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An evidence-based alcohol policy
  1. Nick Sheron1,
  2. Noel Olsen2,
  3. Ian Gilmore3
  1. 1
    Southampton General Hospital, Southampton, UK
  2. 2
    Independent Public Health Consultant, UK
  3. 3
    Royal College of Physicians, London, UK
  1. Dr N Sheron, Division of Infection Inflammation and Repair, University of Southampton Medical School, Tremona Road, Southampton SO16 6YD, UK; nick.sheron{at}

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In October 2007 the BBC performed a survey of British Society of Gastroenterology (BSG) members in which a number of questions were asked about the changing patterns of alcohol-related disease the BSG was seeing in the UK. Of the 115 responses, only nine members had seen no change in alcohol-related liver disease over the last 10 years; 92% reported a rise, usually large. Recurrent themes were the increase in women presenting with alcoholic liver disease and the younger age of presentation. Nearly three-quarters of responders had seen patients of 25 years or under with alcoholic hepatitis or cirrhosis, and nearly a quarter had patients in their late teens. These depressing findings are in line with the report by the Chief Medical Officer in 2001:

In the last 30 years of the 20th century deaths from liver cirrhosis steadily increased, in people aged 35 to 44 years the death rate went up 8-fold in men and almost 7-fold in women, in 25–34 year-olds a 4-fold increase was seen over the 30 year period.

The UK situation is in stark contrast to the decrease in liver mortality in Mediterranean countries over the same period of time (fig 1).

Figure 1 Over the last 30 years standardised cirrhosis mortality rates (cirrhosis deaths/100 000 under the age of 64 years) have increased in the UK, Finland, Denmark and Ireland, countries where traditionally tight controls on alcohol have been relaxed, and decreased in the wine drinking countries of France, Italy and Spain where the traditionally high consumption of cheap wine with meals has reduced. The biggest drop is in France where strict controls (la loi Evin) on the promotion of alcohol were also introduced. (Data obtained from the WHO HFA database.31)

So why is the UK facing this increase in liver deaths when mortality elsewhere is falling? According to death certification data more than 80% of UK liver deaths are due to alcohol-related cirrhosis.1 Other causes of liver disease are also increasing; for example, steatosis and viral hepatitis, but only 205 out of 6889 reported liver deaths in 2005 were due to viral hepatitis.2 While viruses and, more importantly, steatosis secondary to obesity3 may be co-factors in some cases, the evidence suggests that it is our drinking habits that are the problem.

Since 1970 the standardised death rate (SDR) for cirrhosis increased from 1.83 to 9.49, a rise of over 400%, whereas UK alcohol consumption increased by 45%, a gearing of almost 10-fold (fig 2). If we look at alcohol consumption and cirrhosis mortality over the last 30 years in Europe there is a clear link between alcohol consumption and liver death rates.4 The relationship differs between countries. Finland has a higher liver death rate for a given alcohol consumption than France and the UK; Spain and Italy are intermediate. A number of co-factors may influence this relationship, including genetics, diet, drinking patterns, and the relative importance of these factors remains to be determined.4 The Loess line of best fit in fig 2 is sigmoid; this may be a consequence of the complex nature of the relationship for toxicity of alcohol on the liver. Most alcohol-induced disease increases in a linear fashion as intake increases; oral, oesophagus, breast and colon cancer fall into this pattern,5 with no “safe level” of consumption. In contrast, cirrhosis rate increases slowly to a threshold of about 30 units, above which a marked increase occurs; the shape of the risk curve is sigmoid. The European data also show that as deaths increase from a low baseline (Finland, UK and Ireland) they lag behind increases in alcohol consumption. Ireland is still in this honeymoon phase with remarkably low levels of reported liver deaths despite large increases in alcohol consumption (fig 2). There is, unfortunately, no evidence that Irish stout has miraculous properties – at least as far as the liver is concerned – and this paradox most probably results from inaccurate death certification. Irish death certificates underestimated liver deaths by at least 3 to 1 in the past.6 7 The same is probably true of England and Wales, although accuracy improved after changes to coroner’s rules in the late 1980s,8 suggesting that UK liver death rates were underestimated as alcohol consumption rose in the 1960s. The UK figures now appear to be consistent with the data from the rest of Europe, but in contrast to many parts of continental Europe, UK liver death rates are still increasing.

