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Evidence for the effectiveness and cost-effectiveness of interventions to reduce alcohol-related harm

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Evidence for the effectiveness
and cost-effectiveness of interventions
to reduce alcohol-related harm

Evidence for the effectiveness and
cost–effectiveness of interventions
to reduce alcohol-related harm

ABSTRACT
There is a substantial evidence base on the effectiveness of different policies
in reducing the harm done by alcohol. Policies that regulate the economic and
physical availability of alcohol are effective in reducing alcohol-related harm.
Enforced legislative measures to reduce drinking and driving and
interventions individually directed to drinkers already at risk are also
effective. The evidence shows that information and education programmes
do not reduce alcohol-related harm; nevertheless, they have a role in
providing information, reframing alcohol-related problems and increasing
attention to alcohol on the political and public agendas. In all parts of the
European Union, population-based interventions represent a highly cost–
effective use of resources to reduce alcohol-related harm. Brief interventions
for individual high-risk drinkers are also cost–effective, but are harder to
scale up because of their associated training and manpower needs.

Keywords
ALCOHOL DRINKING – prevention and control
HARM REDUCTION
COST–BENEFIT ANALYSIS
EVIDENCE-BASED PRACTICE
PUBLIC POLICY
HEALTH PROMOTION
INTERVENTION STUDIES

ISBN 978 92 890 4175 1
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Contents
Acknowledgements.......................................................................................v
Foreword .....................................................................................................vii
Summary .......................................................................................................1
Introduction ..................................................................................................5
What are alcohol policies? ................................................................... 5
What is the evidence base for alcohol policies?................................... 6
Political, sociocultural and economic factors that impact on harm...... 7
Stakeholders and alcohol policy........................................................... 7
Alcohol policy at different jurisdictional levels ................................... 9
Alcohol policies in a European framework........................................ 10
Alcohol policies in a global framework ............................................. 11
What is Europe? ................................................................................. 15
The health, social and economic impact of alcohol ................................19
At individual level.............................................................................. 19
At societal level.................................................................................. 21
Health inequalities.............................................................................. 25
Raising awareness and political commitment.........................................28
Impact of education and information campaigns ............................... 28
Public support for alcohol policy measures ....................................... 33
Infrastructures for alcohol policy ....................................................... 37
Response of the health sector ....................................................................41
Screening and brief advice programmes ............................................ 41
Treatments for alcohol use disorders and alcohol dependence .......... 44
Community action ......................................................................................47
Community activities ......................................................................... 47
Alcohol and the workplace................................................................. 50
Drink–driving policies and countermeasures .........................................55
Alcohol policy and drink–driving ...................................................... 55
Unrestricted breath-testing ................................................................. 57
Licence suspension............................................................................. 58
Alcohol locks ..................................................................................... 59
Training for servers of alcohol and civil liability............................... 60

Designated driver and safe ride programmes ..................................... 60
Educational programmes.................................................................... 61
Mass media campaigns....................................................................... 62
Addressing the availability of alcohol ......................................................64
Minimum age for purchase of alcohol ............................................... 65
Number of outlets and outlet density ................................................. 65
Days and hours of sale ....................................................................... 68
Addressing the marketing of alcoholic beverages ..................................70
Advertising and expectancies............................................................. 70
Experimental studies .......................................................................... 71
Econometric studies ........................................................................... 72
Cross-sectional studies ....................................................................... 73
Longitudinal studies ........................................................................... 73
Self-regulation.................................................................................... 74
Pricing policies ............................................................................................76
Price and the use of alcohol................................................................ 76
Price and younger drinkers................................................................. 78
Price and heavier drinkers .................................................................. 79
Price and alcohol-related harm........................................................... 79
Affordability of alcohol...................................................................... 81
Price and cross-border trade............................................................... 81
Drinking environments..............................................................................85
Design of premises............................................................................. 85
Training of alcohol servers................................................................. 85
Reducing the public health impact of unrecorded alcohol....................89
Unrecorded alcohol ............................................................................ 89
Smuggled alcohol............................................................................... 90
Overview of effectiveness and cost–effectiveness...................................93
Summary of effectiveness .................................................................. 93
Cost–effectiveness of alcohol policies ............................................... 95
References..................................................................................................103

Acknowledgements
The Regional Office for Europe would like to thank Dr Peter Anderson,
Consultant in Public Health and Honorary Senior Lecturer in Public
Health, Maastricht University, Netherlands, for writing this report and the
following experts for their valuable contributions to this publication.
Dr Allaman Allamani, Centro Alcologico, Gruppo Ricerca e Prevenzione,
Azienda Sanitaria di Firenze, Florence, Italy
Dr Joan Colom Farran, Director, Department of Health, Substance Abuse
Programme, Government of Catalonia, Barcelona, Spain
Dr Gerhard Gmel, Research Department, Swiss Institute for the
Prevention of Alcohol and Drug Problems, Lausanne, Switzerland
Dr Antoni Gual, Alcohol Unit, Government of Catalonia, Barcelona,
Spain
Ms Karin Nilsson Kelly, Ministry of Health and Social Affairs,
Stockholm, Sweden
Dr Barbara Koncz, Addiction Research Unit, Eotvos Lorand University,
Budapest, Hungary
Ms María Villar Librada, Health Promotion, Ministry of Health, Madrid,
Spain
Dr Vicenta Lizarbe, Head of Prevention, Directorate General of Public
Health, Ministry of Health and Consumer Affairs, Madrid, Spain
Dr Jacek Moskalewicz, Department of Studies on Alcoholism and Drug
Dependence, Institute of Psychiatry and Neurology, Warsaw, Poland
Mr Esa Österberg, National Research and Development Centre for
Welfare and Health, Alcohol and Drug Research Group, Helsinki,
Finland
Ms Lila Rabinovich, Analyst, RAND Europe, Westbrook Centre,
Cambridge, United Kingdom
Professor Jürgen Rehm, Centre for Addiction and Mental Health,
Toronto, Canada
Ms Maria Renström, Director, Ministry of Health and Social Affairs,
Public Health Division, Stockholm, Sweden
Ms Lidia Segura, Directorate General of Substance Abuse and Aids,
Department of Health and Social Security, Government of Catalonia,
Barcelona, Spain
Mr Janucz Sieroslawski, Department of Studies on Alcoholism and Drug
Dependence, Institute of Psychiatry and Neurology, Warsaw, Poland
Dr Hana Sovinova, National Institute of Public Health, Prague, Czech
Republic

Dr Daniel Chisholm, Health Economist, Costs, Effectiveness,
Expenditure and Priority Setting, World Health Organization
Mr Dag Rekve, Mental Health and Substance Abuse, World Health
Organization
The Regional Office is grateful to the European Commission and to the
Swedish Ministry of Health and Social Affairs for their financial
assistance with the production of this report. The launch of this
publication was timed to coincide with the Swedish Presidency of the
European Union Expert Meeting on Alcohol and Health 21 September
2009.
The Regional Office also extends a special thank-you to the Department
of Health of the Government of Catalonia, Barcelona, Spain, for hosting
two editorial meetings.
The document was edited by Dr Lars Møller, Regional Adviser a.i.
Alcohol and Drugs, WHO Regional Office for Europe and Dr Srdan
Matic, Unit Head, Noncommunicable Diseases and Environment, WHO
Regional Office for Europe.

Foreword
Alcohol policies aim to minimize the health and social harms that arise from
the use of alcohol. Since alcohol is not an ordinary commodity, these policies
need to address market failures by seeking to deter children from using
alcohol, protecting people who are not drinking from the harm drinking can
cause, and providing all consumers with information about alcohol’s effects.
As health constitutes a substantial resource in modern society, and as health
inequalities hinder human development at both the individual and the societal
level, an additional goal of alcohol policy is to reduce health inequalities
related to alcohol. In addition, alcohol policy should reflect the concept of
stewardship, the liberal state’s commitment to look after the basic needs of its
people, individually and collectively. The state that is guided by the ideal of
stewardship recognizes that the health of the people is one of its primary
assets, and that better health is associated with greater well-being and
productivity.
Since the 1970s, the WHO Regional Office for Europe has promoted an
evidence-based approach to alcohol policies, and it has sponsored a wide
range of reviews and supporting material for Member States to use in
developing them. This report updates the evidence base, which is remarkable
for its extent and robustness. The present evidence base is largely built on
systematic reviews, systematic reviews of systematic reviews, and metaanalyses. It is noteworthy that the present evidence base expands and confirms
previous findings but does not alter their fundamental conclusions.
There is indisputable evidence that the price of alcohol matters. If the price of
alcohol goes up, alcohol-related harm goes down. Younger drinkers are
affected by price, and heavy drinkers are more affected than light drinkers; in
fact, if a minimum price were established per gram of alcohol, light drinkers
would hardly be affected at all. There is also indisputable evidence that the
more readily available alcohol becomes, the greater the harm, and strong
evidence that the more alcohol is marketed, the greater the risk of harm. The
evidence that drink–driving policies matter is also incontrovertible: lowering
the legal blood alcohol concentration limit for drivers – and enforcing it –
saves lives. The evidence is equally clear that providing brief advice for
hazardous and harmful drinking and treating alcohol disorders are effective
interventions that reduce harm. In addition, there is incontestable evidence
that school-based alcohol education does not lead to sustained changes in

behaviour. That does not mean that these educational efforts should be
abandoned, but rather that they should be reframed to build support for
alcohol policy among young people. Finally, the evidence tells us that
drinking environments need to be prohibited from selling alcohol to minors
and intoxicated persons, and that community action and workplace
programmes are potentially effective, although further research on them is
needed.
Knowing the evidence and instituting policy measures on its basis is not
enough, however. Political and public support is needed to implement these
measures effectively, and each country needs to fine-tune the balance between
its alcohol policies and its cultural understanding of alcohol problems.
Fortunately, behaviour is an important determinant of attitudes, and support
for alcohol policies tends to increase after they are implemented and harmful
alcohol consumption decreases.
Dr Nata Menabde, Deputy Regional Director
WHO Regional Office for Europe

Summary
Alcohol policies can be defined as sets of measures aimed at minimizing the
health and social harms from the use of alcohol, recognizing that other
contextual factors also have an impact on alcohol consumption and alcoholrelated harm. Noting that the alcohol beverage industry has become
increasingly involved in the policy arena in order to protect its commercial
interests, it is argued that the responsibilities of economic operators in
reducing the harm done by alcohol should be related to their products, the
core of their businesses. Alcohol policy must also allow an expression of
voice from civil society to balance other interests which may dominate
political decision-making. Supranational common markets and international
trade agreements can have an impact on alcohol policy, but pessimistic
interpretation of both European Union (EU) and global trade agreements is
unwarranted, provided alcohol policy focuses on health objectives rather than
any protectionist objectives.

Harm done by alcohol
Both the volume of lifetime alcohol use and a combination of frequency of
drinking and amount drunk per occasion increase the risk of a wide range of
health and social harm, largely in a dose-dependent manner. At a societal
level, the EU is the heaviest drinking region of the world, with over one fifth
of the European population aged 15 years and over reporting heavy episodic
drinking (defined as five or more drinks on one occasion, or 50g alcohol) at
least once a week. Heavy episodic drinking is widespread across all ages and
all of Europe. The European Region of the World Health Organization
(WHO) has the highest proportion of total ill health and premature death due
to alcohol in the world, with a very close relationship between a country’s
total alcohol consumption per capita and its prevalence of alcohol-related
harm and alcohol dependence. This high level of harm hides enormous
alcohol-related health inequalities between eastern and western Europe,
particularly as regards deaths from injuries. The overall social cost of alcohol
to the EU is estimated to be €125 billion per year.

Raising awareness and political commitment
While providing information and education is important to raise awareness
and impart knowledge, by themselves information and education do not lead

Interventions to reduce alcohol-related harm
page 2

to sustained changes in alcohol-related behaviour. Campaigns and health
education messages funded by the alcohol industry seem to have negative
effects, serving to advance both the industry’s sales and public relations
interests. Although warning labels have little impact on behaviour, they are
important in helping to establish a social understanding that alcohol is a
special and hazardous commodity. There is evidence of public support for a
wide range of alcohol policy measures, although there is still much work to
do, given the existing negative views about the potential impact of higher
alcohol prices. Although at country level it is ultimately a government’s
responsibility to define and be accountable for a clear alcohol policy with
targets, an adequate research base and available intelligence systems, the
existence of an alcohol policy is not enough. A lack of transparency and
information, poor organization and preparation for the introduction of new
policies and laws, poor public health infrastructures, vertically as opposed to
horizontally organized government, a lack of financing, the presence of
corruption and public distrust of authority can all impede the implementation
of effective policy.

Health sector
Although brief advice heads the list of effective and cost–effective evidencebased treatment methods, commonly less than 10% of the population at risk of
becoming hazardous and harmful drinkers are identified and less than 5% of
those who could benefit are offered brief advice. Much is now also
understood about the mechanisms for implementing brief advice programmes
countrywide. For individuals with more severe alcohol dependence and
related problems, a wide variety of specialized treatment approaches have
been evaluated, with evidence for their effectiveness for cognitive behavioural
and pharmacological therapies.

Community action
Community-based programmes that include education and information
campaigns, media advocacy, counter-advertising and health promotion,
controls on selling and consumption venues and other regulations reducing
access to alcohol, enhanced law enforcement and surveillance, can all have an
impact on creating safer drinking and living environments, reducing underage
drinking, reducing harmful patterns of drinking, and reducing drink–driving
accidents, although they can be costly to implement and sustain. Alcohol use
can increase the risk of absenteeism and poor performance at work, and
structural factors at work can increase the risk of harmful alcohol use. The

Summary
page 3

available evidence suggests that workplace-based interventions can have some
limited impact in reducing alcohol-related harm.

Drink–driving
Establishing a blood alcohol concentration (BAC) level and lowering it is
effective in reducing drink–driving casualties. Intensive random breath-testing
and checkpoints reduce alcohol-related injuries and fatalities. There is
evidence for some effectiveness in the setting of lower BAC levels (including
a zero level) for young or novice drivers, administrative suspension of the
driver’s licence for a driver caught with a positive BAC level, and mandatory
treatment and the use of an ignition interlock (a mechanical device which does
not allow a car to be driven by a driver with a BAC above a low level) for
repeat drink–drivers.

Availability of alcohol
The implementation of laws setting a minimum age for the purchase of alcohol
shows clear reductions in drink–driving casualties and other alcohol-related
harms. The most effective means of enforcement is on the sellers, who have a
vested interest in retaining the right to sell alcohol. An increased density of
alcohol outlets is associated with increased levels of alcohol consumption
among young people, with increased levels of assault and with other harms such
as homicide, child abuse and neglect, self-inflicted injury and, with less
consistent evidence, road traffic accidents. While extending times of sale can
redistribute the times when many alcohol-related incidents occur, such
extensions generally do not reduce the rates of violent incidents and often lead
to an overall increase in consumption and problems. Reducing the hours or
days of sale of alcoholic beverages leads to fewer alcohol-related problems,
including homicides and assaults.

