly since 1955. Stated aim  “to reduce alcohol related harm by selling alcohol in a responsible way without profit motive”  (quote)

15 .www.carnageuk.com

16.Wagenaar, AC, Toomey,TL,  Effect of minimum drinking age laws. A review of the literature 1960-2000.  (2002) J of Studies on Alcohol,  suppl. 14:  206-22579 studies of MDLA (minimum legal drinking age) Conclusion  preponderance of evidence indicate found higher MDLA inversely related to traffic crashes  and amount of alcohol consumed.

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