Alcohol in Europe. A public health perspective
A report for the European Commission
Background to the report
At the time that the European Commission has been preparing its own strategy on alcohol to cover the full range of activity that takes place at a European level, it has called for an analysis of the health, social and economic impact of alcohol in Europe. This is the present report, which is an expert synthesis of published reviews, systematic reviews, meta-analyses and individual papers, as well as an analysis of data made available by the European Commission and the World Health Organization.
The report views alcohol policy as “serving the interests of public health and social well-being through its impact on health and social determinants.”
This is embedded in a public health framework, a process to “mobilize local, state, national and international resources to ensure the conditions in which people can be healthy”. A standardized terminology has been proposed throughout the report based on that of the World Health Organization, the specialized United Nations agency on health matters.
Alcohol and the economy of Europe
Europe plays a central role in the global alcohol market, acting as the source of a quarter of the world’s alcohol and over half of the world’s wine production. Trade is even more centred on Europe, with 70% of alcohol exports and just under half of the world’s imports involving the European Union (EU). Although the majority of this trade is between EU countries, the trade in alcohol contributes around €9 billion to the goods account balance for the EU as a whole.
It is hard to place a value on the amount of smuggling in the EU, although the European High Level Group on Fraud estimated that €1.5bn were lost to alcohol fraud in 1996. Price differences play more of a role in the level of legitimate cross-border shopping, where individuals legally bring back alcohol with them from cheaper countries. At least 1 in 6 tourists returns from trips abroad with alcoholic drinks, carrying an average of over 2 litres of pure alcohol per person in several countries.
The economic role of the alcohol industry is considerable in many European countries. Alcohol excise duties in the EU15 countries amounted to €25 billion in 2001, excluding sales taxes and other taxes paid within the supply chain – although €1.5 billion is given back to the supply chain through the Common Agricultural Policy. Due to the relative inelasticity of the demand for alcohol, the average tax rates are a much better predictor of a government’s tax revenue than the level of consumption in a country.
Alcohol is also associated with a number of jobs, including over three-quarters of a million in alcohol production (mainly wine). Further jobs are also related to alcohol elsewhere in the supply chain, e.g. in pubs or shops. However, the size of the industry is not necessarily a good guide to the economic impact of alcohol policies – for example, trends in alcohol consumption show no crude correlation with trends in the number of jobs in associated areas such as hotels, restaurants, and bars, suggesting that the effect of changes in consumption may be relatively weak.
Based on a review of existing studies, the total tangible cost of alcohol to EU society in 2003 was estimated to be €125bn (1.3% GDP), which is roughly the same value as that found recently for tobacco. The intangible costs show the value people place on pain, suffering and lost life that occurs due to the criminal, social and health harms caused by alcohol. In 2003 these were estimated to be €270bn, with other ways of valuing the same harms producing estimates between 150bn Euros and 760bn Euros. Although these estimates are subject to a wide margin of error, they are likely to be an underestimate of the true gross social cost of alcohol given the number of areas where it has been impossible to obtain data.
The use of alcohol in Europe
The EU is the heaviest alcohol consuming region of the world, although the 11 litres of pure alcohol consumed per adult each year is still a substantial fall from a recent peak of 15 litres in the mid-1970s. The last 40 years has also seen a harmonization in consumption levels in the EU15, with rises in central and northern Europe between 1960 and 1980, met by a consistent fall in southern Europe. Average consumption in the EU10 is also closer to the EU15 than ever before, although substantial variation remains within the EU10. Most Europeans consume alcohol, but 55 million adults (15%) abstain; taking this and unrecorded consumption into account, the consumption per alcohol user reaches 15 litres per year.
The heaviest alcohol users account for a substantial amount of the alcohol consumed in a country, with the top 10% of the population consuming one-third to one-half of all the alcohol consumed. While 266 million adults consume alcohol, but up to 20g (women) or 40g (men) per day, over 58 million adults (15%) consume at harmful levels above this, with 20 million of these (6%) consuming alcohol at over 40g (women) or 60g per day (men).
Unlike abstinence, heavy alcohol intake is linked to collective changes in alcohol consumption, so that changes in consumption tend to be seen across the alcohol intake spectrum. Looking at addiction rather than alcohol consumption levels, we can also estimate that 23 million Europeans (5% of men, 1% of women) are dependent on alcohol in any one year.