Marketing of alcohol
Longitudinal studies have shown that various forms of alcohol marketing,
including exposure to alcohol advertising in the traditional media as well as
promotion through the content of films and alcohol-branded merchandise,
have an impact on when young people start to drink and on riskier patterns of
drinking among young people. The effects of exposure seem cumulative and,
in markets where alcohol advertising is more widespread, young people are
more likely to continue to increase their drinking as they move into their midtwenties, while drinking declines at an earlier age in those who are less
exposed. In some jurisdictions, alcohol marketing relies on self-regulation

Interventions to reduce alcohol-related harm
page 4

implemented by economic operators, including advertising, media and alcohol
producers. Evidence from a number of studies shows, however, that these
voluntary systems do not prevent the kind of marketing that make an impact
on younger people.

Price of alcohol
When other factors are held constant, such as income and the price of other
goods, a rise in alcohol prices leads to less alcohol consumption and vice
versa. Price increases reduce the harms caused by alcohol and can also
indicate that heavier drinking has been reduced. Policies that increase alcohol
prices delay the initiation of drinking, slow young people’s progression
towards drinking larger amounts, and reduce heavy drinking among them.
Setting a minimum price per gram of alcohol can be as effective as an acrossthe-board increase in tax, with both options costing heavy consumers far in
excess of the cost to light consumers. Natural experiments in Europe
consequent to economic treaties have shown that as alcohol taxes and prices
have gone down, so sales and alcohol consumption have usually increased.
Cross-border issues are not solved by lowering alcohol taxes.

Drinking environments
Interventions in drinking environments can be important, since the problems
potentially averted commonly harm others than the drinker, including the
consequences of drink–driving and violence. Unfortunately, the evidence
shows that such interventions are of limited impact unless they are backed up
by adequate enforcement.

Illegal and informal alcohol
Non-beverage alcohols and illegally-produced or home-made alcohols can
have health consequences due to a higher ethanol content and contamination
with harmful substances such as methanol, phthalates or ethyl carbamate.
Illegally-traded alcohol can bring a health risk due either to contamination
during the trading process or to its lower cost and thus higher consumption
than legal alcohol. It is estimated that in the mid-1990s, fraud cost the EU
around 8% of the total alcohol excise duty at the time.

Introduction
Alcohol policies are sets of measures aimed at minimizing health and social
harm from the use of alcohol, although other political, sociocultural and
economic factors also have an impact on alcohol consumption and alcoholrelated harm. Much of the evidence for the impact of alcohol policies derives
from North America and northern Europe, but the general principles on which
particular alcohol policy strategies work are fairly well understood and can
often be applied across societies. Noting that the alcohol beverage industry
has become increasingly involved in the policy arena in order to protect its
commercial interests, this section argues that the responsibilities of economic
operators in reducing the harm done by alcohol should be related to their
products, the core of their businesses. Alcohol policy must also allow an
expression of voice (the capacity of individuals to influence the decisions that
shape their lives) by civil society to counteract the vested trade interests which
often dominate political decision-making. While alcohol policies have
traditionally been national matters, enacting policy at local level has a number
of advantages. This section draws attention to the potential impact of
supranational common markets and international trade agreements on alcohol
policy, and reflects that the pessimistic interpretation of both European Union
(EU) and global trade agreements is unwarranted, provided alcohol policy
focuses on health objectives rather than on any protectionist objectives.
Nevertheless, given the need for an international community of support for such
policies and potential help to manage the relationship between alcohol and
trade, a number of public health bodies and scientists have called for a
Framework Convention on Alcohol Policy modelled explicitly on the current
Framework Convention on Tobacco Control.

What are alcohol policies?
Alcohol policies have been defined as sets of measures aimed at minimizing
health and social harm from the use of alcohol (1). There are also a variety of
other policies which can reduce or increase alcohol-related problems but
which are not normally described as alcohol policies, since they are not
implemented specifically to reduce alcohol-related harm as a primary aim. An
example is general road safety measures.
A main goal of alcohol policy is to promote public health and social well-being.
In addition, policy can address market failures by deterring children from using

Interventions to reduce alcohol-related harm
page 6

alcohol, protecting people other than drinkers from the harm done by alcohol,
and providing all consumers with information about the effects of alcohol. As
government increasingly turns its attention to health inequalities, the reduction
of inequalities in alcohol-related ill health becomes an additional policy goal.
Further, the concept of stewardship implies that liberal states have a duty to
look after the important needs of people individually and collectively (2). It
emphasizes the obligation of states to provide conditions that allow people to be
healthy and, in particular, to take measures to reduce health inequalities. The
stewardship-guided state recognizes that a primary asset of a nation is its health:
higher levels of health are associated with greater overall well-being and
productivity (3,4).
The optimal levels and mix of alcohol policy will depend on each society’s
particular goals and willingness to accept different policy instruments. For
example, any attempt to determine the optimal tax on alcohol depends on
empirical facts that can be difficult to measure, such as the scale of the costs
to all consumers and non-consumers, and the differing costs to consumers
with different income levels. It also depends on varying societal values, such
as the extent to which children should be protected, and the specific goal that
the tax seeks to achieve, such as a specific gain in revenue or a specific
reduction in alcohol-related harm.
Alcohol policies can be evaluated in terms of their effectiveness, defined as a
measure of the extent to which a specific policy, programme or intervention,
when deployed in the real world, does what it is intended to do for a specified
population, and their cost–effectiveness, defined as an economic evaluation
that compares the costs of two or more interventions with differences in one
single measure of outcome (5).

What is the evidence base for alcohol policies?
Much of the evaluation literature to establish the effectiveness of alcohol
policies stems from North American and northern European societies,
although some policies have been evaluated throughout Europe (6). The
general principles on which particular alcohol policy strategies work are fairly
well understood and can often be applied across societies. For example,
drink–driving countermeasures are premised on a general deterrence effect,
and taxes on alcoholic beverages are premised on influencing consumer
demand by increasing the cost relative to alternative spending choices. Thus,
the fact that there is a conceptual framework underlying alcohol policies, and

Introduction
page 7

the fact that these principles generally operate across societies, suggest that
research findings from one society will have applicability in another (7).

Political, sociocultural and economic factors that impact
on harm
Although alcohol policy measures may have a significant impact on alcohol
consumption and alcohol-related harm, there are a number of other contextual
factors that also affect consumption and harm. In the southern European
Mediterranean countries, for example, wine consumption fell considerably
before the introduction of alcohol policies and prevention programmes. These
decreases were largely consequent on urbanization and shifts from agriculture
to factory and service work, as well as changes in family structure and the destructuring of meals, supported in more recent years by increased health
consciousness and alcohol policies (8).

Stakeholders and alcohol policy
Reducing alcohol-related harm inherently requires multi-component action,
involving the activities of many stakeholders other than health impinging on the
potential of harmful alcohol use.
In the fiscal sector, alcohol taxes can not only reduce the harm done by
alcohol, including to people other than the drinker, but can also bring in extra
government revenue (9). Taxes can be set at their maximum revenue
potential, although that is seldom achieved. Such taxes are also an efficient
source of revenue to fund publicly-provided, equity-enhancing programmes
that can be used to reduce inequalities. Despite the simplicity of the implicit
model sometimes suggested in debates (reduced consumption leads to reduced
output leads to job losses leads to higher unemployment), most of these
connections in practice require assumptions that rarely hold fully (10). For
example, if people spend less money on alcohol, they will spend more money
on other goods, which will create jobs elsewhere in the economy. In the long
run, the evidence suggests that the effect of alcohol policy on employment
would effectively be zero. On the other hand, the costs that should be
considered are the adjustment costs in the medium and short term, i.e. over a
matter of a few years.
Capital investment has increased considerably in the alcohol production sector
and is associated with higher levels of productivity, particularly for beer and
spirits. In some countries, innovation in the brewing industry has led to a

Interventions to reduce alcohol-related harm
page 8

fivefold increase in the amount of beer produced per employee. Similarly for
wine, mechanical harvesting and pruning are increasingly used in lower-quality
as well as higher-quality production, while the labour intensity of wine grape
production has been reduced by mechanization and the computerization of
irrigation. A greater number of jobs are linked with alcohol in other sectors,
particularly retail and the hotels, restaurants and catering sector. Here, in
general, adjustment costs will be much lower than for drinks production (10).
There are significant commercial interests involved in promoting the
manufacture, distribution, pricing and sale of alcohol (11). The alcohol
beverage industry consists of relatively large-scale producers and wholesalers
who market alcoholic beverages to retailers, who then distribute them through
bars, restaurants and off-premise establishments for sale to consumers. The
alcohol industry has become increasingly involved in the policy arena in order
to protect its commercial interests. A common claim among public health
professionals is that the representatives of the alcohol industry are influential
in setting the policy agenda, shaping the perspectives of legislators on policy
issues and determining the outcome of policy debates. To promote their
interests and influence on national policy decisions, industry sources have
funded a network of national, regional and global “social aspects”
organizations which sponsor selected prevention initiatives or industryfriendly views on alcohol problems and policies through promoting the
concept of corporate social responsibility (12). The Economist has pointed out
that caution should be exercised against the role of the private sector in trying
to do the work of governments, which are the proper guardians of the public
interest, are accountable to all citizens to set goals for regulators, deal with
externalities, mediate among different interests, attend to the demands of
social justice and provide public goods and collect the taxes to pay for them
(13). Thus it has been argued that the responsibilities of economic operators in
reducing the harm done by alcohol should be related to their product, the core
of their businesses. For example, economic operators could consider ways in
which the price and strength of their product can be managed to reduce harm,
such as commitments to support regulation for a minimum pricing structure.
Producers and retailers could commit themselves to share intelligence and
knowledge of illegally traded and illicit alcohol, together with a commitment
to support Europe-wide tax stamps and mechanisms to track the movements
of all alcohol products in the distribution chain.
To be effective, alcohol policy must also allow an expression of voice from
civil society to counteract the vested trade interests which often dominate
political decision-making (14). Nongovernmental organizations are important
partners for all elements of alcohol policy as they are a vital component of

Introduction
page 9

modern civil society, raising people’s awareness of issues and their concerns,
advocating change and creating a dialogue on policy (15).

Alcohol policy at different jurisdictional levels
While alcohol policies have traditionally been a matter for country and subcountry levels of administration, in recent decades this situation has in many
ways been transformed (7). Along with greatly increased trade and travel have
come much greater opportunities for the transfer of alcoholic beverages across
national borders, whether as legal imports or as smuggled goods. Transnational aspects of alcohol production and distribution have grown
enormously in terms of exports and imports, of rapidly consolidating
multinational producers, of international licensing and co-production
arrangements, and of multinational advertising agencies to promote the
products. More important than any of these factors, however, has been the
growth of supranational common markets and international trade agreements.
The level of jurisdictional responsibilities for alcohol policies varies from
country to country, with differing responsibilities at country or federal level,
at regional level and at municipal or local level. Enacting policy at the local
level has a number of advantages (7). Local citizens are close to where
alcohol problems are experienced personally. The community must deal with
injuries and deaths from road traffic accidents. It must provide hospital and
emergency medical services and interventions for people with harmful alcohol
use and alcohol dependence. Alcohol problems are experienced personally by
community members, and efforts to prevent or reduce future problems are
also a personal matter. When local policy advocates propose future policy
positions, they also encounter those who may oppose such policies and who
may have vested interests. This means that policy can create, in a local forum,
a debate between opposing community groups and thus draw news media
attention to such issues. Urban settings can also be risk factors for harmful
alcohol use and harmful patterns of drinking, particularly in areas of low
social capital and when cities develop the night-time economy and nuisance
and harassment from other people’s drinking is common (16). When alcohol
policies and programmes are devolved to jurisdictions within countries,
including local government authorities and municipalities, it is vital that
national or regional legislation enables rather than restricts the ability of local
government authorities and municipalities to act (17). It is also important to
avoid the risk that the least cost–effective policies, including education, are
adopted in local policies.

Interventions to reduce alcohol-related harm
page 10

Alcohol policies in a European framework
Alcohol consumption, the harm done by alcohol policy, and alcohol policy
itself are influenced to a great extent by EU trade law (18). Where a product
like alcohol is both traded and relevant for health, it becomes important to
recognize the Treaty’s obligation that “a high level of human health protection
shall be ensured in the definition and implementation of all Community policies
and activities.” This means there is substantial scope for health concerns to be
incorporated within policies of other Directorates-General and within activities
to improve the single market.
Nevertheless, European trade law can constrain alcohol policies, despite the
existence of certain exemptions on public health grounds. This is particularly
true when legislation treats alcohol only as an economic commodity, without
considering the substantial impact on health of many of these laws. Given that
the EU has a legal commitment to consider health in all its activities, there is a
potential to close this gap at the European level. Governments should be
mindful of when alcohol policy is best implemented at local and municipal
levels, when respect for the laws of different countries in relation to alcohol
policy should be upheld (comity), and when collective action at the European
level is more appropriate.
As observed for social policy more generally, a review of European Court of
Justice and European Free Trade Association court judgments has shown that
they have extended far into the domain of health and social policy (18). Such
a partial “juridification” involves passing the authority for national health
policies to international courts, which is of concern to some civil society
groups. Furthermore, this extended scope is potentially biased towards
economic rather than social interests in its structure, and in practice court
cases show that economic considerations are sometimes put above health
interests.
Yet it can be argued that the pessimistic interpretation of most commentators
on the role of EU law in alcohol policy should be tempered. The courts have
established that retail monopolies are permissible, and confirmed since 1980
the right of national governments to make health-motivated alcohol policies
that distort the EU single market. It can even be argued that the impact of
negative integration on national alcohol policy has been small. In the mid1990s, the Finnish and Swedish governments took the view that abolishing the
wholesale, import and export monopolies in the Nordic countries was unlikely
to have an impact on alcohol-related harm as long as the retail monopoly was
maintained. Import restrictions may have been lifted, but the Swedish

Introduction
page 11

Government has stated that “Swedish alcohol policy stands firm”, given that
private importers will still have to pay Swedish alcohol taxes.
Policy-makers can draw at least two lessons from experience of the court cases
in drawing up alcohol policy compliant with EU law. First, broadly-focused
policies have more difficulty in passing proportionality tests, and policy-makers
should recognize that even a slight targeting of a generally broad policy, for
example as seen with the French Evin law on advertising, could make a
significant difference (19). Second, alcohol policies have historically often
resulted from intertwined economic and health concerns, but this has now
become much more problematic. Policies must therefore be explicitly targeted
at health and social concerns, which means that one potential influence on
alcohol policy (national alcohol producers) is removed at a stroke. Perhaps the
strongest conclusion to draw is that EU law is unquestionably relevant to
alcohol policy and must be closely watched as case law and any future treaty
negotiations continue to develop.

