Behind The Medical Headlines

The trouble with alcohol… Part 2: Alcohol and society

• Dr S Al-Shamma, Specialist Registrar, Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
• Dr MG Lombard, Consultant Physician and Hepatologist, Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK

Summary

In the second of a two-part series on alcohol, Drs Safa Al-Shamma and Martin Lombard discuss the socio-economic aspects of alcohol consumption as they relate to the UK and Scotland in particular, and examine how drinking behaviour might be influenced.

Declaration of interests: None declared.

‘Ideal’ and moderate levels of consumption

Alcohol consumption has traditionally been measured using the arbitrary ‘unit’ of alcohol. This represents the volume of ‘absolute’ alcohol, as opposed to the volume of the beverage. A unit is not standardised and varies throughout the world. In the UK, a unit is defined as 8 g or 10 ml of ‘pure’ alcohol, compared with 14 g or 18 ml in the US and 12 g or 15.2 ml in France. Difficulties arise in calculating an individual’s alcohol consumption due to the wide variety of beverages with differing alcohol by volume (ABV) percentages. The best method of calculating the units in a specified volume of a beverage with a known ABV is to use the following formula: volume of alcohol (ml) x ABV/1,000.

Until recently, it has been accepted that drinking alcohol in moderation confers numerous health benefits, particularly cardiovascular protection. More recent studies, however, seem to dispute these traditional findings.¹ The debate as to whether ‘ideal’ levels of alcohol consumption actually exist still rages, as does the argument about what exactly constitutes moderate or non-harmful alcohol consumption.

It has been difficult to define moderate alcohol consumption, largely due to significant inter-population and inter-individual variability. In otherwise healthy individuals, it appears that men can tolerate alcohol better than women. This phenomenon is more complex than can be solely attributed to the higher volume of distribution found in men.

From large population observational studies, the amount of alcohol consumption associated with the lowest mortality was 6 g per day for men and only around 4 g per day for women (around half a unit). The current consensus for weekly alcohol limits is 21 units for men and 14 units for women. Recently, increased emphasis has been placed on safe daily alcohol consumption limits of around three units per day for men and two units per day for women. Alcohol-free days and the avoidance of binge drinking also appear to be important factors in reducing alcohol-related harm. Liver disease may still occur in patients despite an apparent adherence to current recommended weekly limits. People consuming greater than recommended levels are considered ‘hazardous’ drinkers, while those drinking excessively despite obvious detrimental effects are ‘harmful’ drinkers.

Society of excess

The unabated rise in alcohol consumption in the UK, and Scotland in particular, has been well-documented and is a major cause for concern. Over the past 40 years, alcohol consumption has doubled in the UK from 5.7 l of pure alcohol per head in 1960 to 11.3 l in 2005, according to the BBPA Statistical Handbook, which uses Customs and Excise data on alcohol clearance in the UK. Alcohol Focus Scotland² puts this increase down to three main factors, aptly called the three As of alcohol: acceptability, affordability and availability.

Acceptability

Alcohol is seen as a social pastime in today’s society and excess drinking, particularly over the weekend, is considered acceptable. Drunken behaviour is often viewed in a humorous light and accepted by young people. Despite an increased crackdown by the police on such behaviour, the overall concern generated is often less than that seen with drug abuse.

Affordability

Alcohol in the UK has become increasingly cheap in relative terms over the past 50 years. The more affordable it has become, the greater the consumption experienced. European and North American studies have confirmed that alcohol behaves like most commodities – as prices rise, demand falls and vice versa. Cheap alcohol also means easy affordability for children.

Availability

In terms of availability, there has been a sharp rise in the number of licensed premises selling alcohol. Most major supermarkets sell alcohol, often at a loss, in order to attract customers.

Burden of disease

Research confirms that there is a direct association between the amount of alcohol a nation consumes and the increasing burden of harm. The liver is not the sole organ to suffer. Alcohol is the third most important factor implicated in the disease burden of developed countries, after smoking and hypertension. In 2002, despite a falling trend, about 600,000 people died of alcohol-related disease in Europe alone.³

The increasing health burden of alcohol problems has slowly become more high profile and has consequently garnered greater attention from the media. The BBC has increasingly reported on the health consequences associated with alcohol abuse, often presenting stark statistics. A recent BBC article, for instance, reported a doubling of the number of patients diagnosed with alcohol-related liver disease in Scotland between 1996 and 2006 from 1,731 to 3,541,⁴ placing Scotland at the top of Europe in terms of cirrhosis rates. In line with rising cirrhosis rates, the number of patients dying from this disease has also been increasing. The number of cirrhosis-related deaths is an important marker of a nation’s alcohol problems. People in the most deprived areas are, unsurprisingly, the most likely to be admitted with and die of alcohol-related diseases.

In England, admissions to NHS hospitals where alcohol-related disease was the primary or secondary diagnosis have doubled since 1996 and stood at 207,788 in 2006.⁵ In the same year, 6,517 deaths were attributed to alcohol, with 4,160 deaths due to liver disease.⁵ For the UK as a whole, a total of 8,758 alcohol-related deaths occurred in 2006, compared with 4,144 deaths in 1991.⁶ Overall, alcohol-related mortality in the UK was 13.4 per 100,000 population (having doubled from 6.9 per 100,000 in 1991). The biggest rise in death rates was seen in men aged 35–54.⁶ The alcohol-related death rate in Scottish men was almost twice as high as the rest of the UK and, worryingly, Scottish women had a higher alcohol-related mortality rate than English men.

