Written evidence submitted by the Alcohol Health Alliance UK (AHA) (PEG0228)

 

Introduction

The Alcohol Health Alliance UK (AHA) is an alliance of more than 55 non-governmental organisations that work together to promote evidence-based policies to reduce the harm caused by alcohol. Members of the AHA include medical royal colleges, charities and treatment service providers. We welcome the chance to respond to this inquiry.

 

Summary

 

 

 

 

 

 

What core/guiding principles should the Government adopt/prioritise in its recovery package, and why?

  1. As the UK emerges from the most acute phase of the pandemic, securing economic recovery and limiting the extent and impact of a recession will be the priority. The key to a strong and resilient economy is a healthy population; preventing poor heath in the population therefore needs to be a core principle of the recovery efforts.

 

  1. We did not go into this pandemic fighting fit. It is estimated that, before COVID-19, half of the burden of disease in this country was preventable.[8] A major contributor to that is alcohol.

 

    1. In England, alcohol has become the leading risk factor for death and illness among 15-to-49-year-olds.[9] There are more than 1.2 million alcohol-related hospital admissions every year in England alone.[10] In the UK, alcohol causes almost 12,000 cases of cancer annually, and it is the leading cause of liver disease, with over 5,700 alcohol-specific deaths due to liver disease annually.[11]

 

    1. The UK Chief Medical Officers (CMOs) recommend not to regularly drink more than 14 units of alcohol per week to keep risks low. However, in England, 22% of people over 16 consume more than 14 units of alcohol per week.[12] Moreover, 1.6 million adults in England may have some degree of alcohol dependence.[13]

 

  1. The poor health caused by alcohol has a significant negative impact on the economy. It not only causes higher costs for public services, such as the NHS, but also undermines the productivity of the working age population, leading to reduced tax receipts due to lower employment and earnings.

 

    1. In 2016, the overall societal harm of alcohol was estimated at between £27-£52 billion.[14] Public Health England (PHE) notes that “the financial burden which alcohol-related harm places on society is not reflected in its market price, with taxpayers picking up a larger amount of the overall cost of harm compared to individual drinkers”.[15]

 

    1. Alcohol has a negative impact on the UK’s productivity. More working years of life are lost through alcohol than through the ten most common cancers combined.[16] The UK Government’s official estimate suggests that alcohol costs the British economy £7.3 billion a year, through: (1) the loss of working age people from the labour force due to premature death, (2) higher unemployment among heavy drinkers and (3) higher rates of sickness absence due to alcohol consumption.[17] This estimate does not include presenteeism: the cost to the economy of workers who are less productive when they are at work due to their drinking (either because they are intoxicated or hungover). This cost is estimated to be between £1.2 billion and £1.4 billion a year.[18]

 

    1. Alcohol also adds considerable pressure onto public services, with annual costs to NHS England of £3.5 billion.[19] Alcohol-related incidents are estimated to take up more than a third of ambulance time and account for a quarter of A&E work.[20] About 40% of violent crime across the UK involves alcohol.[21] Police report that more than half of their time is spent on alcohol-related case work.[22]

 

  1. There are further concerns that the pandemic and subsequent lockdown have made the situation worse.

 

  1. The impact of the pandemic and subsequent lockdown on alcohol consumption is not clear yet. While sales in supermarkets increased significantly in the early weeks of lockdown, it is unclear if this off-set the complete lack of on-trade consumption during lockdown. The latest HRMC figures show that alcohol duty revenue fell by 2.4% from April to July, compared to the previous year.[23] This suggests a small decrease in overall alcohol consumption.

 

  1. However, at the individual level, there is a mixed picture: while some people reduced their alcohol consumption, others increased theirs. Worryingly, those who drank more seemed to be those who were already drinking at high levels before the pandemic: a UCL study found that high-risk drinking has increased by over 80% during lockdown.[24]

 

  1. Moreover, there are concerns that there will be a spike in people needing support with their alcohol use over the coming months. Experiencing bereavement, job loss, financial insecurity, stress or anxiety are all factors that could lead to somebody drinking more alcohol: The pandemic has increased the amount that I drink when I am alone at home. I have also used alcohol to manage huge increases in stress and demands at work (as a psychological therapist in the NHS). It is more difficult to access the usual ways that I would manage stress (socialising and cinema and coffee shops etc).[25]

 

  1. To prevent a further crisis, it is essential to ensure that treatment services have the capacity and sufficient funding to provide support to all those who need it.