Alcohol policies in a global framework
International trade law is a generic term for many legal provisions covering
varying geographical areas and issues. The most high-profile global
agreement for many years was the General Agreement on Tariffs and Trade
(GATT) on goods, which was agreed in 1948 by 23 countries and
progressively revised and expanded to over 100 countries by the 1970s. In
1995, the World Trade Organization (WTO) was created as a permanent
body, and a further agreement was signed, the General Agreement on Trade in
Services (GATS), that covered broadly-defined services. These are the
agreements that are most likely to affect alcohol policies (20,21).
There are two parts to the WTO system. First, there is the law itself: a set of
agreements that all members have signed up to, although there are many areas
where countries can either opt in or out of commitments in particular areas.
Second, there is the enforcement of the law, which approximately follows a
three-step process: (i) a country makes a complaint to the WTO; (ii) after a
delay for negotiations, WTO members appoint a panel of international legal
experts who judge the case, if necessary with the help of scientific/technical
experts; (iii) if the judgment is subject to appeal, the case is referred to the
permanent Appellate Body who make a new judgment.
The WTO agreements potentially prohibit a wide range of alcohol policies that
could inadvertently benefit domestic businesses over foreign ones (22). Yet

Interventions to reduce alcohol-related harm
page 12

both GATT (Article XX) and GATS (Article XIV) explicitly state that nothing
in either agreement “shall be construed to prevent the adoption or enforcement
by any contracting party of measures … necessary to protect … human health.”
This applies as long as such measures are not a “disguised restriction on trade”
or “unjustifiable discrimination”. While this health defence therefore appears to
allow countries to implement alcohol policies when they are violating
international trade commitments, the crucial word here is “necessary”. Those
alcohol policies that violate a country’s trade commitments must pass a WTO
necessity test, which means that “the measure be the least trade-restrictive
measure reasonably available in the circumstances to meet the objective of
protecting health”.
The argument that the WTO is a threat stems, therefore, from the nature of
this necessity test, which is interpreted narrowly and whose burdens are
“substantial and difficult”. As well as the burden of proof being upon the
defending country to show that the policy is not a disguised restriction on
trade, countries must also show that the alternatives will not be equally
effective.
Policies that aim to protect domestic alcohol industries from foreign
competition are unlikely to be permissible under WTO law, whether they are
tariff- or non-tariff-based (22). The removal of such policies could lead to
increased alcohol consumption via a combination of reduced prices (through
comparative advantage and improvements in productivity) and increased
marketing. In Switzerland, the liberalization of spirits was found to lead to
price reductions and their increased consumption (23). WTO agreements are,
therefore, likely to lead to an increase in alcohol-related harm, independently
of their effect on health policies.
The consistent response of the arbitrating bodies when dealing with fused
protectionist and public health policy interests has been to rule against the
former objective (protectionist) while reaffirming the rights to meet the latter
(public health).
In contrast, policies that are motivated purely by health considerations are
likely to be defended by the WTO, with the caveat that policies will still be
subject to a necessity test which certain highly trade-restrictive policies are
unlikely to pass. For example, freezing preferences for particular drinks or
quantitative restrictions such as economic needs tests are unlikely to be
possible for countries that have made commitments in relevant sectors.
Nevertheless, countries are entirely free to set their own level of health
protection, and a purely health-motivated policy can be confident of being

Introduction
page 13

upheld in the WTO courts. When considering less trade-restrictive
alternatives, they are further permitted to take into account issues of
implementation. They can also follow minority reasonable scientific opinion
when assessing risks – which is arguably a form of the precautionary
principle. The view of the European Spirits Organization – CEPS that
voluntary self-regulation and education are “reasonable alternatives” to
regulation is, therefore, unlikely be upheld by a WTO panel (22).
This conclusion is also true for the ongoing discussions about domestic
regulation, which appear to threaten a necessity test on all (even tradeirrelevant) policies. Such a development would increase the number of
alcohol policies deemed illegal, but only those that are fully or partly
protectionist; those that are fully motivated by health considerations would be
unaffected. This still raises the question of how a country can demonstrate to
WTO that its policies are motivated by health considerations alone. It is not
easy for an outside observer to decide on the goals of a policy: is an alcohol
advertising ban a way of reducing alcohol-related harm, a political response to
public pressure, a way of protecting domestic companies from foreign
competition – or all three? Furthermore, support for many policies depends on
a coalition of actors with different reasons for agreeing with a policy (the
government itself, health professionals, the domestic and international alcohol
industries, drinkers, etc.).
In the face of this complexity, a promising avenue seems to be clearly
demonstrating motives in the design, architecture and structure of a policy. In
other words, a policy can be explicitly designed to maximize the impact on
health with minimal economic disruption (mirroring the terms of the necessity
test).
Thus, trade policies are likely to increase alcohol-related harm through their
effect on fully or partly protectionist policies. Countries are, however,
effectively still free to regulate purely on health grounds, and in this sense the
view that the health defence is ineffective or weak is overstated. Indeed, the
WTO is arguably highly deferential to health policies, at least compared to
other safeguards in the WTO agreement (22). Yet there are signs of a belief
among the public health community that a greater number of health-motivated
policies may not be permissible under WTO law. For example, one recent
review for the World Health Organization (WHO) notes that “current
international trade law and the presence of the free trade movement over
controls on public health suggest that [controls on manufacture and
distribution] may be of limited relevance in a number of countries” (23).
Similar comments for areas including taxation policy and advertising

Interventions to reduce alcohol-related harm
page 14

restrictions can also be found in a WHO review on trade law and alcohol and
a resolution of the American Public Health Association (22).
It is important to send a clear message to policy-makers that, in general, they
are free to adopt nearly any policy on alcohol as long as it is motivated purely
by health considerations and is designed to be as trade-friendly as possible.
For existing policies that are compromises between health and protectionist
interests, policy-makers can decide to wait and see if they are challenged at
the WTO, and if they are, to redesign the policy on health grounds rather than
abolish it completely. Any perceptions to the contrary may be needlessly
damaging to public health.
It is accepted almost unanimously by those in the health field that trade
negotiations and disputes must be made more transparent, increase the
involvement of civil society and of health interests such as WHO, particularly
given the diversity in how different stakeholders perceive relevant issues (22).
The extension of the necessity test to domestic regulation may be unlikely to
occur but it is still possible and therefore in need of close attention.
The potential impact of a number of different policy options for changes in
trade obligations on alcohol has been considered in the public health
literature, as under.
•

WTO agreements – or more easily, their interpretation – can be
changed in various ways that would be beneficial for health (24). In
particular, the burden of proof for the health defence could be changed
by requiring a country invoking the health exception simply to show
that it was not patently unreasonable to keep its present policies.
Alternatively, measures could be given a rebuttable presumption of
legitimacy under international trade law. Such changes would change
the balance between trade and health when considering partly
protectionist and partly health-motivated policies.

•

The World Medical Association and others have suggested carving
alcohol out of trade agreements completely (25). While this is the
strongest way of defending partly protectionist policies, alcohol is no
different to other commodities whose regulation also commonly
combines legitimate and illegitimate objectives, and it may be hard to
argue that alcohol is an exceptional case. Where alcohol differs from
other commodities is in the potential increase in harm from the removal
of purely protectionist policies. The importance of this depends on
whether alternative measures are seen as capable of counteracting the

Introduction
page 15

effects of liberalization. The Secretariat of the Pacific Community has
argued that resisting globalization will always be a stronger option for
alcohol, and this has led to the carving out of both alcohol and tobacco
from the Pacific Islands Community Trade Agreement (26).
•

Increasingly, some of those in the alcohol field suggest that there should
be a framework convention on alcohol policy (27) modelled explicitly on
the current Framework Convention on Tobacco Control, or an alternative
method for creating a binding international agreement on alcohol (28).
This would not automatically make WTO-inconsistent policies somehow
permissible, but it would provide an international community of support
for such policies and potentially help to manage the relationship between
alcohol and trade. It may also add weight to the defence of such policies
under trade disputes, although how this would affect partly protectionist
policies would remain to be seen.

Whatever the views on these options, governments can take action within the
current system to minimize the possible effects of trade on alcohol-related
harm (22). First, they can avoid making any further commitments related to
alcohol in future, thus allowing themselves to pursue partly health-focused
and partly protectionist policies – which is what most existing alcohol policies
are likely to be. This also allows them to avoid the negative effects of
liberalization per se and to pursue purely health-focused but, potentially,
highly trade-distorting policies. Second, to the extent that this is politically
feasible and desirable, they can introduce stringent alcohol policies to
counteract the effect of liberalization that is taking place. Finally, they can
ensure, and be shown to ensure, that their alcohol policies try to achieve their
health and social welfare goals with the minimum possible impact on trade, in
order to make the chances of being found to breach WTO law as remote as
possible.

What is Europe?
This report sometimes refers to the WHO European Region and sometimes to
the EU. The WHO European Region includes 53 Member States: Albania,
Andorra, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bosnia and
Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia,
Finland, France, Germany, Georgia, Greece, Hungary, Iceland, Ireland, Israel,
Italy, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Malta,
Monaco, Montenegro, Netherlands, Norway, Poland, Portugal, Republic of
Moldova, Romania, Russian Federation, San Marino, Serbia, Slovakia,

Interventions to reduce alcohol-related harm
page 16

Slovenia, Spain, Sweden, Switzerland, Tajikistan, The former Yugoslav
Republic of Macedonia, Turkey, Turkmenistan, Ukraine, United Kingdom,
Uzbekistan.1
The EU includes 27 member states: Austria, Belgium, Bulgaria, Cyprus,
Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece,
Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands,
Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden and the United
Kingdom.2 For descriptive purposes in this report, they are sometimes
grouped as follows:
•

EU15: Austria, Belgium, Denmark, Finland, France, Germany, Greece,
Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden,
United Kingdom

•

EU10: Bulgaria, Czech Republic, Estonia, Hungary, Latvia, Lithuania,
Poland, Romania, Slovakia, Slovenia

•

EU7: Bulgaria, Czech Republic, Hungary, Poland, Romania, Slovakia,
Slovenia

•

EU5: Czech Republic, Hungary, Poland, Slovakia, Slovenia

•

EU3: Estonia, Latvia, Lithuania

•

EU2: Bulgaria, Romania.

The EU member states are also sometimes grouped according to the following
WHO classification.
•

Eur-A: very low adult/very low child mortality
Andorra, Austria, Belgium, Croatia, Cyprus, Czech Republic, Denmark,
Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy,
Luxembourg, Malta, Monaco, Netherlands, Norway, Portugal, San
Marino, Slovenia, Spain, Sweden, Switzerland, United Kingdom.

•

Eur-B: low adult/low child mortality
Albania, Armenia, Azerbaijan, Bosnia and Herzegovina, Bulgaria,
Georgia, Kyrgyzstan, Montenegro, Poland, Romania, Serbia, Slovakia,
Tajikistan, The former Yugoslav Republic of Macedonia, Turkey,
Turkmenistan, Uzbekistan.

1

WHO Regional Office for Europe [web site]. Copenhagen, WHO Regional Office
for Europe, 2009 (http://www.euro.who.int/AboutWHO/About/MH, accessed 13 July
2009).
2
Europa [web site]. European countries. Brussels, European Union, 2009
(http://europa.eu/abc/european_ countries/index_en.htm, accessed 13 July 2009).

Introduction
page 17
•

Eur-C: high adult/low child mortality
Belarus, Estonia, Hungary, Kazakhstan, Latvia, Lithuania, Republic of
Moldova, Russian Federation, Ukraine.

Summary of the introduction to alcohol policies
What we know


States have a duty to look after the important needs of their
populations, including the harm done by alcohol.



Higher levels of health are associated with greater overall
well-being and productivity.



There is an extensive evidence base for alcohol policies.



Contextual factors can influence the level of alcoholrelated harm, independently of alcohol policy.



Different sectors and different jurisdictional levels have
differing and specific responsibilities to reduce alcoholrelated harm.



Alcohol policy is influenced by EU trade law, but case law
has often supported alcohol policy measures supportive of
public health.



Alcohol policies are also influenced by WTO agreements,
but policies motivated purely by considerations of health
are likely to prevail.

What we do not know

⊗

There is no specific evaluation of alcohol policies in some
countries of southern and eastern Europe.

⊗

The real extent to which trade law at both European and
global levels can undermine effective alcohol policy.

Interventions to reduce alcohol-related harm
page 18

Policy implications of the introduction to alcohol policies
Alcohol policies are the tool by which governments take the
responsibility to reduce the harm done by alcohol to both
drinkers and non-drinkers. In implementing such policies,
governments could encourage a wide range of stakeholders and
jurisdictional levels to fulfil their responsibilities in reducing
alcohol-related harm. Governments could closely monitor the
potential impact of trade agreements on alcohol policy, and
ensure that their policies have a strong and effective public health
base.

The health, social and economic impact of
alcohol
This section notes that both the volume of lifetime alcohol use and a
combination of frequency of drinking and amount drunk per occasion increase
the risk of a wide range of health and social harm, largely in a dose-dependent
manner. The risk of a lifetime-attributable death from a chronic alcoholrelated condition is found to increase linearly from zero consumption in a
dose–response manner with the volume of alcohol consumed, and from an
acute alcohol-related condition increases from zero consumption in a dose–
response manner with frequency of drinking and exponentially with the
amount drunk on any one occasion. The risk of death remains below 1 in 100
for both men and women if they stick to an upper limit of 20g alcohol or less
on one occasion, even if these occasions are every day. At a societal level, the
EU is the heaviest drinking region of the world, with over one fifth of the
European population aged 15 years and over reporting heavy episodic
drinking (defined as five or more drinks on one occasion, or 50g alcohol) at
least once a week. Heavy episodic drinking is found not to be a prerogative of
young people or of northern European people, but is widespread across all
ages and all of Europe. The WHO European Region has the highest
proportion of total ill health and premature death due to alcohol in the world,
with a very close relationship between a country’s total per capita alcohol
consumption and its prevalence of alcohol-related harm and alcohol
dependence. This high level of harm hides enormous alcohol-related health
inequalities between eastern and western Europe, particularly as regards
deaths from injuries. The overall social cost of alcohol to the EU is estimated
to be €125 billion per year, with an intangible cost of some €270 billion/year.