The health cost of alcohol-related problems in Scotland has also soared to an estimated £405 million in 2007.⁷ Other than health costs, alcohol-related crime is estimated to cost Scotland around £379 million a year,⁷ and around 45% of offenders in prison admit to having been drunk at the time of committing their offence. The ‘economic/productivity lost’ cost to society is estimated at around £820 million. The overall cost to Scotland of excess drinking is currently estimated as around £2.25 billion,⁷ equating to around £500 per year for every adult. Similarly, in England alcohol misuse was estimated to have cost the health service around £1.4–1.7 billion⁵ in 2004, and the economy as a whole around £6.4 billion.⁶

The solution?

The scale of the alcohol problem has reached near-epidemic levels, and urgent action is necessary. Despite recent advances, outcome remains poor in established liver disease. Its burden on healthcare will continue to be a major drain on resources. As with smoking, prevention will always be the most important ‘management’ modality. This is not merely a logical conclusion: in the years following prohibition in the US, there was a significant reduction in the rates of liver cirrhosis deaths. More recently, in Italy and France, a reduction in average alcohol consumption has led to a fall in alcohol-related mortality within a relatively short period of time.

The Scottish Government has recently published a discussion paper for an alcohol misuse strategy,⁷ which will involve the public. Moreover, the Scottish medical colleges have recently collaborated in the formation of Scottish Health Action on Alcohol Problems (SHAAP),⁸ the overall aims of which are to encourage an increased awareness of the extent of the problems as well as ensuring nationwide involvement in the decision-making process to develop solutions.

Interventions need to be targeted at the population as a whole rather than at high-risk groups only. No one single strategy is likely to succeed, but rather a combination of any number of approaches is needed. A World Health Organization review³ found that the most effective strategies included tighter drink-driving laws, price control policies and brief interventions for hazardous drinkers (up to 20–30-minute sessions explaining the likely adverse outcome of such alcohol consumption levels, performed by the general practitioner or specialist nurses). Clearly, ensuring adequate resources is vital for the success of such interventions.

The simplest and perhaps most effective solution would be to raise the prices of alcoholic beverages since the low pricing of alcohol has at the very least exacerbated the problem of dangerous drinking. The UK tax levied on alcoholic drinks has only increased in line with inflation over the past years, and this provides leeway to increase taxation, particularly on higher strength beverages. Cider is taxed at a lower rate than beer and is therefore an attractive beverage to vulnerable groups, especially children and people of lower economic status, because it is cheaper relative to its alcoholic strength.

It might prove valuable to follow the example of European countries where success in reducing the level of alcohol consumption has been achieved. France experienced a decline of alcohol consumption from 17.7 l per head in 1960 to around 10 l per head in 1999.⁷ This may be attributed to its aggressive restriction in advertising and tougher drink-driving laws, as well as a major cultural shift away from long lunches where wine was consumed. Alternative leisure activities, such as sport, have also become more popular.

Increasing the legal age for drinking to 21 has recently been proposed as a potential measure aimed at reducing childhood drinking and addiction, which has been an increasing problem. To that end, identifying and helping children whose parents abuse alcohol may be just as important.

The alcohol industry needs to be more strictly regulated. An end to ‘happy hours’, where drinks are sold at low prices, is required. Manufacturers have successfully targeted young adults and children with clever packaging and attractive drinks. Licensing-hour regulations have recently been relaxed, and this needs to be reconsidered.

The media will have a vital role to play in changing a nation’s attitudes and behaviours in the long term. As mentioned above, the alcohol problem has already attracted increased media attention, and this needs to continue. Improved understanding and greater awareness of the harms and dangers of alcohol excess need to be effectively communicated. Stricter limitations on advertising, or perhaps even a complete ban on advertising as with the tobacco industry, may be an avenue worth further exploration.

In conclusion, urgent action is required for a problem that has been ignored for too long. The approach needs to be population-wide. Structured and regulatory interventions are more likely to be successful than an information-based approach. Social inequality and maldistribution of wealth are important contributing factors to alcohol-related mortality and need to be addressed in wider alcohol policies. The eventual aim should be for a cultural shift in attitudes away from the currently accepted standards. Unless a true desire to eliminate the problem exists, the alcohol epidemic will continue to grow unabated.

References

1. Jackson R, Broad J, Connor J et al. Alcohol and ischaemic heart disease: probably no free lunch. Lancet 2005; 366(9501):1911–2.
2. Alcohol Focus Scotland
3. World Health Organization. Alcohol policy in the WHO European Region: current status and the way forward.Copenhagen/Bucharest: WHO; 2005.
4. BBC News. Liver disease ‘doubles in decade’
5. NHS Data Information Centre. Alcohol statistics
6. UK Statistics Authority. Alcohol deaths: rates in the UK continue to rise.
7. Scottish Government. Changing Scotland’s relationship with alcohol: a discussion paper on our strategic approachEdinburgh: Scottish Government; 2008.
8. Scottish Health Action on Alcohol Problems