 

  1. Reducing alcohol harm needs to be an integral part of any recovery effort.[26] It would not only be a boon for the population’s health, but also for our economy. In addition to driving wider improvements across the economy through improvements in population health, some of the most effective policies to reduce consumption of unhealthy commodities also raise revenue. Public health policies thus have a key role to play in unleashing economic potential, particularly in more disadvantaged parts of the country.

 

What opportunities does this provide to reset the economy to drive forward progress on broader Government priorities, including the ‘levelling up’ agenda?

 

  1. Reducing alcohol harm can also contribute to the government’s priority of ‘levelling up’. It is an important route to reducing health inequalities, as acknowledged by Public Health England.[27]

 

  1. The burden of ill health in this country is not equally distributed.

 

  1. Before the pandemic, the gap in life expectancy between the most and least deprived areas in England was 9.5 years for men and 7.5 for women.[28] Moreover, those living in the most deprived areas spend almost two decades more in poor health, compared to those in the least deprived areas.[29] Since 2010, improvements in life expectancy have mostly stagnated, and inequalities in life expectancy and healthy life expectancy between lower and higher socioeconomic groups have widened, especially among women.[30]

 

  1. Preventable diseases that can increase the risk of dying from COVID-19, including diabetes, respiratory and cardiovascular diseases, are also more common in the most deprived areas.[31]

 

  1. Alcohol is a significant driver of health inequalities. Alcohol use accounts for up to 27% of the socioeconomic inequalities in mortality.[32] Moreover, premature mortality related to alcohol and drug use is among the most unequal causes of death.[33]

 

    1. Even though more deprived groups generally consume less alcohol, they are disproportionately more likely to experience the impacts of alcohol-related health conditions.[34]

 

    1. In England, people from the most deprived decile are up to 60% more likely to both die from an alcohol-related cause or to be admitted to hospital due to alcohol than those from the least deprived decile.[35]

 

    1. There are also stark regional differences. In the North East of England, alcohol specific mortality is 45% higher than the English average; in the North West, it is 36% higher. Similarly, alcohol-related hospital admissions are 24% higher in the North East and 16% higher in the North West, compared to the English average.[36]

 

    1. In Scotland, 40% of the total costs associated with alcohol consumption arise from the 20% most deprived areas.[37]

 

  1. The pandemic has both highlighted and compounded inequalities. PHE estimates that infection and death rates in deprived areas are twice that of the least deprived areas, and notes that the rate of comorbidities in deprived groups warrants additional investigation.[38]

 

  1. It should be a top priority for the government to eliminate these pre-existing inequalities which contributed to such a disproportionate impact from COVID-19. Given the impact alcohol has on health inequalities, reducing alcohol harm needs to be central to any strategy to address health inequalities, ‘level up’ and build a more resilient society.

 

 

What lessons should the Government learn from the pandemic about actions required to improve the UK’s resilience to future external shocks?

  1. A key lesson to be learned from the pandemic is the need to focus on improving the country’s health and drive down preventable illness. The level of pre-existing poor health has undoubtedly impacted on the severity of the epidemic. Many of the comorbidities associated with adverse outcomes from COVID-19 are linked to alcohol. It is further likely that ill-health due to alcohol might be linked to the higher rates of death and illness in the most deprived areas. Reducing alcohol harm is an integral part of any plan to build resilience against future shocks, particularly in communities most vulnerable to them.

 

  1. In 2019, the government published the Prevention Green Paper Advancing our health: prevention in the 2020s. We are still awaiting the government’s response to the consultation. While much of the framework of the paper remains relevant, the unprecedented impact that COVID-19 has had on the nation’s health, the health and social care system, and the economy means there is a need to review and renew the prevention strategy.

 

  1. A new comprehensive strategy is vital to tackle the legacy of the lockdown and secure a resilient, healthy population and economy in the aftermath of the COVID-19 pandemic. A bold new prevention strategy, building on and going beyond, the Prevention Green Paper, needs to be evidence-based and include action to reduce the affordability of alcohol and introduce effective alcohol marketing controls.

 

  1. Reducing the affordability of alcohol is one of the most effective policies to reduce alcohol harm, as recommended by the World Health Organization (WHO), PHE and others. This can best be done by increasing alcohol duty (which also raises urgently needed revenue), and by introducing minimum unit pricing (MUP).