At individual level
Both the volume of lifetime alcohol use and a combination of frequency of
drinking and amount drunk per occasion increase the risk of alcohol-related
harm, largely in a dose-dependent manner (29). Alcohol is an intoxicant
affecting a wide range of structures and processes in the central nervous
system which, interacting with personality characteristics, associated
behaviour and sociocultural expectations, are causal factors for intentional and
unintentional injuries and harm to people other than the drinker (29),
including interpersonal violence (30), suicide (31), homicide (32), crime (33)

Interventions to reduce alcohol-related harm
page 20

and drink–driving fatalities (34), and a contributory factor for risky sexual
behaviour (35), sexually transmitted diseases (36) and HIV infection (37).
Alcohol is a potent teratogen with a range of negative outcomes to the foetus,
including low birth weight, cognitive deficiencies and foetal alcohol disorders
(38). Alcohol is neurotoxic to brain development, leading in adolescence to
structural hippocampal changes (39) and, in middle age, to reduced brain
volume (40). Alcohol is a dependence-producing drug, similar to other
substances under international control, through its reinforcing properties and
neuroadaptation in the brain (41). It is an immunosuppressant, increasing the
risk of communicable diseases (42), including tuberculosis (43). Alcoholic
beverages are classified as a carcinogen by the International Agency for
Research on Cancer, increasing the risk of cancers of the oral cavity and
pharynx, oesophagus, stomach, colon, rectum and breast in a linear dose–
response relationship (44,45). Acetaldehyde, which occurs in alcoholic
beverages as well as being produced in ethanol metabolism, is a potential
pathway for cancer risk, with a global average of lifetime cancer risk from
alcoholic beverages of 7.6 in 10 000 (46).
Alcohol has a bi-form relationship with coronary heart disease. In low and
apparently regular doses (as little as 10g every other day), alcohol appears to
be cardio-protective (47), but at high doses, particularly when consumed in an
irregular fashion, it is cardio-toxic (48). It should be noted that considerable
concern remains about the extent to which the observed cardio-protection is
due to systematic definition errors (49,50), drinking patterns and genetic
factors (51), and the extent to which the size of the protective effect is
overestimated (52,53).
The risk of hospitalization for an alcohol-related diagnosis increases linearly
with alcohol consumption (54). As stated above, the risk of a lifetimeattributable death from a chronic alcohol-related condition increases linearly
from zero consumption in a dose–response manner with the volume of alcohol
consumed (55), and from an acute alcohol-related condition increases from
zero consumption in a dose–response manner with frequency of drinking and
exponentially with the amount drunk on an occasion (56). Estimates for
Australia show that for people who regularly drink 20g alcohol per day, the
lifetime risk of death from an alcohol-related disease is about 0.4 in 100.
Above that level, the risk increases with the number of drinks per day and is
above 1 in 100 at 30g/day, increasing more sharply for women than for men
(57). Similar estimates show that the risk of death from an alcohol-related
injury increases with the frequency of drinking, with the risks of death for
men being higher than those for women at all levels of drinking. The risk of
death from injury remains below 1 in 100 for both men and women if they

Impact of alcohol
page 21

always drink 20g alcohol or less on an occasion, even if the occasions are
every day (57).
Surrogate and illegal alcohols can bring an extra health risk from high ethanol
levels and toxic contaminants, such as methanol and lead (58), often
compounded by social marginalization (59).
Wide socioeconomic differences in alcohol-related mortality are well
documented (60). In the United Kingdom, occupational social class is a risk
factor for alcohol-related mortality and hospitalization, particularly among
men (61), while in Nordic studies, alcohol-related mortality rates are 1.9–
3.2 times higher among male manual workers than among non-manual
workers (62). Research from Finland further suggests that socioeconomic
variables act on the collective as well as the individual level (63): areas with
the most manual workers had 20% more mortality directly attributable to
alcohol than areas with the least, even after accounting for the individual
relationship of occupation to mortality. Similar effects held for
unemployment, urbanization and social cohesion (measured as both family
cohesion and voter turnout), which accounted for around 40% of the alcoholattributable mortality gap between areas after taking account of all of these
variables at individual level. This suggests that the drinking behaviour of
people living nearby may be important for the behaviour of the individual.

At societal level
The EU is the heaviest drinking region of the world with, on average, each
adult drinking 11 litres of pure alcohol each year – a level over two and a half
times the average of the rest of the world (9). Some 53 million adults (14%)
do not drink alcohol at all, while some 58 million (16%) can be classified as
heavy drinkers (women who consume on average more than 20g alcohol/day
and men more than 40g/day) (9). In any one year, some 23 million adults
(6%) are found to be dependent on alcohol. The Eurobarometer survey
conducted at the end of 2006 found that some 80 million Europeans aged
15 years and over (over one fifth of the adult EU population) reported heavy
episodic drinking (defined in the Eurobarometer survey as five or more drinks
on one occasion, or 50g alcohol) at least once a week in 2006, a proportion
that has increased since 2003 (64). A much higher proportion of all men
(31%) than women (12%) reported heavy episodic drinking at least once a
week. Some 25 million Europeans aged 15 years and over (1 in 15 of the adult
population) reported that heavy episodic drinking was their usual pattern of
consumption during the previous month. According to the Eurobarometer

Interventions to reduce alcohol-related harm
page 22

survey, heavy episodic drinking was not a prerogative of the young or of
northern Europeans. Whereas 24% of those aged 15–24 years reported heavy
episodic drinking at least once a week in 2006, such drinking was also
common among those aged 55 years and over, with 18% reporting heavy
episodic drinking at least once a week. The proportion of the total population
reporting that they were heavy episodic drinkers was 54% in Ireland and 33%
in Spain, much higher than in Finland (17%) and Sweden (11%).
Not surprisingly, this high level of consumption and pattern of drinking brings
with it a high level of harm: the WHO European Region has the highest
proportion of total ill health and premature deaths due to alcohol in the world
(Fig.1) (65).
At the ecological level there is a very close relationship between a country’s
total per capita alcohol consumption and its prevalence of alcohol-related
harm and alcohol dependence, implying that when alcohol consumption
increases, so does alcohol-related harm and the proportion of people with
alcohol dependence, and vice versa (66–67).
It is difficult to estimate the overall social harm due to alcohol in the EU (9).
Alcohol is associated with crime across the whole of Europe, with estimates
from differing countries and differing types of crime ranging from 20% to
80%, much of it with alcohol playing a causal role. Seven million adults in the
EU15 report being in fights when drinking over the past year and, based on a
review of a small number of national costing studies, the economic cost of
alcohol-attributable crime has been estimated to be €33 billion in the EU for
2003 (9). This cost is split between police, courts and prisons (€15 billion),
crime prevention expenditure and insurance administration (€12 billion) and
property damage (€6 billion). Property damage due to drink–driving has also
been estimated at €10 billion, while the intangible cost of the physical and
psychological effects of crime has been valued at €9–37 billion. Some 2000
homicides (4 in 10 of all murders) are estimated to be due to 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 €68 billion. Estimates of the scale of harm in
the workplace are more difficult, although nearly 5% of drinking men and 2%
of drinking women in the EU15 report that alcohol has a negative impact 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 €9–19 billion and €6–23 billion, respectively.

Impact of alcohol
page 23

Fig. 1. Alcohol-attributable burden of disease in DALYsa as a proportion
of all DALYs, by sex and WHO region, 2004 (%)

Notes: AFR: African Region; AMR: Region of the Americas; EMR: Eastern Mediterranean Region;
EUR: European Region; SEAR: South-East Asia Region; WPR: Western Pacific Region.
a

WHO uses a measure called disability-adjusted life years (DALYs) to estimate the number of
healthy years of life lost due to each risk factor. For example, while a year of perfect health will
count as 1 and a year of death will be 0, a year of damaged health that significantly affects quality
of life will be somewhere in between. DALYs measure a gap in health between the current
position and what could be achieved.
Source: Rehm et al (65).

Much of the harm caused by alcohol is borne by people other than the drinker
responsible (9). This includes 60 000 low-birth-weight babies, 16% of child
abuse/neglect and 5–9 million children living in families adversely affected by
alcohol. Alcohol also affects other adults, including an estimated 10 000
deaths in drink–driving accidents for people other than the drink-driver, and 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 €33 billion due to crime, €17 billion for
health care systems, and €9–19 billion of absenteeism.
Based on the results of 21 European studies, the total tangible cost of alcohol
to the EU was estimated to be €125 billion (range of estimates: €79–
220 billion) in 2003, equivalent to 1.3% of gross domestic product (0.9–2.4%)
(Fig. 2) (9). Actual spending on alcohol-related problems accounts for

Interventions to reduce alcohol-related harm
page 24

€66 billion of this, while potential production not realized due to absenteeism,
unemployment and premature mortality accounts for a further €59 billion.
Aside from the tangible monetary costs, alcohol causes an intangible cost of
somewhere between €152 and €764 billion, which incorporates the value
people place on pain, suffering and life itself due to crime and lost healthy life
due to alcohol. This intangible cost is not an economic loss in the normal
sense of the term and cannot be compared to, for example, gross domestic
product (nor can it be simply added to the tangible cost, given that they both
include estimated values for lost life but the estimates are done in different
ways). This cost does, however, offer a more accurate estimate of the full
economic and human cost of alcohol to the EU.

Fig. 2. The tangible cost of alcohol in the EU by cost component, 2003
Traffic accidents
damage, €10bn

Health, €17bn
Treatment/
prevention, €5bn

Crime –
damage, €6bn
Crime –
defensive,
€12bn

Crime – police,
€15bn

Mortality, €36bn
Unemployment,
€14bn

Source: Anderson & Baumberg (9).

Absenteeism,
€9bn

Impact of alcohol
page 25

Health inequalities
There are enormous differences in life expectancy between different parts of
the EU, revealing a waste of human capital, threatening the cohesion and
stability of the Union and leading to inefficiency in overall productivity. For
example, in 2002 the difference in male life expectancy at the age of 20 years
between the EU15 and EU5 was 5.8 years, the EU2 6.8 years, and the EU3
9.8 years. About 25% of the difference in life expectancy between the EU10
and the EU15 for men aged 20–64 years in 2002 can be attributed to alcohol,
largely as a result of differences in heavy episodic drinking patterns (68).
The alcohol-related health gap is reflected largely in differences from
cardiovascular and injury mortality. For example, in contrast to western
European countries, cardiovascular mortality in eastern European countries,
markedly in the Baltic States, rose suddenly to a peak in 1994 and then fell
back to its previous level (Fig. 3). This trend exactly mirrored that for
intoxication-related deaths – for example, those from injury – and for more
direct measures of alcohol consumption, suggesting that the vascular risk in
these countries was due to the rise in peak drinking between 1990 and 1994.
The most widely accepted interpretation of this phenomenon is that it is
mainly a consequence of the temporal pattern of alcohol consumption. As the
volume of alcohol consumed is concentrated into fewer drinking occasions,
the vascular risk increases (48). Another, and not mutually exclusive,
explanation may be due to interaction with folate intake, whose intake tends
to be lower in eastern Europe (68). Alcohol interferes with folic acid
absorption and metabolism at several points (69), and the benefits of alcohol
consumption on risk of cardiovascular disease disappear with low intake of
folic acid (70).
Another example is premature mortality from injuries, the cause of one in
seven of all preventable mortality in the EU (68). In Europe, there are three
clear strata of fatal injury mortality: compared with the EU15 countries, the
rates are double in the seven central and eastern European countries and at
least five times as high in the three Baltic States. The leading cause of fatal
injury mortality is alcohol, causing one third of all mortality from accidents
and injuries among Europeans aged 20–64 years. In the Baltic States, one
third of all premature mortality is due to injuries, with nearly one half of all
deaths from injury due to alcohol (Table 1). Since half of the health gap
between the EU15 and the Baltic States is attributed to injuries, it can be
concluded that at least one quarter of the health gap is due to alcohol. A major

Interventions to reduce alcohol-related harm
page 26

(EU3)

Standardized rates per
100 000 person-years

Fig. 3. Cardiovascular mortality in the Baltic States
compared with the EU15, men aged 20–64 years, 1980–2002

RR: rate ratio, RD: rate difference, APC: annual percentage change.
Source: Zatonski et al (68).

Table 1. Alcohol-attributable mortality from injuries in people aged 20–64
years, 2002
Alcohol-attributable injury mortality

EU15

EU7

EU3

Men:

16.9
29%
3.1
19%

44.1
38%
7.0
29%

160.0
48%
27.9
42%

Mortality rate of alcohol injuries
Proportion of alcohol injuries in all injuries
Women: Mortality rate of alcohol injuries
Proportion of alcohol injuries in all injuries
Source: Zatonski et al (68).

cause of the health gap results from poor health infrastructures in some of the
EU10 countries, including an historical exclusively epidemiological focus on
communicable as opposed to noncommunicable diseases, a lack of

Impact of alcohol
page 27

understanding and access to modern epidemiology and public health and to
evidence-based medicine, and a lack of effective public health interventions,
as well as harmful drinking patterns, an insecure environment and high levels
of social exclusion (68).
Summary of the evidence of the health, social and economic
impact of alcohol
What we know


The risk of death from an alcohol-related illness or injury
increases with increasing alcohol consumption.



At 20g of alcohol consumed on average per day or per
drinking occasion per day, the lifetime risk of death from
an acute or chronic condition is less than 1 in 100.



For a given level of alcohol consumption, people from
lower socioeconomic groups are at increased risk of an
alcohol-related death, compounded by areas with a higher
degree of disadvantage.



The burden of the social harm done by alcohol is estimated
at €125 billion each year in the EU.



Twenty-five per cent of the difference in male middle age
life expectancy between eastern and western Europe can
be attributed to alcohol.

What we do not know
⊗

The avoidable burden of the social cost of alcohol that
could be averted with effective alcohol policies in Europe.

Policy implications of the evidence of the health, social and
economic impact of alcohol
For the individual, the lifetime risk of death from alcohol can be
averted by reducing alcohol consumption. Consuming less than
20g/day reduces the lifetime risk of death from alcohol to below
1 in 100. Concerted support could be given to the development
and implementation of alcohol policy in many of the newer
member states to lessen the health inequalities between different
regions of the EU and to support increases in overall efficiency
and productivity in Europe.

Raising awareness and political commitment
This section notes that while the provision of information and education is
important to raise awareness and impart knowledge, by themselves
information and education do not lead to sustained changes in alcohol-related
behaviour. Education can, however, be a tool for awareness and raising
support, and an important feature of a broader alcohol strategy. Campaigns
and health education messages funded by the alcohol industry seem to have
negative effects, serving to advance the interests of both the industry’s sales
and public relations. Although warning labels have little impact on behaviour,
they are important in helping to establish a social understanding that alcohol is
a special and hazardous commodity. Popular perceptions of actions and
responsibilities relating to alcohol are of obvious importance for policymaking, with policy-makers both contributing to perceptions as well as
responding to them. There is evidence of public support for a wide range of
alcohol policy measures, although there is still much work to do, given the
existing negative views about the potential impact of higher alcohol prices.
Although at country level, it is ultimately a government’s responsibility to
define and be accountable for a clear alcohol policy, with targets, an adequate
research base and available intelligence systems, the presence of an alcohol
policy is not enough. A lack of transparency and information, poor
organization and preparation for the introduction of new policies and laws,
poor public health infrastructures, vertically as opposed to horizontally
organized government, a lack of financing, the presence of corruption, and
public distrust of authority are all impediments to the implementation of
effective policy.

Impact of education and information campaigns
Providing information and education is important to raise awareness and
impart knowledge, but, particularly in an environment in which many
competing messages are received in the form of marketing and social norms
supporting drinking, and in which alcohol is readily accessible, do not lead to
sustained changes in alcohol-related behaviour (7).

