Eric Carlin Director SHAAP Scottish Health Action on

Eric Carlin, Director SHAAP (Scottish Health Action on Alcohol Problems) “The Scottish Experience” Big Alcohol, Big Tobacco, Big Influence Seminar, Palace of Westminster, 1 st April 2014

I will: • Provide a description of Scotland Alcohol and SHAAP • Discuss Scotland’s Alcohol Problem and historical antecedents • Explain how evidence-based policy was formulated and adopted • Note the persistent opposition of the Alcohol industry to this • Illustrate why Minimum Unit Pricing policy is vitally important • Challenge 6 of the myths and lies perpetrated by its opponents • Call on the industry – MUP legislation should have been enacted a year ago to the day - to cease its opposition

Scotland

Scotland Alcohol

SHAAP Established by Scottish Medical Royal Colleges in 2006. Our function: To provide a coherent and authoritative medical voice on reducing the impact of alcohol on the health and wellbeing of the people of Scotland to promote measures that can be adopted to reduce this harm.

Membership – SHAAP/SIGA • • • Royal College of Physicians of Edinburgh Royal College of Psychiatrists of Scotland Royal College of Paediatrics & Child Health in Scotland Royal College of GPs in Scotland Royal College of Nursing Royal College of Physicians & Surgeons of Glasgow Faculty of General Dental Practice Royal College of Surgeons of Edinburgh Royal College of Public Health Royal College of Emergency Medicine

Alcohol is not simply a Public Health issue • 70% of assaults presenting to hospital emergency departments alcohol-related • Half of Scottish prisoners drunk when committing the offence • Cost to the Scottish estimated at £ 3. 6 billion per year (4. 3 billion Euros) • 96% of Scots see alcohol abuse as a problem

Dundee - 1922 General Election Edwin Scrymgeour - Winston Churchill - Prohibition Party Liberal Party 32, 578 votes 20, 466 votes

Per capita (litres per head per year) consumption of pure alcohol in the UK population, 1900– 2010 Sources: BBPA Statistical Handbook; Cancer Research UK

Litres of pure alcohol sold per adult (aged ≥ 16 years) in Scotland England & Wales, by market sector, 1994 -2011 Source: Nielsen/CGA (Data for 1995 -2000 not available)

Why have Scottish Health Professionals become so concerned about Alcohol? Alcohol Hospitalisations and Deaths in Scotland 1982 -2012 900 30 800 700 600 20 500 15 400 300 10 Discharges Deaths 200 5 100 0 0 1982 1986 1990 1994 1998 2002 2006 2010 Alcohol-related deaths (rates) Alcohol-related discharges (rates) 25

How does Scotland compare to other countries? Chronic Liver Disease mortality rates 1950 -2006 Updated from Leon and Mc. Cambridge, Lancet 367 (2006)

Strategy Measure Effect Price Controls Taxation graduated by strength Controlling cheapest price High ? High Treatment Brief Interventions High Intensive treatment for dependence High/Mid Availability Enforced age limits Restricted hours Retail monopolies Outlet Density High Mid Mid Safer Environment Enforcement of licensing codes Server Training Mid Marketing Limiting exposure to advertising Mid Education and Information Integrated campaigns Low Classroom Education Only Nil Public Campaigns / Warning Labels Nil (WHO 2003)

Alcohol Treatment in Scotland • Current practice and service provision across the country is varied • Comorbid mental and physical disorders are common. • Between 2008/9 and 2011/12, 272, 040 Alcohol Brief Interventions (ABIs), exceeding cumulative target of 210, 530 • In 2011 -12, 97, 830 Alcohol Brief Interventions (ABIs), exceeding target of 61, 081

Costs and savings per 100, 000 population Recommendation Offering psychological interventions to harmful drinkers and people with mild alcohol dependence For people with mild to moderate dependence and complex needs, or severe dependence, offering an intensive community programme following assisted withdrawal Offering acamprosate or oral naltrexone in combination with an individual psychological intervention after a successful withdrawal for people with moderate and severe alcohol dependence Estimated net saving of implementation Costs (£ per year) 1, 800 – 23, 400 3000 – 18, 600

WHO GLOBAL ALCOHOL STRATEGY ACTIONS IN SCOTLAND 2010 Public Education to mobilise support for effective policies Consistent messages from health , police and welfare organisations Early Identification and brief advice National programme established in 2009 Effective specialist treatment Additional investment and national guidance Community action with media advocacy Range of local “Focus on Alcohol” projects Drink driving action Consistent enforcement. Plans to reduce legal limit Effective licensing of alcohol sales Legislation under review Regulation of marketing Ban on multi-buy discounts and regulation of shop displays Price controls (cheapest alcohol) Minimum unit price law passed. Legal challenge failed. Under appeal Server training and monitoring Now compulsory.