Figure 2 There are clear correlations between liver death rates and overall alcohol consumption (Pearson correlation R = 0.83, p<0.001) but also country-specific differences in death rates at various alcohol levels. Finland appears to have a lower tolerance to alcohol than France or Spain, the UK being intermediate. The line of best fit was calculated using the Loess function in SPSS. (Data are from the WHO HFA database.31)

So what are the options for reducing mortality from liver disease? The development of liver disease is a silent process, with few signs or symptoms at an early stage. As a result, patients present with features of advanced disease, such as variceal haemorrhage or ascites, and resources are concentrated on managing these often terminal crises. It is not surprising that, despite advances in endoscopy, liver transplantation and critical care, survival figures have not improved greatly over the last 30 years and remain at around 50% overall.9 The key to reducing liver mortality is to reduce consumption, and strategies to do this fall into two broad catagories. The first option is to reduce the overall alcohol intake of the population; the second is to specifically target heavy drinkers – individuals at high risk of cirrhosis.

Reducing overall alcohol intake is generally the favoured public health approach. If done via taxation it has a targeted element, in that it affects heavy drinkers more than light ones. It is effective in reducing not only alcohol-related disease but also passive damage from alcohol misuse. In the UK, alcohol is implicated in around half of all homicides, and nearly three-quarters of domestic violence, sexual assault and rape:10 the passive effects of smoking on health were important in preparing public opinion for the ban on smoking in public places but are minor when compared to the third-party damage from alcohol. An excellent example of the effectiveness of reducing population alcohol consumption is the crackdown introduced by Mikhail Gorbachov in Russia in the mid 1980s, as a result of which deaths rates dropped dramatically. Over 1.2 million lives were saved over 5 years, half of them from reduced accidents, violence and poisonings. Unfortunately, many of these saved lives were then lost in a rebound of deaths that followed the free market reforms of Boris Yeltsin.11 12

Alcohol is subject to the same factors that determine sales of any other product, namely the 4Ps of marketing theory: price, product, promotion and place of sale. All these factors have changed substantially in the last 30 years. Alcohol has become increasingly affordable as a result of increases in living standards, and by 2003 was more than 50% more affordable than in 1980.13 The consequences of this are stark (fig 3).

Figure 3 UK standardised liver mortality rates (deaths/100 000) compared with the trend in affordability of alcohol relative to 2005. The close temporal nature of the link reflects the acute on chronic nature of alcoholic liver disease mortality. (Data are from WHO HFA-DB31 and the Office for National Statistics, London, Statistics on Alcohol 2006, table 7.2, p. 71.)

Alcoholic drinks have also increased in strength, 5% alcohol by volume (bv) lager has largely replaced 3.5% bv beer, a 40% increase. Similarly, most wine sold at supermarkets is no longer 10–12% but 14–15% bv, the point at which duty increases to the next threshold. Promotion includes £250 million spent on direct alcohol advertising and a greater sum spent on other forms of marketing, much of it directed towards young people. These marketing techniques include the sale of alcohol in larger measures, a large pub measure of wine contains around 3.5 units, an increase of 350%. Similarly, spirits measures in many pubs have gone up from 25 to 35 cl, a 40% increase. Finally, the retail outlets have changed markedly. Pubs, particularly in city centres, have become standing-only (vertical drinking) establishments with extended hours, and off-sales outlets have become dominated by supermarkets, whose purchasing power encourages heavy discounting and loss-leaders.14 15 Traditional pubs and independent wine and spirit merchants have struggled against this competition.