School-based information and education
Many systematic reviews have evaluated school-based education and
concluded that classroom-based education is not effective in reducing alcohol-

Raising awareness
page 29

related harm (71,72). Although there is evidence of positive effects on
increased knowledge about alcohol and on improved alcohol-related attitudes,
there is no evidence for a sustained effect on behaviour. One systematic
review of 14 systematic reviews identified 59 high quality programmes, of
which only 6 were able to demonstrate any evidence for effectiveness (72). It
is interesting to note that one of the series of reviews that did find a positive
outcome (73) was based on inappropriate analyses which, on proper analysis,
found no effect (74). It has been suggested that parenting and social marketing
programmes might have more promise but, even here, mixed effects have
been found. For example, a systematic review of 14 parenting programmes
found reductions in alcohol use in only 6 programmes (75), and a systematic
review of 15 social marketing programmes found 8 out of 13 studies showing
some significant effects on alcohol use in the short term (up to 12 months), 4
out of 7 studies showing some effect at 1–2 years, and 2 out of 4 studies
showing some effect over 2 years (76).
A systematic review of preventive interventions addressing under-age
drinking identified 25 reviews and over 400 interventions. The evidence for
127 of these was reviewed and only 12 were found to have promising
evidence on alcohol outcomes (77). The promising interventions were mixed,
and it was not possible to identify any clear group or category of programmes
that showed promise.
A number of suggestions have been made as to how the impact of schoolbased education programmes might be improved by: encouraging programme
planners to adopt a formative phase of development that involves talking to
young people and testing the intervention with young people and teachers;
providing the programme at relevant periods in young people’s development;
ensuring programmes are interactive and based on skill development; setting
goals for changing behaviour that are relevant and inclusive of all young
people; including booster sessions in later years; including information that is
of immediate practical use to young people; and including appropriate
teachers (78–82). Further, any improvements to school education should be
embedded in the concept of the school as a health-promoting setting (83).
While education primarily aims to affect behaviour through influencing
attitudes, there is some evidence to suggest that in fact attitudes are influenced
by behaviour, thus raising the question of whether interventions should focus
on attitudes or behaviour. Research in adolescent smoking has found that
attitudes towards smoking were neither a consistent nor strong predictor of
smoking behaviour over time (84). The same study found that in fact, past
smoking was related to attitudes indicating that adolescents adapted their

Interventions to reduce alcohol-related harm
page 30

attitudes to match their behaviour. It also suggests that other factors play
important roles in beginning and continuing to smoke, such as favourable
social images and peers who smoke.
Public education campaigns. In general, public information campaigns have
been found to be ineffective in reducing alcohol-related harm (1). Exceptions
are mass media campaigns to reduce drinking and driving which, when
implemented in the presence of strong drinking and driving countermeasures,
can have an impact (85). Counter-advertising, a variant of public information
campaigns which provides information about a product, its effects and the
industry that promotes it in order to decrease its appeal and use, has
inconclusive effects (1).

Campaigns based on drinking guidelines
While campaigns based on drinking guidelines have been used in a number of
countries, there have been no rigorous evaluations of whether or not
publicizing such guidelines has any impact on alcohol-related harm (9).
Campaigns funded by the alcohol industry. Most of the research comparing
tobacco industry prevention campaigns with tobacco control campaigns
suggests they perform less well and, in many instances, can be
counterproductive, with tobacco company advertisements being more likely to
elicit positive emotions and less likely to elicit negative emotions than
tobacco control advertisements. Further, industry prevention campaigns
consistently cause young people to become more favourably inclined towards
the tobacco industry (86,87). This is not surprising as it reflects the true
purpose of these campaigns: they are part of what are becoming increasingly
elaborate corporate social responsibility programmes, designed to improve the
image and reputation of the company (88).
With alcohol, there is evidence that social responsibility messages, whether
stand-alone or when added to product advertisements, benefit the reputation
of the sponsor more than public health. For example, a study that assessed the
impact of adding drink–driving messages to bar advertisements showed that
inclusion of the message had positive effects on the perception of the
advertiser in terms of concern about the safety of bar customers, but did not
affect the attitudes or intentions variables (89). Similarly, another study found
the message in alcohol industry social responsibility spots to be ambiguous,
especially for 16–18-year-olds, but that the source of the message (the alcohol
company) was favourably perceived. Two thirds of the sample perceived the

Raising awareness
page 31

spots to be fairly or very similar to beer commercials, with over two thirds
agreeing that the spots suggested that beer drinking was fun (90).
There is also evidence, as with tobacco, that alcohol companies are more
circumspect about their messaging than public health sources are (91). Thus
they tend to avoid the negative consequences of irresponsible drinking (92)
and set their messages within a “drinking is normal” context. They also co-opt
social responsibility messaging to serve product marketing objectives,
conflating the two agendas. Thus, seemingly pro-health messages can end up
serving to advance both industry sales and public relations interests (12).
Consumer labelling and warning messages. Evaluation of the impact of the
mandated health warnings on alcohol product containers that were introduced
in the United States did not demonstrate that exposure produced a change in
drinking behaviour, although some intervening variables were affected, such
as intention to change drinking patterns (93). Since 2007, a health warning has
been placed on alcoholic drinks packaging in France in order to promote
abstinence during pregnancy, supported by a press campaign and extensive
media coverage. Two telephone surveys were conducted in 2004 and 2007
among two independent representative quota samples of the French
population aged 15 year and over (approximately 1000 people interviewed in
each survey) (94). It was found that the recommendation that pregnant women
should not drink alcohol was better known after the introduction of the health
warning (87% of the respondents) than before (82%) (p<0.001). After the
introduction of the label, 30% thought that the risk for the foetus started after
the first glass compared with 25% in 2004 (p<0.01). These rather modest
results contrast with evidence from tobacco, where there is evidence of
impact, but this may reflect the nature of the warning labels, since it seems
that the introduction of more graphic and larger warnings for cigarettes, with
rotating messages, has affected behaviour (95). Nevertheless, warning labels
are important in helping to establish a social understanding that alcohol is a
special and hazardous commodity (96).
What to do about education and information. When looking at education
alone, the lack of evidence for effectiveness could lead to policy-makers
considering withdrawing funds from education programmes altogether. This
would involve several risks, including: losing the importance of education for
society in improving individual capital; losing an important means of gaining
awareness of and support for other control measures; and leaving a gap which
may be filled by better-funded industry-backed programmes. Many education
programmes focus on young people, and there is evidence that young adults
and adults are often overlooked. These groups often serve as drinking role

Interventions to reduce alcohol-related harm
page 32

models for young people and also support easy access to alcohol, which is
associated with increased drinking in all age groups, and are therefore an
important target audience (97). The conceptual shift from influencing attitudes
to affecting behaviour to looking at the influence of behaviour on attitudes is
important to consider, especially among young people. It may be more
effective to focus education/information activities on policy-makers and the
general public as a means to raise awareness of the burden of alcohol-related
harm and the benefits of effective measures to reduce this harm. Interventions
could be reframed to encourage and support consumer advocacy by providing
information on how the public can influence alcohol policy.
Summary of the evidence of education and information
campaigns
What we know


There is extensive and consistent evidence that schoolbased information and education programmes do not lead
to sustained changes in behaviour.



Although showing some promise, there is no consistent
evidence to demonstrate that parenting programmes and
social marketing programmes lead to sustained changes in
behaviour.



Although poorly researched, there is no consistent
evidence that public education campaigns lead to sustained
changes in behaviour.



There are no rigorous evaluations to demonstrate whether
or not campaigns based on drinking guidelines lead to
sustained changes in behaviour.



Although there is limited research, there is some evidence
that campaigns funded by the alcohol industry can have
negative effects.



There is some evidence to show that consumer labelling
and warning messages do not lead to sustained changes in
behaviour.

Raising awareness
page 33

What we do not know
⊗

The extent to which educational and information
campaigns can be made more effective.

Policy implications of the evidence of educational and
information campaigns
Providing information and education on the risk of alcohol and
how to reduce it is needed for an educated population and for the
development of individual capital, although as an isolated policy
measure it will not reduce alcohol-related harm. Education policy
could benefit from incorporating a conceptual shift from
influencing attitudes to effect behaviour to looking at the
influence of behaviour on attitudes. Education and information
activities could be reframed to encourage and support consumer
advocacy by providing information on how the public can
influence alcohol policy.

Public support for alcohol policy measures
Popular perceptions of actions and responsibilities relating to alcohol are of
obvious importance for policy-making, with policy-makers both contributing
to perceptions and responding to them. The 2006 Eurobarometer report
provided some European comparative results on public attitudes towards
alcohol policy areas (64).

Drink–driving
The Eurobarometer survey found that although 51% of the EU population
appears to know that the maximum legal blood alcohol level (BAC) for
drivers is between 0.01 and 0.59 g/litre, which is indeed the case in 19
member states, 36% of the EU population did not know the current legal BAC
level in their own countries. In two countries with a zero limit, the population
is more aware of the limit – the Czech Republic (75%) and Slovakia (57%) –
although in the third country, Hungary, there is less awareness (39%). In
Ireland, Malta and the United Kingdom, where the legal BAC is above
0.8 g/litre, 96% of respondents in Malta, 70% in the United Kingdom and
66% in Ireland did not know their current legal BAC level. A higher
proportion of those ignorant of the rate was found among women (43%),

Interventions to reduce alcohol-related harm
page 34

respondents aged 55 years and over (44%), respondents who had finished
their full-time education by the age of 15 years (51%), “house persons”
(53%), retired persons 42%), inhabitants of large towns (41%) and those who
do not drink alcohol (52%).
In the 2004 Sartre study, more than 88% of the drivers interviewed thought
that the penalties for drink–driving offences should be much more severe,
with homogeneity across countries (98). Forty-five per cent of participants
thought that drivers should not be allowed to drink any alcohol before driving,
more in the eastern European countries (60%), a similar figure in northern
(47%) and western (43%) European countries, and lower in southern
European countries (26%). More than two thirds of all drivers were in favour
of having a maximum alcohol limit of 0.5 g/litre. Eighty per cent of drivers
from countries where this limit is already in place and 75% of drivers from
countries with a limit of 0.8 g/litre are in favour of the 0.5 g/litre limit. In
general, the more the current legal limit differs from 0.5 g/litre, independent
of whether it is higher or lower, the less do the drivers favour a maximum
limit of 0.5 g/litre. This result indicates that the acceptance of legal regulation
is strongly influenced by habituation and personal experience. Eighty-two per
cent of the drivers interviewed were very or fairly in favour of having a legal
BAC limit for novice drivers of 0.0 g/litre.
In the Eurobarometer survey, almost three quarters of Europeans surveyed
(73%) said they tended to agree that the legal BAC for young and novice
drivers should be lowered to 0.2 g/litre, including 70% from Spain and 64%
from Italy, with 51% of Europeans totally agreeing to this proposal. People
from Germany, the Netherlands and Sweden were most likely to agree to a
lower level. People from the Czech Republic, Hungary and Slovakia were
least likely to agree, but this is probably explained by the fact that the limit in
those three countries is already zero for all drivers. Eight in ten (80%) EU
citizens, including 90% from Spain and 82% from Italy, tended to believe that
random police alcohol checks on EU roads would reduce people’s alcohol
consumption before driving, with 47% totally agreeing with this statement.
There was support for this statement in all countries surveyed.
In the Sartre study, one third (32%) of the drivers were very much in favour
and another 25% somewhat in favour of having an alcohol meter in the car to
prevent them from driving if over the BAC limit. More than 70% of people
were in favour in France, Greece, Portugal and Sweden, while in Austria,
Germany and Greece, fewer than 30% of the drivers were in favour.
Interestingly, drivers who were in favour of an alcohol meter were nearly 50%

Raising awareness
page 35

more likely to have reported drinking and driving while over the limit than
those who were not in favour of an alcohol meter.

Consumer information
According to the Eurobarometer survey, three quarters (77%) of the
population of the EU, including 79% from Italy and 84% from Spain, agreed
with putting warnings on alcohol bottles and advertisements, to warn pregnant
women and drivers of the dangers of drinking alcohol. In all the countries
surveyed, the majority of respondents would support such a concept, with the
lowest support in Finland (45%), Denmark (41%) and the Netherlands (38%).
Seventy-five per cent of alcohol consumers and 72% of those considering the
protection from alcohol-related harm to be the responsibility of individuals
supported warnings on bottles and advertisements, compared with 83% of
those who had not drunk alcohol in the previous 12 months, and 84% of those
who think public authorities have to intervene to protect individuals from
alcohol-related harm.

Availability of alcohol
Eighty-seven per cent of EU citizens, including 82% from Italy and 92% from
Spain, stated in the Eurobarometer survey that they agreed with banning the
selling and serving of alcohol to people under the age of 18 years, with two
thirds of the population (65%) saying that they “totally agreed” with such
restrictions. Public opinion in all countries was in favour of the concept of
prohibiting the selling and serving of alcohol to young people under 18 years
of age. Even in countries where there were fewest people in favour, the
majority of the population – Belgium (72%), Denmark (72%) and the
Netherlands (61%) – responded with a considerable degree of support. As
many as three quarters of respondents aged between 15 and 24 years agreed
with the statement.

Advertising of alcohol
According to the Eurobarometer survey, three quarters of the EU population
(76%), including 81% from Spain and 70% from Italy, would approve the
banning of alcohol advertising targeting young people in all member states,
with every second respondent (50%) responding that they “agree totally” with
this idea. A country-by-country analysis shows that in all countries the
majority of respondents would favour such a ban, the strongest support (93%)
being seen in Slovakia (with 68% “totally agreeing”), and less support in
Luxembourg (58%, with 41% “totally agreeing”) and Denmark (59%, with
37% “totally agreeing”).

Interventions to reduce alcohol-related harm
page 36

Price
According to the Eurobarometer survey, two thirds of the EU population
(68%), including 64% from Spain and 54% from Italy, believed that higher
prices for alcohol would NOT discourage young people and heavy drinkers
from alcohol consumption. Eighty-five per cent of people from the
Netherlands doubted that price would have a dissuasive effect, whereas 60%
of people from Finland thought that higher alcohol prices would restrain
younger people and heavy drinkers from consumption; the higher support in
Finland could be due to the increases in alcohol consumption and related harm
that followed reductions in tax at the time of the survey. Over half of the
people in Romania also considered that higher prices would restrain young
people’s and heavy drinkers’ alcohol consumption; this view might be
explained by a lower level of income in Romania compared to other EU
countries.
There is evidence that media advocacy can lead to reframing the solution to
alcohol-related problems in terms of a coordinated approach by relevant
sectors, such as health, enforcement, nongovernmental organizations and
municipal authorities, resulting in increased attention to alcohol on the
political and public agendas (7). Further, public perspectives of what
constitutes alcohol-related harm are influenced by changes in alcohol policy,
such that when policy becomes more rigorous, what is perceived as individual
alcohol-related harm becomes stricter (99).
Summary of the evidence of the public support for alcohol
policies
What we know


Three quarters of Europeans would support a lower legal
BAC level for young and novice drivers; four fifths
believe that random breath testing would reduce drinking
and driving.