Although many women quit alcohol when pregnant, a significant number (25%-50%) continue to use alcohol, and some continue to consume to heavy levels. Patterns in alcohol use behaviour can also be seen for socio-economic status (SES), where those with low SES are less likely to use alcohol at all. Despite a complex picture for some aspects of alcohol intake (with some measures showing opposite trends for men and women), getting alcohol intoxicated and becoming dependent on alcohol are both more likely among drinkers of lower SES.
Nearly all 15-16 year old students (>90%) have consumed alcohol at some point in their life, on average beginning to use alcohol at 12 years of age, and getting alcohol intoxicated for the first time at 14 years. The average alcohol amount consumed on a single occasion by 15-16 year olds is over 60g of alcohol, and reaches nearly 40g even in the lower-consuming (for 15-16 year olds) south of Europe. Over 1 in 8 (13%) of 15-16 year olds have been alcohol intoxicated more than 20 times in their life, and more than 1 in 6 (18%) have ‘binged’ (5+ alcoholic drinks on a single occasion) three or more times in the last month.
Most countries show a rise in binge alcohol use for boys from 1995/9 to 2003, and nearly all countries show this for girls (similar results are found for non-ESPAD countries using other data). This is due to a rise in binge alcohol intake and intoxication across most of the EU 1995-9, followed by a much more ambivalent trend since (1999-2003).
The impact of alcohol on individuals
Alcohol increases the risk of a wide range of social harms, generally in a dose dependent manner – i.e. the higher the alcohol consumption, the greater the risk. Harms done by someone else’s alcohol use range from social nuisances such as being kept awake at night through more serious consequences such as marital harm, child abuse, crime, violence and homicide.
Generally the higher the level of alcohol consumption, the more serious is the crime or injury. The volume of alcohol consumption, the frequency of alcohol use and the frequency and volume of heavy episodic alcohol intake all independently increase the risk of violence, with often, but not always, heavy episodic alcohol use mediating the impact of volume of consumption on harm.
Apart from being a drug of dependence, alcohol is a cause of some 60 different types of diseases and conditions, including injuries, mental and behavioural disorders, gastrointestinal conditions, cancers, cardiovascular diseases, immunological disorders, lung diseases, skeletal and muscular diseases, reproductive disorders and pre-natal harm, including an increased risk of prematurity and low birth weight. For most conditions, alcohol increases the risk in a dose dependent manner, with the higher the alcohol consumption, the greater the risk.
The frequency and volume of heavy episodic alcohol use are of particular importance for increasing the risk of injuries and certain cardiovascular diseases (coronary heart disease and stroke).
The impact of alcohol on Europe
Alcohol places a significant burden on several aspects of human life in Europe, which can broadly be described as ‘health harms’, ‘economic harms’ and ‘social harms’.
Seven million adults report being in fights when consuming alcohol over the past year.
Alcohol’s economic harm
The economic cost of alcohol attributable crime (based on a review of a small number of national costing studies) has been estimated to be €33bn in the EU for 2003. This cost is, split between police, courts and prisons (€15bn), crime prevention expenditure and insurance administration (€12bn) and property damage (€7bn). Property damage due to driving under the influence of alcohol has also been estimated at €10bn, while the intangible cost of the physical and psychological effects of crime has been valued at €9bn-37bn (€52bn for the cost of alcohol-related crime).
Alcohol also impacts on the family, with 16% of child abuse and neglect attributed to alcohol use and 4.7m to 9.1m children (6%-12%) living in families adversely affected by alcohol.
An estimated 23 million Europeans are dependent on alcohol in any one year, with the pain and suffering this causes for family members leading to an estimated intangible impact of €68bn.
Estimates of the scale of harm in the workplace are more difficult, although nearly 5% of alcohol consuming men and 2% of alcohol consuming women in the EU15 report a negative impact of alcohol on their work or studies. Based on a review of national costing studies, lost productivity due to alcohol attributable absenteeism and unemployment has been estimated to cost €9bn to 19bn and €6bn to 23bn respectively.
Looking from a health perspective, alcohol is responsible for about 195,000 deaths each year in the EU.
Measuring the impact of alcohol through Disability-Adjusted Life Years (DALYs) shows that alcohol is responsible for 12% of male and 2% of female premature death and disability. This makes alcohol the third highest of twenty-six risk factors for ill-health in the EU, ahead of overweight/obesity and behind only tobacco and high blood pressure.