The strategies that effectively reduce overall alcohol consumption have been subject to extensive expert review by the World Health Organization,16 the Academy of Medical Sciences,17 and on behalf of the European Commission.4 The unanimous conclusion of the evidence reviews is that the most effective means of reducing consumption and alcohol-related harm is to tackle price. If this is mediated through excise duty, it has the added benefit of increasing income to the government for other effective interventions.18 Furthermore, the burden of increased taxation is directly proportional to levels of consumption; according to the Pareto principle, another useful concept from marketing theory, 80% of sales of any product are to the 20% of people who consume the most.19

Restrictions on the promotion of alcohol are also effective, countering the influence of alcohol marketing on the drinking habits of children and young people.20 The de-regulation of alcohol controls in Nordic countries has been extensively and reviewed.21 22 Major changes include abolition of rationing in Sweden in 1955 (25% increase in sales, 400% increase in admission for delirium tremens (DTs)), introduction of beer sales in groceries in Finland in 1969 (248% increase in sales, and large rises in morbidity and mortality) and the introduction in 1965 then removal in 1977 of medium beer sales in groceries in Sweden (notable effects in younger drinkers). Although some of these changes were marked, on the whole the effect of changes in availability is less consistent and predictable than changes to the price of alcohol. The effect of the current UK experiment with licensing laws is yet to be determined. Perhaps it is unsurprisingly that there are few signs of the promised “continental-style café culture”.

According to the model constructed by the WHO, increased taxation is the most effective tool, followed by restrictions on promotion and, finally, by reducing the availability of alcohol. The alcohol industry and the UK government have favoured an emphasis on education- and information-based initiatives. There is no evidence4 that these approaches reduce alcohol-related harm although an evidence base is emerging in other public health areas,23 and in the longer term these measures may turn out to be of some use. Information, advice and education campaigns may be important in changing attitudes and in preparing public opinion for the introduction of effective measures, but appear ineffective when used alone.24

Young people suffer disproportionately from a high alcohol-related mortality. In Europe around 25% of young male and 10% of young female deaths are alcohol related4 and these are reduced by measures aimed at the per capita consumption. Specifically targeted interventions are disappointing in reducing young deaths, with some exceptions. For example, random breath testing4 and plastic beer glasses25 both have a strong evidence base.

Seeking to change the drinking behaviour of patients is a challenge to all hepatologists and gastroenterologists on a daily basis, but it is possible to make a difference. Not everyone with physical harm from alcohol is heavily dependent, and it is often easier to stop or curtail someone’s drinking than to get them to lose weight. When patients have advanced liver damage we can give stark odds of imminent death if they continue drinking and, given appropriate support, 30–60% of patients with cirrhosis will stop drinking.26 27 Unfortunately, for many, this advice this comes too late. Figures from Alcohol Concern and confirmed in the BBC survey suggest woefully inadequate specialist alcohol services in most parts of the UK. “Brief interventions” (BIs) have been developed to change the behaviour of subjects without evidence of moderate-to-severe dependency alcohol dependence or alcohol-related disease and have been the subject of many randomised controlled trials;28 they are both effective and cost effective29 but require resources to implement and these have been difficult for local services to find. For example, no central funding came with the Alcohol Harm Reduction Strategy for England (AHRSE) in 2004, compared to £1.4bn attached to a national drug strategy. Early detection of physical damage would make it possible for interventions to be more targeted, timely and personalised, and hence more effective.30

With alcohol consumption and liver deaths still increasing, in 2007 a number of royal colleges learned societies, charities, non-governmental organisations (NGOs) and others, including the British Society of Gastroenterology and the British Association for Study of the Liver, formed the UK Alcohol Health Alliance (UK-AHA) with the aim of promoting evidence-based measures to reduce alcohol related deaths in the UK. These include funding of improved treatment, intervention and prevention services; increasing alcohol taxation; reducing promotion and marketing of alcohol to children; and specific measures to reduce drink driving. An increase in taxation by 25% would cause a significant reduction in liver deaths, and would provide more than £4 billion in extra income to tackle the whole spectrum of alcohol-related harm. The increase in alcohol duty in the 2008 budget represents a step in the right direction, although there is a concern that the increase is likely to be absorbed by producers and retailers rather than passed on to consumers. One of the turning points in the long fight against smoking-related disease was the informed involvement of chest physicians in directing health policy. If we are to turn the tide of UK liver deaths, a similar level of informed debate amongst the UK hepatology and gastroenterology community will be an important factor.


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