Three quarters of Europeans would support labels warning
pregnant women and drivers not to drink.



Nine tenths of Europeans support a ban on selling and
serving alcohol to young people aged under 18 years.



Three quarters of Europeans would support a ban on
advertising that targets young people.

Raising awareness
page 37



Two thirds of the European population believe that higher
prices would not discourage young people and heavy
drinkers from alcohol consumption.

What we do not know
⊗

How best to convey the message and seek public support
for higher prices on alcohol to reduce alcohol-related
harm.

Policy implications of the evidence of public support for
alcohol policies
There is a range of effective policy measures, including those on
drinking and driving, consumer labelling, advertising controls
and controls on a minimum age of purchase, for which there is
overwhelming public support from European citizens. The one
policy measure that European citizens are sceptical about is that
which is most effective – price. Concerted campaigns could be
mounted to seek public support for price policy measures.

Infrastructures for alcohol policy
At country level, it is ultimately a government’s responsibility to define and
be accountable for a clear alcohol policy for the whole country and for regions
within a country (7). Many different decision-making authorities are involved
in the formulation and implementation of alcohol policy, including the health
ministry, the transportation authority and the taxation agency. Governments
need to establish effective and permanent coordination machinery, such as a
national alcohol council, comprising senior representatives of many ministries
and other partners, to ensure that a coherent approach is taken to alcohol
policies and that policy objectives are properly balanced in both their political
and technical aspects.
Targets make policy objectives more specific, allow progress towards them to
be monitored and inspire many partners actively to support alcohol policy
developments (9). Targets require an assessment of the present situation and
help to determine priorities. They can focus discussion on what it had been
hoped to achieve and why, and whether or not this was successful and why.

Interventions to reduce alcohol-related harm
page 38

They provide a powerful communication tool, taking policy-making out of
bureaucratic confines and making it a clearly understood public issue; they
give all partners a clearer understanding of the scope of the policy; they
strengthen accountability for health; and they motivate people for action.
Accountability for the health impact of alcohol policies and programmes rests
with all sectors of society, as well as government officials who create policy,
allocate resources and initiate legislation (9). Mechanisms such as alcohol
policy audits, litigation for damage to health and public access to reports on
impact assessments can ensure that both the public sector and private industry
are publicly accountable for the health effects of their alcohol policies and
activities. Accountability can be achieved through mechanisms for
coordinating, monitoring and evaluating progress in policy implementation
and through procedures for reporting to elected bodies, as well as through the
mass media.
One method of financing programmes to reduce the harm done by alcohol is
an earmarked tax (100). This means that a proportion of tax revenue collected
from alcohol is devoted to a specific activity, such as policy implementation
or health care.
But the presence of an alcohol policy, although important, is not enough
(101). Policy needs to be sensitive to cultural values and historical experience
and to engage the many different sectors that have an impact on alcoholrelated harm. Policy needs to be comprehensive, minimizing any negative
consequences due to perverse incentives (102,103). A lack of transparency
and information, poor organization and preparation for the introduction of
new policies and laws, poor public health infrastructures, vertically as
opposed to horizontally organized government, a lack of financing, the
presence of corruption, and public distrust of authority are all impediments to
the implementation of effective policy (104,105).

Research
A firm research base is a pre-requisite for alcohol policies and actions (106).
A clear finding is that Europe, and particularly southern and eastern Europe,
lags behind other parts of the world in carrying out and publishing research on
alcohol and alcohol policy (9). The scientific community should be involved
in developing scientifically sound, socially relevant and feasible bases for
decisions relating to alcohol policy. Research is not value-free, in the sense
that the framing and choice of topics inevitably reflects judgments and
choices between competing priorities. The duty of the scientific community is

Raising awareness
page 39

to be faithful to the research evidence, which means that the findings of
research may contradict current policies and programmes. There is good
reason, then, for there to be some distance between the public health scientific
community and both governments and the alcohol beverage industry.
However, there must be a much better match between the needs for alcohol
policy research as perceived by decision-makers and planners on the one
hand, and the research priorities set by the research community on the other.
To be useful, research evidence has to be communicated simply and given
meaning by making it relevant to current issues. Such sustained contributions
may only be possible in the context of a long-term, publicly-funded research
programme designed to engage members of the scientific community in each
country in the collection, evaluation and interpretation of research data
relevant to a country’s alcohol policy needs.
Research and development efforts cannot be implemented without building
the appropriate capacity. Effective alcohol policy needs competent and wellinformed personnel working in settings supportive of their efforts.
Investments must, therefore, be made in both institutional and human capacity
for the development of research.
The responsibility for translating scientific research into effective policy is
distributed across a wide variety of government agencies and public interest
groups. In addition, there need to be systematic mechanisms for ensuring that
new evidence from research is actually introduced into policy and programme
practice. If all existing knowledge about which alcohol policy approaches
work and which do not were fully applied, there could be a major impact on
improving public health.
Information systems are key components in making knowledge more widely
available (9). Intelligence is broader than information. It implies identifying
and interpreting essential knowledge for making decisions from a range of
formal and informal sources. Intelligence should include: current and future
trends and system performance (e.g. levels, trends and inequalities in areas of
alcohol consumption and alcohol-related harm); risk factors for harm;
vulnerable groups; organizational or institutional challenges in implementing
policy; governance; important contextual factors and actors (the political,
economic and institutional context); actors’ roles and motivations; users’ and
consumers’ preferences; opportunities and constraints for change; and events
and reforms in other sectors with implications for alcohol policy. This
information should be available on electronic media and be published
regularly in a publicly accessible form, so as to promote an informed and open

Interventions to reduce alcohol-related harm
page 40

debate among politicians, professionals and the public concerning outcomes
and determinants, and future priorities for action and investment.
Summary of the evidence of infrastructures
What we know


An alcohol policy supported by adequate resources is a
pre-requisite for government action.



Alcohol policies need to be supported by an adequate
research base, ensuring that the knowledge of research is
widely available.



Alcohol policies need to be supported by effective
information systems that allow monitoring of the
implementation of policy.

What we do not know
⊗

We do not know the most effective infrastructures to
ensure the effective and transparent implementation and
enforcement of policy.

Policy implications of infrastructures
Alcohol policies are best prepared and implemented based on
research and information. Having a good policy is not enough: to
be effective, policy requires public support and the action of a
wide range of stakeholders working across different levels of
governance.

Response of the health sector
There is a clear gap in the potential contribution of the health sector’s
response in reducing the harm done by alcohol. In primary health care
settings, commonly less than 10% of the population at risk of becoming
hazardous and harmful drinkers are identified and less than 5% of those who
could benefit are offered brief interventions (107). A 2004 needs assessment
study in England found that only 1 in 18 (5.6%) of alcohol-dependent drinkers
actually accessed treatment each year, with regional variations ranging from 1
in 102 to 1 in 12 (108). The health sector workforce in Europe is an enormous
resource with great potential. Disorders related to alcohol use are included as
mental and behavioural disorders within the ICD-10 classification of mental
and behavioural disorders, and there is a legal imperative to provide help and
treatment for alcohol use disorders. This section notes that brief advice heads
the list of effective and cost–effective evidence-based treatment methods.
Much is now also understood about the mechanisms for implementing brief
advice programmes countrywide. For individuals with more severe alcohol
dependence and related problems, a wide variety of specialized treatment
approaches have been evaluated with evidence for their effectiveness for
behavioural and pharmacological therapies.

Screening and brief advice programmes
Brief advice heads the list of effective evidence-based treatment methods
(109). A systematic review and meta-analyses of the effectiveness of brief
interventions for hazardous and harmful alcohol consumption have found a
positive impact of such interventions on alcohol consumption, mortality,
morbidity, alcohol-related injuries, alcohol-related social consequences, use of
health care resources and laboratory indicators of harmful alcohol use (110).
Brief interventions have been shown to be effective in both men and women,
with evidence suggesting a trend towards increased effectiveness among men.
Study populations are made up primarily of adult populations, although
limited evidence has been identified for the effectiveness of brief
interventions in children, adolescents and young adults. Socioeconomic status
has not been shown to influence the effectiveness of such interventions. The
available evidence suggests that even very brief interventions may be
effective in reducing negative alcohol-related outcomes, enhanced by

Interventions to reduce alcohol-related harm
page 42

motivational interviewing (111), but with little additional benefit arising from
increased exposure (110).
While the majority of studies have been conducted in primary care settings,
limited evidence has also been identified for other health care settings. Three
reviews specifically focusing on the use of brief interventions in emergency
care have found limited evidence for the effectiveness of such interventions in
emergency care settings (112–114). A further review presented inconclusive
evidence of the effectiveness of brief interventions in inpatient and outpatient
settings (115). No systematic reviews presenting information on the
effectiveness of brief interventions in non-health care settings have been
identified, and there are no recent systematic reviews of the impact of brief
interventions in pregnancy (116). One US-based study of 304 pregnant women,
selected because they screened positive on the T-ACE3 score and were
considered at risk for prenatal alcohol use, were randomized with a support
partner of their choice (usually husbands or biological fathers of their unborn
children) to receive a brief intervention or not. Brief interventions for prenatal
alcohol reduced subsequent consumption most significantly for the women with
the highest consumption initially (regression coefficient: b = -0.163; standard
error: (b) = 0.063, p <0.01) (117). Moreover, the effects of the brief intervention
were significantly enhanced when a partner participated (b = -0.932; standard
error: (b) = 0.468), p <0.05).
There is evidence from a range of studies in primary care settings for the
potential influence of training and support for general practitioners in alcohol
screening and the use of brief intervention materials on implementation rates
and the detection of at-risk drinkers (118). A systematic review of 12 studies
found that a combination of educational and office support programmes
increased screening and advice-giving rates of primary health care providers
from 32% to 45% (119). Evidence from qualitative studies show that some
nurses in the United Kingdom see training as an incentive in carrying out
alcohol-related work; a sample of general practitioners in Finland perceived
that they lacked training in identifying the early stages of alcohol misuse; and
general practitioners in a Danish focus group study felt that they lacked
training in counselling skills.
Evidence has been found for the actual and perceived effect that
implementation of screening and brief interventions has on a practitioner’s
workload, particularly if all young people and adults are screened as routine
3

T-ACE is a modification of the CAGE screening for alcoholism test and was designed
for use in obstetric settings to identify at-risk drinkers.

Response of the health sector
page 43

practice. The extra time that such implementation demands can be a barrier to
acceptability and therefore willingness to deliver such a programme.
Implementation of routine screening and brief intervention programmes
requires team-working between physicians, nurses and non-clinical personnel,
with consideration required regarding the extent of involvement and specific
roles of team members.
Visits to primary care for specific clinics and registrations of new patients are
seen to be less threatening occasions on which to discuss drinking, embedded
in a general discussion around lifestyle issues such as diet, exercise and
smoking. There is further evidence from three United Kingdom qualitative
studies that practitioners and users regard clinics, registration sessions and
routine consultations as opportunities for discussions in a less threatening
environment and context.
There is evidence for general under-activity in discussing drinking with service
users. Evidence suggests that even when drinking is heavy, service users are not
being asked about their drinking, and advice on drinking behaviour is provided
less often than for other lifestyle behaviour, such as exercise, diet and smoking,
and less often than service users expect. Some possible reasons are found in a
Finnish qualitative study of general practitioners, who reported that they were
reluctant to ask users about their drinking unless they saw clear signs of risky
drinking behaviour (120).
There is evidence from primary care practitioners’ views of a shortfall in
perceived knowledge in terms of detecting individuals at risk. There is also
evidence of confusion regarding current guidelines relating to drinking
behaviour and the known benefits of drinking in moderation. This can affect
practitioners’ confidence in and motivation towards implementing screening
and brief intervention programmes effectively. There is qualitative evidence
from three studies focusing on users’ views that a discussion of drinking is
facilitated by a good relationship with the health professional. In addition,
there is evidence that practitioners are concerned not to offend users in
relation to discussing alcohol for fear of disturbing the therapeutic
relationship.
Several studies show that even when considering a very brief intervention, the
cost–effectiveness results appear encouraging. As would be expected, the
studies which consider more extended interventions generally show greater
effects from consumption and resource use. The results of several studies are
driven by the long-term cost savings made in the use of resources, particularly
as regards motor vehicle accidents. These costs are uncertain – limited data

Interventions to reduce alcohol-related harm
page 44

means that they can only be estimated with wide confidence intervals.
However, the two studies where it was possible to split out the costs of motor
vehicle accidents from other costs both presented favourable economic
results, even if such accidents were not included (121,122).
Four studies provide evidence on the likely quality-adjusted life-year (QALY)
gain associated with screening plus brief intervention for hazardous and
harmful alcohol use (122–125). These studies estimate that the lifetime
QALY gain due to screening plus brief intervention is likely to be in the
region of 4–19 per 1000 compared to no intervention, depending on the exact
intervention and whether it is repeated over time. Further evidence suggests
that this could be higher if within-family external quality of life effects are
included in the analysis. The primary care studies overall appear to show that
screening plus brief intervention result in modest effects. However, the
economic analyses suggest that the size of these effects, in tandem with
resource use and other cost effects, are sufficient for the interventions to be
classed as cost–effective.

Treatments for
dependence

alcohol

use

disorders

and

alcohol

For individuals with more severe alcohol dependence and related problems, a
wide variety of specialized treatment approaches have been evaluated
(109,126–128), with evidence of effects for behavioural therapies, where a
systematic review of 17 studies found a combined effect size of 0.33
(SE=0.08) for reduced alcohol consumption and alcohol-related difficulties
(129), and pharmacological therapies including γ-Aminobutyric acid (GABA)
agonists, where a systematic review of 17 randomized controlled trials found
a relative risk of point prevalence abstinence of 1.40 (95% CI: 1.24, 1.59) at
6 months and 1.62 (95% CI: 1.37, 1.92) at 12 months (130), and those
including opiate antagonists, where a systematic review of 29 randomized
controlled trials found a significant reduction in relapse, at least in the short
term (3 months): the relative risk (95% CI) equalled 0.64 (0.51, 0.82) (131).
There is evidence that matching individuals with alcohol use disorders to
specified treatment does not improve outcome (132). Although Project
MATCH found a significant positive impact of treatment and no differences in
outcome between 12-step facilitation therapy designed to help patients become
engaged in the fellowship of Alcoholics Anonymous, a 12-session cognitive
behavioural therapy designed to teach patients coping skills to prevent a relapse
into drinking, and a motivational enhancement therapy designed to increase
motivation for and commitment to change (132), the mesa-grand study found

Response of the health sector
page 45

evidence of ineffectiveness of 12-step facilitation from 6 studies and of
ineffectiveness of Alcoholics Anonymous from 7 studies (109). An additional
systematic review of 8 studies found no studies that unequivocally
demonstrated the effectiveness of Alcoholics Anonymous or 12-step facilitation
approaches for reducing alcohol dependence or alcohol-related problems (133).
There is a limited literature related to economic models for the assessment of
treatments for alcohol use disorders (128), and it is dominated by studies
exclusively based on premature mortality outcomes from those abstaining
from drinking after an intervention rather than attempting to model the natural
flow of patients with alcohol use disorders. A promising approach is to use a
modified Markov model to model lifetime QALYs and health care costs from
different drinking patterns over time (134).
Summary of the evidence of the health sector’s response
What we know


There is extensive and consistent evidence that brief
advice in health care settings reduces alcohol-related harm.