Alcohol’s health harm
This health impact is seen across a wide range of conditions, including 17,000 deaths per year due to road traffic accidents (1 in 3 of all road traffic fatalities), 27,000 accidental deaths, 2,000 homicides (4 in 10 of all murders) 10,000 suicides (1 in 6 of all suicides), 45,000 deaths from liver cirrhosis, 50,000 cancer deaths, of which 11,000 are female breast cancer deaths, and 17,000 deaths due to neuropsychiatric conditions as well as 200,000 episodes of depression (which also account for 2.5 million DALYs). The cost of treating this ill-health is estimated to be €17bn, together with €5bn spent on alcohol treatment and prevention. Lost life can either be valued as lost productive potential (€36bn excluding health benefits), or in terms of the intangible value of life itself (€150bn-710bn after accounting for health benefits).
Young people shoulder a disproportionate amount of this burden, with over 10% of youth female mortality and around 25% of youth male mortality being due to alcohol. Little information exists on the extent of social harm in young people, although a third of a million (6%) 15-16 year old students in the EU report fights and 200,000 (4%) report unprotected sex due to their own alcohol consumption.
Between countries, alcohol plays a considerable role in the lowered life expectancy in the EU10 compared to the EU15, with the alcohol attributable gap in crude death rates estimated at 100 (men) and 60 (women) per 100,000 population. Within countries, many of the conditions underlying health inequalities are associated with alcohol, although the exact condition may vary (e.g. cirrhosis in France, violent deaths in Finland). Worse health in deprived areas also appears to be linked to alcohol, with research suggesting that directly alcohol-attributable mortality is worse in deprived areas beyond that which can be explained by individual-level inequalities.
Alcohol’s harm to others
Many of the harms caused by alcohol are borne by people other than the alcohol user responsible. This includes 60,000 underweight births, as well as 16% of child abuse and neglect, and 5-9 million children in families adversely affected by alcohol. Alcohol also affects other adults, including an estimated 10,000 deaths in driving under the influence accidents for people other than the driver under the influence of alcohol, with a substantial share of alcohol-attributable crime also likely to occur to others. Parts of the economic cost are also paid by other people or institutions, including much of the estimated €33bn due to crime, €17bn for healthcare systems, and €9bn-19bn of absenteeism.
Natural experiments and time series analyses both show that the health burden from alcohol is related to changes in consumption. The impact of a one litre change in consumption is highest in the low-consuming countries of the EU15 (northern Europe), but still significant for cirrhosis, homicide (men only), accidents, and overall mortality (men only) in southern Europe. While some have argued that the greater change in northern Europe reflects the ‘explosive’ alcohol consumption norm there, this may also reflect the greater proportional size of a one-litre change in the low consuming northern European countries. Overall, it has been estimated that a one litre decrease in consumption would decrease total mortality in men by 1% in southern and central Europe, and 3% in northern Europe.
Evaluating alcohol policy solutions
Driving under the influence policies
The driving under the influence (DUI) policies that are highly effective include unrestricted (random) breath testing, lowered blood alcohol concentration (BAC) levels, administrative license suspension, and lower BAC levels for novice drivers. The limited evidence does not find an impact from designated driver and safe drive programmes. Alcohol locks can be effective as a preventive measure, but as a measure with DUI offenders only work as long as they are fitted to a vehicle. The World Health Organization has modelled the impact and cost of unrestricted breath testing compared with no testing; applying this to the EU finds an estimated 111,000 years of disability and premature death avoided at an estimated cost of €233 million each year.
Education, awareness and persuasion programs
The impact of policies that support education, communication, training and public awareness is low. Although the reach of school-based educational programs can be high because of the availability of captive audiences in schools, the population impact of these programs is small due to their current limited or lack of effectiveness. Recommendations exist as to how the effectiveness of school-based programmes might be improved. On the other hand, mass media programmes have a particular role to play in reinforcing community awareness of the problems created by alcohol use and to prepare the ground for specific interventions.
Alcohol affordability and availability measures
There is very strong evidence for the effectiveness of policies that regulate the alcohol market in reducing the harm done by alcohol. Alcohol taxes are particularly important in targeting young people and the harms done by alcohol in all countries. If alcohol taxes were used to raise the price of alcohol in the EU15 by 10%, over 9,000 deaths would be prevented during the following year and an estimate suggests that approximately €13bn of additional excise duty revenues would also be gained. The evidence shows that if opening hours for the sale of alcohol are extended more violent harm results. The World Health Organization has modelled the impact of alcohol being less available from retail outlets by a 24-hour period each week; applying this to the Union finds an estimated 123,000 years of disability and premature death avoided at an estimated implementation cost of €98 million each year.