 

    1. The 2012 Alcohol Strategy recognised that “cheap alcohol is too readily available and industry needs and commercial advantages have too frequently been prioritised over community concerns”.[39] Since then, off-trade beer has become 29% more affordable.[40]

 

    1. One person commented on how easy it was to get cheap alcohol during the lockdown: “I think it was shocking and shocked me how at a time when we need mental health and physical health to be at its best shops and delivery apps are there to serve ever cheaper booze at anytime of day. The apps allow the alcohol abuser to hide completely and have it delivered to their door.” Francesca[41]

 

 

    1. Alcohol duty has been repeatedly cut or frozen since 2012. These cuts will cost the Treasury over £1.5bn in 2020/21 in foregone revenue.[42] Increasing alcohol duty by 2% above inflation every year, would not only increase revenue, but would, between 2020-2032, also save,:
  1. more than 5,000 lives in England and Scotland,
  2. £794 million for NHS England and £46 million in Scotland, and
  3. £156 million in England and £13 million in Scotland by reducing workplace absences.[43]

             

    1. The forthcoming alcohol duty review offers an opportunity to create a fairer alcohol duty system, whereby taxes recoup the social harm alcohol causes. To ensure stronger drinks always cost more, all alcohol should be taxed according to strength.

 

    1. MUP specifically targets cheap, high-strength alcohol, while leaving prices in pubs and restaurants largely untouched. A 50p MUP in England is estimated to save 525 lives annually (at full effect).[44]

 

  1. MUP can further help reduce health inequalities: 90% of the lives saved from a 50p MUP in England would come from low income groups.[45]

 

  1. Scotland introduced MUP in May 2018 and Wales in March 2020. Early results from Scotland indicate an overall fall in consumption following the introduction of MUP.[46] Moreover, this fall appears to have occurred particularly amongst those consuming the most.[47]

 

  1. There is also overwhelming evidence that alcohol advertising influences drinking behaviour, especially of children and young people.[48] The current self-regulatory marketing system and codes of conduct are inadequate and are failing to protect children and vulnerable people.

 

    1. Exposure of children and young people to alcohol marketing leads them to drink at an earlier age and to drink more than they otherwise would.[49] A survey of Scottish primary schools found that nine out of ten children recognised the beer brand ‘Foster’s’, a higher recognition rate than for leading brands of crisps, biscuits and ice-cream.[50]

 

    1. In the first instance, various small policies can be introduced to help protect children from alcohol marketing. These include ending sports sponsorship, restricting alcohol advertising to R18 films and not allowing it near schools. The Republic of Ireland has brought in several of these policies.

 

    1. Ultimately, however, comprehensive restrictions on alcohol marketing across multiple media are one of the best and most cost-effective ways to reduce alcohol harm, as recommended by the WHO.[51] There are international examples of good practice, such as in France, where alcohol advertising and sponsorship is not permitted on TV and radio. Alcohol advertising is only permitted in adult print media and limited to descriptive qualities of the product, such as strength and provenance, accompanied by a health warning.[52]

 

 

September 2020


[1] DHSC (2018). Prevention is better than cure.

[2] PHE (2016) The public health burden of alcohol and the effectiveness and cost-effectiveness of alcohol control policies

[3] Public Health England (2020). Disparities in the risks and outcomes of COVID-19.

[4] Home Office (2012) A Minimum Unit Price for Alcohol Impact Assessment. London: Home Office.

[5] Institute of Alcohol Studies (2019) Financial Headache, the cost of workplace hangovers and intoxication to the UK economy.

[6] Home Office (2012). Impact assessment: a minimum unit price for alcohol.

[7] The Institute of Alcohol Studies (2015). Alcohol’s impact on emergency services.

[8] DHSC (2018). Prevention is better than cure.

[9] PHE (2016) The public health burden of alcohol and the effectiveness and cost-effectiveness of alcohol control policies

[10] Public Health England (accessed March 2020). Local alcohol profiles for England.

[11] Brown, KF. et al. (2018). The fraction of cancer attributable to modifiable risk factors in England, Wales, Scotland, Northern Ireland, and the United Kingdom in 2015; The British Journal of Cancer; British Liver Trust (2019). Facts and statistics; Office of National Statistics (2018). Alcohol specific deaths in the UK: registered in 2018.

[12] NHS Digital (2019). Health Survey for England 2018 adult’s health-related behaviours.

[13] Public Health England (2016). Health matters: harmful drinking and alcohol dependence.

[14] Burton, R. et al. (2016). A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an England perspective. The Lancet.

[15] PHE (2016) The public health burden of alcohol and the effectiveness and cost-effectiveness of alcohol control policies

[16] PHE (2016) The public health burden of alcohol and the effectiveness and cost-effectiveness of alcohol control policies

[17] Home Office (2012) A Minimum Unit Price for Alcohol Impact Assessment. London: Home Office.