There is consistent evidence that organizational factors can
increase the implementation of brief advice programmes.



There is consistent evidence that brief interventions are
cost–effective.



There is consistent evidence that behavioural and
pharmacological therapies are effective in treating alcohol
use disorders.

What we do not know
⊗

The extent to which brief advice works in non-health care
settings.

⊗

The extent to which interventions reduce risk in
pregnancy.

⊗

Sufficient information about the cost–effectiveness of
treatments for alcohol use disorders.

Interventions to reduce alcohol-related harm
page 46

Policy implications of the health sector’s response
Organizational factors, including training and office support, can
enhance the widespread implementation of early identification
and brief advice programmes for hazardous and harmful alcohol
consumption. Options should be considered for delivering either
universal programmes to all drinkers at risk, or targeted
programmes to particular groups (for example, adult males) or to
those attending particular clinics (for example, hypertension
clinics) (135). Brief advice programmes could be supported by
the availability of evidence-based treatments for alcohol use
disorders, a classified ICD-10 disorder.

Community action
This section shows that there is evidence that community-based programmes
can have an impact on creating safer drinking and living environments and
reducing underage drinking, harmful patterns of drinking and drink–driving
accidents, although they can be costly to implement and sustain. Such
programmes should include controls on venues for the sale and consumption
of alcohol, other regulations reducing access to alcohol, enhanced law
enforcement and surveillance, and the development of community
organization and coalitions supported by education and information
campaigns, media advocacy, counter-advertising and health promotion. The
section also shows that alcohol use can increase the risk of absenteeism and
poor performance at work, and structural factors at work can increase the risk
of harmful alcohol use. The available evidence suggests that workplace-based
interventions have some limited impact in reducing alcohol-related harm.

Community activities
Community-based prevention programmes can be effective in reducing
drinking and driving, alcohol-related traffic fatalities and injuries from assault
(136), although they can sometimes be associated with adverse consequences
(137). Community mobilization has been used to raise awareness of problems
associated with on-premise drinking, develop specific solutions to problems,
and pressure bar-owners to recognize that they have a responsibility to the
community in terms of such bar-related issues as noise level and customer
behaviour. Evaluation results from community mobilization approaches, as
well as documentation from grassroots projects, suggest that community
mobilization can be successful in reducing aggression and other problems
related to drinking on licensed premises.
A review of 10 community-based prevention trials which have sought to
reduce harm from alcohol found that strategies included education and
information campaigns, media advocacy, counter-advertising and health
promotion, controls on venues for the sale and consumption of alcohol, other
regulations reducing access to alcohol, enhanced law enforcement and
surveillance, and community organization and coalition development (136).
Interventions which showed promise were those that paid particular attention
to controls on access, included the environmental contexts of where the

Interventions to reduce alcohol-related harm
page 48

products are sold and distributed, and involved enforcement of public health
polices (138).
Community and neighbourhood characteristics are important in moderating
the pricing and promotion of beer, as well as reducing binge-drinking.
Communities with more effective enforcement of minimum purchase ages
have lower rates of alcohol use and binge-drinking (139). Community action
projects can mobilize awareness and concern about alcohol-related harm
(140,141). Social capital as measured by aggregate reports of student
volunteerism is associated with a decreased risk of binge-drinking,
drunkenness and alcohol-related harm (142), and as measured by high trust is
related to a reduced risk of illegally produced and purchased alcohol (143).
Since 1996, a multi-component programme based on community
mobilization, training in responsible beverage service for servers and stricter
enforcement of existing alcohol laws has been conducted in Stockholm,
Sweden. This has shown no significant difference in serving practices to
intoxicated customers but, from time-series analysis, an estimated 29%
reduction in violent crimes in the intervention area compared with the control
area (144). The cost of the programme was estimated as €796 000. The
average cost of a violent crime was estimated as €19 049, which implied
overall savings of €31 314 million related to the judicial system (78%),
production losses (15%), health care issues (5%) and other damages (2%),
with a base case cost–saving ratio of 1:39 (145).
The Community Trials Project was a five-component community-level
intervention to reduce alcohol-related harm among all residents of three
communities (146). It included components covering media and mobilization,
responsible beverage service, sales to young people to reduce underage access
to alcohol, drinking and driving, and access to reduce the availability of
alcohol. The project led to a reduction in drink–driving accidents, injuries
from assaults and harmful alcohol use. Finally, cost-benefit analyses
estimated that the trial resulted in savings of €2.9 for every €1 spent on
programme implementation, based on reductions in automobile crashes alone.
A community intervention project in the Northern Territories in Australia
aimed to reduce levels of alcohol consumption and related harm down to
national levels by 2002 by using a range of strategies including education,
increased controls on alcohol availability and expanded treatment and
rehabilitation services (147). The Living With Alcohol (LWA) programme
was originally funded by a specific levy on the sale of alcohol products with
more than 3% alcohol by volume until 1997, when a federal ruling prohibited

Community action
page 49

states and territories from raising licence fees and additional taxes on
alcoholic beverages, tobacco and petrol. As a direct result, the LWA levy was
removed in August 1997 which, in turn, resulted in a fall in the real price of
alcoholic beverages with more than 3% alcohol by volume. The Federal
Government continued to fund the LWA programme at the same level until
2000. After this time, LWA funds were dispersed directly to existing
programmes and services. The programme was effective in reducing acute
alcohol-related deaths by 4.6 per 100 000 adults in the Northern Territories
compared with reductions of 1.6 per 100 000 acute alcohol-related deaths in
the control area, largely owing to the period of the tax levy.
Summary of the evidence of community action
What we know


There is some evidence that multi-component communitybased programmes including community mobilization,
responsible beverage service and stricter enforcement of
existing alcohol laws can lead to reductions in alcoholrelated traffic fatalities and injuries from assault.



There is limited evidence that such community-based
programmes can be cost–effective.

What we do not know
⊗

Although community programmes are implemented across
a range of European countries with differing cultures, we
do not know the extent to which specific community
programmes developed in one culture or setting are fully
transferable to another culture or setting.

Policy implications of community action
Community-based programmes can be expensive to implement,
and to be effective require long-term sustainability. Although
there is some evidence for cost–effectiveness, caution should be
taken in terms of transferability from other cultures as well as
gaining local support and mobilization before evidence-based
community action programmes are designed and implemented.

Interventions to reduce alcohol-related harm
page 50

Alcohol and the workplace
At the societal level, there are relationships between per capita alcohol
consumption and sickness absence rates. A Swedish study found that a one
litre increase in total consumption was found to be associated with a 13%
increase in sickness absence among men (p <0.05) (148). The relationship
was not statistically significant for women. This has been confirmed with
individual level micro-data from Finland, which showed that alcohol
consumption is associated with sickness absence, particularly among loweducated males (149). Based on 21 European studies, it has been estimated
that at €59 billion (range €39 billion–102 billion), productivity losses
contributed 47% of the total social cost of alcohol to Europe (9). These
findings are similar to other estimates (65).
Although earlier overviews analysing absenteeism rates of people at all levels
of alcohol consumption yielded mixed results (150), more recent studies have
found that alcohol is related to absenteeism. For example, a small-scale
United States study found a significant relationship between alcohol use and
workplace absences (151). Workers were roughly twice as likely to be absent
from work the day after alcohol was consumed. A much larger and more
recent study of 13 582 Australian workers found clear evidence of the impact
of drinking patterns on absenteeism (152). Compared to low-risk drinkers,
workers drinking at short-term high-risk levels at least yearly, at least monthly
or at least weekly were 3.1, 8.7 and 21.9 times, respectively, more likely to
report alcohol-related absenteeism. Workers drinking at long-term risky or
high-risk levels were 4.3 and 7.3 times, respectively, more likely to report
alcohol-related absenteeism compared to low-risk drinkers. Compared to
workers who were low-risk drinkers, the odds of illness/injury absenteeism in
the previous 12 months were 1.3 times greater for workers who drank at least
yearly at short-term high-risk levels and 1.5 times greater for workers who
drank at least weekly at short-term high risk levels. The odds of illness/injury
sick leave in the previous three months were not significantly greater for
workers who drank at long-term risky or high-risk levels compared to workers
who were low-risk drinkers.
Harmful alcohol use and episodic heavy drinking increase the risk of arriving
late and leaving early from work or disciplinary suspension, resulting in loss
of productivity, turnover due to premature death, disciplinary problems or low
productivity from the use of alcohol, inappropriate behaviour (such as
behaviour resulting in disciplinary procedures), theft and other crime, and
poor co-worker relations and low company morale (153). One study
conducted at 114 worksites of seven corporations showed an almost linear

Community action
page 51

relationship between increasing average consumption and a summary measure
of job performance, finding the strongest associations between consumption
and getting to work late, leaving early, and doing less work, and only a weak
association with missing days of work (154).
There has been little research on the role of an adverse work environment in
increasing the risk of disorders from alcohol use (155). There is some
evidence of an association of shift-work, low levels of technical responsibility
at work and job insecurity with alcohol consumption. However, associations
of an adverse work environment with alcohol use are often moderated by
workers’ distinct coping characteristics. Moreover, studies in this area are
rarely based on an explicit stress-theoretical model that identifies “toxic”
components of an adverse work environment, with special emphasis on its
psychosocial dimensions such as the demand–support control model of job
strain, and the effort–reward imbalance model.
Recent analysis of the Whitehall II occupational cohort of London-based civil
servants study found that, as regards women, there was a clear grade gradient
with the highest proportion of problem drinkers being among those in the
highest two grades, which was not the case for men (155). In men, the effort–
reward imbalance was associated with alcohol dependence after taking
account of age and employment grade, with those classified as putting in high
efforts but receiving low rewards being at highest risk of becoming alcoholdependent. This association was also seen for women, although it was not as
marked. In addition, low decision latitude in women was associated with
increased risk of alcohol dependence. Neither high job demands nor low work
support were associated with alcohol dependence. These associations between
work characteristics and alcohol dependence did not appear to be mediated
through physical illness, poor mental health, or adverse changes in social
supports or network size. Most other studies of psychosocial work
characteristics and alcohol have used measures of alcohol consumption rather
than alcohol problems or alcohol dependence, and most have found little or no
association between work characteristics and amount consumed.
A Finnish study found a relationship between burnout and the risk of alcohol
dependence in both men and women (156). Burnout is a consequence of
chronic work stress. According to the most used definition in scientific
research, burnout is a state of exhaustion in which one becomes doubtful
about the value of one’s work and one’s competence. It has been related most
consistently to psychosocial work characteristics, mainly high demands and
low resources at work, but also to individual, interpersonal, other
organizational and societal factors. In the Finnish study, each one-point

Interventions to reduce alcohol-related harm
page 52

increase in burnout score was associated with an 80% increase in the
incidence of alcohol dependence among women and a 51% increase among
men. After adjustment for sociodemographic factors, the odds ratio of burnout
for alcohol dependence was 2.06 (95% CI 1.52–2.81) in a logistic regression
analysis for women and 1.51 (95% CI 1.28–1.79) for men. Again, the
association between burnout and alcohol dependence can also derive from a
connection between stress and alcohol use on a neurobiological level. Both
intracellular and dopaminergic extracellular mechanisms may be involved in
the interaction between stress, craving for stress relief and addictive forms of
behaviour such as alcohol use.
Despite the structural relationships between the work environment and the
risk of alcohol use disorders, few intervention studies have investigated the
impact of changing work structures on reducing workplace alcohol-related
harm (157). An exception to this is a study that compared two work settings
with distinctly different managerial cultures (158). One setting had a
traditional hierarchical United States management design and the other was
based on a Japanese management model transplanted to the United States.
Although overall alcohol consumption rates in both populations were similar,
the traditional management design was associated with more permissive
norms regarding drinking before or during work shifts (including breaks) and
higher workplace drinking rates. By contrast, the transplant management
design was associated with greater enforcement of alcohol policies which, in
turn, predicted more conservative drinking norms and lower alcohol
availability at work. Qualitative research clearly indicated that the transplant
design facilitated the social control of alcohol problems, whereas the
traditional design appeared to undermine such control.
A recent systematic review of workplace interventions for alcohol-related
problems identified only 10 intervention studies (159). Interventions
comprised three broad types of strategy: psychosocial skills training; brief
interventions, including feedback of results of self-reported drinking, lifestyle
factors and general health checks; and alcohol education delivered via an
internet website. The psychosocial interventions included peer referral, teambuilding, stress management and skills derived from the social learning
model. For health checks, topics covered in addition to alcohol were smoking,
exercise, diet, weight, stress, depression, blood pressure, cholesterol, diabetes,
cancer, safety and preventive health-care risks. Only one study reported no
statistically significant results, while seven studies reported significant
reductions in various self-reported measures of alcohol consumption or
alcohol-related problems. The counselling-based interventions either reported
no effect, or the effect was small, self-reported only, or measured desire to

Community action
page 53

change rather than actual behaviour. The four mail-out/feedback brief
intervention studies were practical and, possibly, sustainable interventions that
achieved outcomes somewhat comparable to the more intensive counselling
interventions, although the outcomes were self-reports.
One study which used objective outcome measures described the impact of a
workplace peer-focused substance abuse programme in the transportation
industry, implemented in phases from 1988 to 1990 (160). The programme
focused on changing workplace attitudes towards on-the-job substance use in
addition to training workers to recognize and intervene with co-workers who
had a problem. The programme was strengthened by federally mandated
random drug and alcohol testing (implemented, respectively, in 1990 and
1994). With time-series analysis, the association of monthly injury rates and
costs with phased programme implementation was analysed, controlling for
industry injury trend. The combination of the peer-based programme and
testing was associated with an approximate one third reduction in injury rate,
avoiding an estimated US$ 48 million in employers’ costs in 1999. In the
same year, the peer-based programme cost the company US$ 35 and testing
cost another US$ 35 per employee. The programme avoided an estimated
US$ 1850 in injury costs to employers per employee in 1999, corresponding
to a benefit–cost ratio of 26:1.
Summary of the evidence of workplace policies
What we know


Alcohol can increase the risk of absenteeism and poor
performance at work.



Structural work factors can influence the risk of alcoholrelated harm.



There is some limited evidence that alcohol policies and
programmes at the workplace, including peer support and
brief advice, can reduce alcohol-related harm.

What we do not know
⊗

The impact of structural changes at the workplace on the
risk of alcohol-related harm has not been studied.