Alcohol marketing regulation, ban of alcohol advertising
Restricting the volume and content of commercial communications of alcohol products is likely to reduce harm. Advertisements have a particular impact in promoting amore positive attitude to alcohol use amongst young people. Self regulation of commercial communications by the alcohol industry does not have a good track record for being effective. The World Health Organization has modelled the impact of an advertising ban; applying this to the EU, finds an estimated 202,000 years of disability and premature death avoided, at an estimated implementation cost of €95 million each year.
Shaping alcohol consumption environments
There is growing evidence for the impact of strategies that alter the alcohol consumption context in reducing the harm done by alcohol. However, these strategies are primarily applicable to alcohol use in bars and restaurants, and their effectiveness relies on adequate enforcement. Passing a minimum alcohol use age law, for instance, will have little effect if it is not backed up with a credible threat to remove the licenses of outlets that repeatedly sell to minors. Such strategies are also more effective when backed up by community based prevention programmes.
Screening and brief interventions
There is extensive evidence for the impact of brief interventions, particularly in primary care settings, in reducing alcohol harm. The World Health Organization has modelled the impact and cost of providing primary care-based brief interventions to 25% of the at-risk population; applying this to the EU finds an estimated 408,000 years of disability and premature death avoided at an estimated cost of €740 million each year.
A comprehensive EU-wide alcohol policy package
Using the World Health Organization’s models, and compared to no policies at all, a comprehensive European Union wide package of effective policies and programmes that included random breath testing, taxation, restricted access, an advertising ban and brief physician advice, is estimated to cost European governments €1.3 billion to implement, and is estimated to avoid 1.4 million years of disability and premature death a year, 2.3% of all disability and premature death facing the European Union.
This investment in EU-wide alcohol prevention and control is only about 1% of the total tangible costs of alcohol to society and only about 10% of the estimated income gained from a 10% rise in the price of alcohol due to taxes in the EU15 countries.
European and global alcohol policy
The most prominent international legal obligations that affect alcohol policy are the General Agreement on Tariffs and Trade (GATT) dealing with goods, and the General Agreement on Trade in Services (GATS). Past cases on these have shown that the World Trade Organization (WTO) will prioritize health over trade in some circumstances (for example, a ban on asbestos imports), although policies must pass a series of strict tests in order to be maintained.
However, by far the greater effect on alcohol policy in practice has come from the trade law of the European Union (EU). Most of the cases relating to alcohol stem from the ‘national treatment’ rule on taxation, which means that states are forbidden from discriminating – either directly or indirectly – in favour of domestic goods against those from elsewhere in the EU. No exceptions can be made to this on health grounds, with the result that countries face certain restrictions in the design of their tax policy. In contrast, the increasingly influential European Court of Justice (ECJ) has unambiguously supported advertising bans in Catalonia and France, accepting that “it is in fact undeniable that advertising acts as an encouragement to consumption”.
Standardized excise duties are a longstanding goal of the EU in order to reduce market distortions, where large differences in tax rates between nearby countries lead to large amounts of shopping abroad. This leads to lost revenue for the high-tax government, as well as creating pressure to lower taxation rates, as has occurred in some of the Nordic countries.
The production of alcoholic drinks in the form of wine receives €1.5 billion worth of support each year through the Common Agricultural Policy (CAP), including the co-financing of sales promotion campaigns on “the health benefits of moderate wine consumption”. The economic and political importance of these subsidies makes it hard to progress from a public health perspective.
The international body most active on alcohol has been the World Health Organization (WHO), whose European office has undertaken several initiatives to reduce alcohol related harm in its 52 Member States. These include the Framework for Alcohol Policy in the European Region, the European Charter on Alcohol and two ministerial conferences, which confirmed the need for alcohol policy (and public health more broadly) to be developed without any interference from commercial or economic interests.
Although the EU itself cannot pass laws simply to protect human health (Member States have not conferred this power on the European institutions), some policies dealing with the internal market can incorporate substantial health concerns, such as the alcohol advertising clause within the Television Without Frontiers Directive.
Otherwise, the EU’s action on alcohol has come through ‘soft law’, in the form of nonbinding resolutions and recommendations urging Member States to act in a certain way.