[18] Institute of Alcohol Studies (2019) Financial Headache, the cost of workplace hangovers and intoxication to the UK economy.

[19] Home Office (2012). Impact assessment: a minimum unit price for alcohol.

[20] The Institute of Alcohol Studies (2015). Alcohol’s impact on emergency services.

[21] 39% in England and Wales, 46% of violent crime in Scotland, approximately 40% in Northern Ireland: Office of National Statistics (2019). The nature of violent crime in England and Wales: year ending March 2018; Scottish Government (2019). Scottish crime and justice survey 2017-2018: main findings; Police Service of Northern Ireland (2019). Trends in domestic abuse incidents and crimes recorded by the police in Northern Ireland 2004/05 to 2018/19.

[22] The Institute of Alcohol Studies (2015). Alcohol’s impact on emergency services.

[23] HM Revenue & Customs (2020). UK Alcohol Duty Statistics. May to July 2020 update.

[24] Jackson, S. et al (2020). Association of the Covid-19 lockdown with smoking, drinking, and attempts to quit in England: an analysis of 2019-2020 data.

[25] Respondent to a survey by the Alcohol Health Alliance UK, August 2020

[26] Finlay, I. & Gilmore, I. (2020). Covid-19 and alcohol – a dangerous cocktail. BMJ Editorial.

[27] Public Health England (2016). Health matters: harmful drinking and alcohol dependence, health inequalities and alcohol dependence.

[28] ONS (2017). How does deprivation vary by leading cause of death?

[29] ONS (2017). How does deprivation vary by leading cause of death?

[30] Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health Equity in England: The Marmot Review 10 Years On. Institute of Health Equity; 2020.

[31] NHS Digital (2020). National Diabetes Audit - Report 1 Care Processes and Treatment Targets 2018-19, full report; ONS (2017). How does deprivation vary by leading cause of death?; PHE (2018). Health Matters: NHS Health Check - A world leading CVD prevention programme.

[32] Probst, C. et al (2020). The role of alcohol use and drinking patterns in socioeconomic inequalities in mortality: a systematic review. The Lancet Public Health.

[33] Lewer, D. et al (2019). Premature mortality attributable to socioeconomic inequality in England between 2003 and 2018: an observational study. The Lancet Public Health.

[34] Institute of Alcohol Studies, Socioeconomic groups' relationship with alcohol.

[35] Public Health England (2020). Local Alcohol Profiles for England.

[36] Public Health England (2018). Local Alcohol Profiles for England.

[37] Johnston. M. C. et al (2012). Inequalities in the Distribution of the Costs of Alcohol Misuse in Scotland: A Cost of Illness Study Alcohol and Alcoholism.

[38] Public Health England (2020). Disparities in the risks and outcomes of COVID-19.

[39] HM Government (2012) The Government’s alcohol strategy

[40] IAS analysis, based on ONS RPI data and NHS Digital's Alcohol Affordability Index

[41] Respondent to a survey by the Alcohol Health Alliance UK, August 2020

[42] Institute of Alcohol Studies (2020) March 2020 Budget analysis

[43] Angus, C. & Henney, M. (2019). Modelling the impact of alcohol duty policies since 2012 in England and Scotland. The University of Sheffield and IAS.

[44] Angus, C. et. al. (2015). Modelling the impact of Minimum Unit Price and Identification and Brief Advice policies using the Sheffield Alcohol Policy Model Version 3.

[45] Meier PS, et al. (2016) Estimated Effects of Different Alcohol Taxation and Price Policies on Health Inequalities: A Mathematical Modelling Study. PLoS Medicine

[46] National Health Service Health Scotland (2019). MESAS monitoring report 2019.

[47] O’Donnell, A. et al. Immediate impact of minimum unit pricing on alcohol purchases in Scotland: controlled interrupted time series analysis for 2015-18. BMJ

[48] Anderson, P. et. al. (2009). Impact of alcohol advertising and media exposure on adolescent alcohol use: A systematic review of longitudinal studies. Alcohol and Alcoholism 44(3), 229-243.

[49] PHE (2016) The public health burden of alcohol and the effectiveness and cost-effectiveness of alcohol control policies

[50] Alcohol Focus Scotland (2017) Promoting good health from childhood. Reducing the impact of alcohol marketing on children in Scotland

[51] WHO (2017) ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases’

[52] Institute of Alcohol Studies Marketing factsheet