UK AFFORDABILITY TRENDS Health Scotland 2011

180 900 160 800 140 700 120 600 100 500 80 400 60 Affordability 300 40 Admissions 200 20 100 0 0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 Alcohol-related discharge rates Affordability index Alcohol affordability and alcohol-related hospital admissions, 1982 -2011

Mc. Cambridge et al (2013): “Alcohol industry actors…have consistently opposed whole-population approaches, …favouring instead targeted interventions that focus on a supposedly problematic minority of drinkers and emphasising the role of individual responsibility. Industry actors have been strongly criticised for producing incomplete and distorted views of the evidence and influencing research funding and publications in biased ways. These tactics mirror those of the tobacco industry, to which some producer organisations are closely related. ”

Lies and Misinformation re Minimum Unit Pricing (MUP) 1. No evidence for effectiveness 2. Punishes the ‘responsible’ majority for the behaviour of a few 3. Tax would be better than MUP 4. Regressive – unfairly affects the poor 5. Everything’s getting better so no need for new regulation 6. It’s illegal

1. Lies and Misinformation: No evidence for effectiveness Sheffield Modelling (2009): Increasing levels of minimum pricing show steep increases in effectiveness: overall. Estimated changes in consumption are: 40 p -2. 7% 45 p -4. 7% 50 p -7. 2% Stockwell et al, study using empirical data: British Columbia, 20022009: • 3 increases in minimum prices for beer & 4 for spirits • 10% increase in average minimum price associated with 9% reduction alcohol-related hospital admissions and 32% reduction in wholly alcohol related deaths

2. Lies and Misinformation: MUP punishes the ‘responsible’ majority for the behaviour of a few Holmes et al The Lancet 2013: “Irrespective of income, moderate drinkers were little affected by a minimum unit price of £ 0· 45 in our model, with the greatest effects noted for harmful drinkers. ”

3. Lies and Misinformation: Tax would be better than MUP The constraints in EU excise duty directives mean that excise duty can’t be used to achieve the same outcomes as MUP. A system which results in higher prices for higher strength alcohol is more consistent with health aims than one which results in similar prices for alcohol of significantly different strengths. As well as this, it’s not either/or. The Tax system should work wth MUP

4. Lies and Misinformation: MUP is regressive – unfairly affects the poor Holmes et al (2013): “Because harmful drinkers on low incomes purchase more alcohol at less than the minimum unit price threshold compared with other groups, they would be affected most by this policy. Large reductions in consumption in this group would however coincide with substantial health gains in terms of morbidity and mortality related to reduced alcohol consumption. ”

Reduced Alcohol Affordability can be linked to reduced Health Inequalities

5. Lies and Misinformation: Everything’s getting better so no need for new regulation • Ignores historic size of Scotland’s problem • Recent reductions relate to affordability, in fact reinforcing the arguments for MUP

ALCOHOL DEATHS ARE STARTING TO FALL …. . AFTER A 20 YEARS’ RISE

6. Lies and Misinformation: MUP is illegal • Court of Session ruling (2013): • “The views of the Commission and of the Member States who submitted comments or opinions are, of course, of interest; but no more than that. ” • “I do not consider it necessary or appropriate to refer any question to the Court of Justice for a preliminary ruling. ” • “I am in no doubt that reduction of alcohol consumption generally, and reduction of consumption by hazardous and harmful drinkers in particular, are both legitimate aims …There is not the slightest suggestion that it is a disguised restriction on trade…it is clear that the initiative has been conceived and developed as a health initiative and that it enjoys prodigious support from health professionals and health agencies. ” • “In my opinion none of the challenges to the minimum pricing measures is well founded. There is no proper basis for the petitioners being granted any of the remedies which they seek. The petition is refused. ”

Thank you! shaap. director@rcpe. ac. uk www. shaap. org. uk