Interventions to reduce alcohol-related harm
page 54

Policy implications for workplaces
Alcohol policy that reduces per capita alcohol consumption will
reduce the harm done by alcohol in the way of absenteeism and
poor performance at work. A number of programmes can be
implemented at the workplace, including peer support and brief
advice, which will probably reduce the harm done by alcohol.
The way that work is organized should also be considered so that
work itself does not increase the likelihood of harmful alcohol
use, particularly for those occupations most at risk such as bar
staff, seafarers and miners (161).

Drink–driving policies and countermeasures
This section shows that the setting of a BAC level and lowering it is effective in
reducing drink–driving casualties. Intensive random breath-testing, where
police regularly stop drivers on a random basis to check their BAC level, and
checkpoints where all cars are stopped and drivers suspected of drink–driving
are breath-tested, do reduce alcohol-related injuries and fatalities. There is
evidence for some effectiveness in setting lower BAC levels, including a zero
level, for young or novice drivers, administrative suspension of the driver’s
licence for a driver caught with a positive BAC level, and mandatory treatment
and the use of an ignition interlock (a mechanical device which does not allow a
car to be driven by a driver with a BAC above a low level) for repeat drinkdrivers. In contrast, there is evidence that designated driver schemes have no
effect.

Alcohol policy and drink–driving
Many alcohol policy measures can reduce alcohol-related road traffic
fatalities, including higher prices for alcohol, minimum purchase age laws and
control over the density of outlets (162,163). The implementation of effective
drink–driving policies can lead not only to high public and political
commitment for such measures (164) but also to reductions in overall alcohol
consumption (165), indicating how other policy measures can be
progressively implemented to reduce the harm done by alcohol in a way that
often generates increased public support for the policy concerned.

Introducing and lowering legal blood alcohol levels
Effects of introducing a legal limit. A systematic review of studies evaluating
the impact of introducing laws that set a legal BAC limit found beneficial
effects when such limits were introduced, although the magnitude of these
effects varied considerably (166). For example, the impact of introducing a
0.8 g/litre limit appeared to be much stronger in the United Kingdom than in
Canada. Beneficial effects often appeared to decrease over time, perhaps due
to a diminishing perceived risk of being caught.
Effects of reducing a legal limit. Systematic reviews have evaluated the
impact of lowering legal limits in parts of Canada, the United States, Australia

Interventions to reduce alcohol-related harm
page 56

and Europe (166–169). In the great majority of cases, the lower limit
introduced and evaluated is either 0.5 or 0.8 g/litre.
An analysis conducted in the EU15 of the impact of reducing BAC levels
from 0.8 g/litre to 0.5 g/litre found that lowering BAC levels did not have a
global impact unless the regulation was enforced in practice by random
checks on the road (170). When the two regulatory measures were
implemented together, the fatality rate per population declined 4.3%, while
the fatality rate per kilometre driven fell by 6.1%, with a time lag of two years
to observe the effectiveness.
Sweden has two BAC limits, a lower one for drunken driving and a higher
one for aggravated drunken driving. The lower legal limit was reduced from
0.5 g/litre to 0.2 g/litre in 1990. Time-series analyses controlling for alcohol
consumption and distance driven found significant reductions in fatal
collisions, single-vehicle collisions and all collisions of 9.7%, 11% and 7.5%,
respectively (171,172). The age distribution of drivers had changed
somewhat, which could have accounted for about a third of the reduction in
fatal collisions and reduced the impact on fatal collisions to about 6%. The
average BAC of those convicted declined significantly, although modestly,
from 0.168 g/litre before to 0.154 g/litre after the 0.2 g/litre limit was
introduced, with the largest reductions appearing at the highest BAC levels.
The limit for aggravated drunken driving was reduced from 1.5 to 1 g/litre in
1994. Time-series analyses controlling for the effects of alcohol sales and
gasoline sales, and incorporating the reduction of the lower limit in 1990 as a
control variable, demonstrated a significant intervention effect of the 1994 law
on fatal collisions, with reductions of about 13% being observed (173). The
effects on collisions resulting in severe injury appeared somewhat more variable but in the same direction. The 1994 law also introduced other changes,
including an increase in the maximum term of imprisonment for the
aggravated drunken driving offence; thus it is not possible to ascribe the
traffic safety effects of the 1994 law exclusively to the reduced legal limit.
France reduced its legal limit from 0.8 g/litre to 0.5 g/litre in 1996. In a study in
the French province of Haute-Savoie, total fatalities involving a drinking-driver
declined from about 17.5/100 000 total population per year in the years
preceding the introduction of the law (1993–1995) to 11.2/100 000 in 1997
(174). The effect seems, however, to have been delayed for unknown reasons or
may have involved factors additional to the introduction of the 0.5 g/litre limit,
since the first year of operation of the new law seemed to have no effect. The

Drink–driving
page 57

impact of the new law was more pronounced for drivers at higher BACs (over
0.8 g/litre) than for drivers in the range 0.5–0.8 g/litre.
Denmark reduced its limit from 0.8 g/litre to 0.5 g/litre in 1998. Survey data
indicated that after the introduction of the new law drivers reduced the amount
of alcohol they consumed before driving, and that these reductions were
attributed to the changed legal limit (175). Inspection of collision data
suggested that while the proportion of collisions resulting in injury involving a
drinking-driver (BAC of 0.5 g/litre or more) appeared to decline with the
introduction of the law, the proportion of fatal collisions involving a drinkingdriver appeared to increase. It is possible that the follow-up period of 10 months
may have been too short to assess the impact of the change accurately.
Austria reduced its limit from 0.8 g/litre to 0.5 g/litre in 1998. There appeared to
be declines in both the numbers of drivers with BACs over 0.8 g/litre and those
with BACs between 0.5 and 0.8 g/litre, although statistical tests were not
reported (176). The absolute numbers of drunk-driving collisions resulting in
personal injuries appeared to decline with the introduction of the law.
In the United States, several states have reduced their legal limits to
0.8 g/litre. A meta-analysis of nine research studies of sufficient design
quality and level of implementation found that laws setting a legal BAC level
of 0.8 g/litre resulted in a median reduction of 7% in alcohol-related motor
vehicle fatalities (177).

Lower limits for young and novice drivers
A systematic review of the impact of laws setting a lower BAC level for
young or inexperienced drivers found that the three studies that examined
fatal crash outcomes reported declines of 24%, 17% and 9%; the two studies
that examined crashes resulting in injuries reported declines of 17% and 4%;
and the one study that examined crashes in which the investigating police
officer believed that the driver had been drinking alcohol reported a decline of
11% (177). Graduated driver licensing, which gradually introduces novice
drivers to higher-risk driving situations, is effective in reducing crash rates
among novice drivers (178).

Unrestricted breath-testing
Unrestricted or random breath-testing means that there are no restrictions on
the police as regards motorists they can stop and require to take a breath, even
if these have not been suspected of having committed an offence or been

Interventions to reduce alcohol-related harm
page 58

involved in an accident (179). Any motorist, at any time, may be required to
take a test, and there is nothing that the driver can do to influence the chances
of being tested. Testing varies from day to day and from week to week, and
refusal to submit to a breath test is equivalent to failing. Selective breath
testing refers to checkpoints in which police must have reason to suspect the
driver has been drinking.
Australia has considerable experience with random breath-testing. A timeseries analysis for four Australian states found that unrestricted breath-testing
was twice as effective as selective checkpoints (180). In Queensland, for
example, unrestricted breath-testing resulted in a 35% reduction in fatal
accidents, compared with 15% for selective checkpoints. Since their
implementation, drink–driving enforcement and publicity campaigns in
Victoria have emphasized their effectiveness in reducing serious crashes
during peak alcohol consumption times (181).
A meta-analysis of 23 studies of unrestricted and selective breath-testing has
found that crashes thought to involve alcohol dropped by a median of 18%
(for random breath-test checkpoints) and 20% (for selective breath-test
checkpoints) following the establishment of sobriety checkpoints. Fatal
crashes thought to involve alcohol dropped by a median of 22% (for random
breath-test checkpoints) and 23% (for selective breath-test checkpoints)
following the establishment of sobriety checkpoints. Crashes declined
regardless of the follow-up time of the study, dropping by a median of 18%
for follow-up times of less than one year and 17% for follow-up times of more
than one year (177).

Licence suspension
Suspending the licence of those convicted of impaired driving is only partially
effective as a way to reduce drink–driving recidivism and alcohol-related
crashes. Without some form of education, counselling or treatment
programme, the effects of suspension on alcohol-impaired driving last only as
long as the driver is incapacitated by suspension of his/her licence, and these
periods can be relatively short. A review of 46 studies on licence suspension
found that suspension was followed by an average reduction of 5% in alcoholrelated accidents and a reduction of 26% in fatal accidents (182). There is
little evidence that prison sentences or fines have a specific deterrent effect by
promoting avoidance of future offences. Nevertheless, the authority to impose
a prison sentence may provide the legal basis for referring offenders to
treatment programmes, which have been shown to reduce recidivism of

Drink–driving
page 59

drink–driving in first and multiple offenders. A meta-analysis of
215 independent evaluations of remedial programmes found them to yield an
average reduction of 8–9%, both in recurrence of alcohol-impaired driving
offences and in alcohol-related accidents (183).

Alcohol locks
One measure to prevent drink–driving offenders from driving while impaired is
to place interlocks in the ignition to prevent an alcohol-impaired driver from
operating the vehicle. To operate a vehicle equipped with an ignition interlock
device, the driver must first provide a breath specimen. If the alcohol
concentration in the specimen breath exceeds the predetermined level, the
vehicle will not start. As a measure to reduce circumvention of the device (i.e.
someone else blows into the mouthpiece), random retests are required while the
vehicle is running. Interlocks can also be fitted to public service and heavy
goods vehicles as a preventive measure.
A review of eight studies of interlock programmes conducted under the authority
of a local court or a motor vehicle department found them to be more effective
than full licence suspension in preventing recidivism among alcohol-impaired
drivers (184). However, seven of the studies found that, once the interlock is
removed, offenders have the same recidivism rate as suspended offenders.
A systematic Cochrane review identified 1 randomized controlled trial,
10 controlled trials and 3 ongoing trials (185). In the randomized control trial,
recidivism was lower in the intervention group while the device was still
installed in the vehicle, but the benefit disappeared once the device was
removed. In all 13 non-randomized controlled trials, recurrence of offences
was again lower among interlock participants than the controls. However, the
favourable results did not extend to the period after the interlock was
removed.
Alcolock devices and programmes were introduced in Sweden in 1999 in two
types of programme (186,187). A primary prevention strategy was initiated to
prevent alcohol-impaired driving in three commercial transport companies
(buses, trucks, taxis). A secondary prevention trial was begun as a voluntary
two-year programme for drink–driving offenders involving strict medical
requirements, including counselling and regular checkups by a medical doctor.
Alcolocks in commercial vehicles have been well accepted by professional
drivers, their employers and their passengers, and the number of vehicles with
alcolocks as a primary prevention measure is rapidly growing in Sweden. Three

Interventions to reduce alcohol-related harm
page 60

out of a thousand starts in the primary prevention programme were blocked by
the alcolock after measuring a BAC higher than the legal limit with a lock point
of 0.2 g/litre. Only 11% of eligible drink–driving offenders took part in the
voluntary secondary prevention programme, of whom 60% had a diagnosis of
alcohol dependence. During the programme, alcohol consumption decreased as
measured by five biological alcohol markers, and the rate of drink–driving
offences fell sharply from a yearly rate of approximately 5% to almost zero.
However, those dismissed from the programme appeared to return to their
previous drink–driving behaviour, although more recent follow-up suggested
some evidence of lasting changes in reduced accidents and recidivism (188).

Training for servers of alcohol and civil liability
Training programmes for servers of alcohol and bartenders aiming to prevent
impaired driving by teaching them how to identify impairment, refuse service
and provide transport have been evaluated in Australia, the Netherlands and
North America,. A systematic review of server intervention training
programmes, while noting that the evidence reviewed primarily comes from
small-scale studies in which the participants may have been unusually
motivated and the researchers had a high degree of control over the training,
identified three qualifying studies which found that such training was
associated with decreases in the proportion of intoxicated drinkers ranging
from 17% to 100% (median = 33%), and one study assessing a state-wide
server-training programme that found that training was associated with a 23%
decrease in single-vehicle night-time injury crashes (177).

Designated driver and safe ride programmes
There is no universal definition of a designated driver. The most common
definition requires that the designated driver abstain from all alcohol, be
assigned before alcohol is consumed and drive other group members to their
homes (189). Other definitions employ a risk and harm reduction strategy, in
which the primary goal is not necessarily abstinence but to keep the
designated driver’s BAC under the legal limit.
A systematic review was conducted to assess evidence of the effectiveness of
designated driver programmes for reducing alcohol-impaired driving and
alcohol-related crashes. This evaluated population-based campaigns
encouraging the use of designated drivers as well as programmes conducted in
drinking establishments that provided incentives for people to act as
designated drivers (189). Only one study of a population-based designated

Drink–driving
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driver promotion campaign was identified. Survey results indicated a 13%
increase in respondents “always” selecting a designated driver, but no
significant change in self-reported alcohol-impaired driving or riding with an
alcohol-impaired driver. Seven studies (five of which were reported in the
same journal article, and six of which were by the same two principal authors)
evaluated the number of patrons who identified themselves as designated
drivers before and after programmes were implemented, with a mean increase
of 0.9 designated drivers per night. An eighth study reported a 6% decrease in
self-reported alcohol-impaired driving or riding in a car with an intoxicated
driver among respondents exposed to an incentive programme.
Interpretation of these results was complicated by the fact that only two of the
studies reported the number of patrons or groups of patrons in the bar during
each observation period. Thus, although the incentive programmes generally
found small increases in the number of patrons identifying themselves as
designated drivers, the extent to which these changes related to the actual use
of designated drivers was unclear. Finally, it was impossible to estimate the
public health effects of observed changes in the number of self-identified
designated drivers without information on what their behaviour would have
been in the absence of a designated driver programme. Thus, due to the small
sizes of the effects observed and the limitations of the outcome measures, the
present evidence is insufficient to draw any conclusions about the
effectiveness of either type of designated driver promotion programme
evaluated. Further, no study has evaluated whether the use of designated
drivers actually decreases alcohol-related motor vehicle-related injuries.

Educational programmes
A systematic review of the literature to assess the effectiveness of school-based
programmes for reducing drinking and driving and riding with drinking drivers
identified 13 peer-reviewed papers or technical reports which met specified
quality criteria and included evaluation outcomes of interest (85). The papers
evaluated three classes of intervention: school-based instructional programmes,
peer organizations and social norming campaigns. For instructional
programmes, whereas the median effects of five studies found no effect on selfreported drinking and driving, the median effects of four studies found a
reduction in self-reported riding with drinking drivers. Only one study looked at
crashes and found no effect. Two studies of the effectiveness of peer
organization programmes provided evidence for effect. Two studies of social
norming programmes appeared to reduce drink–driving and led to more
frequent use of designated drivers.

Interventions to reduce alcohol-related harm
page 62

Mass media campaigns
As mentioned in the section on raising awareness and political commitment
above, a systematic review of the effectiveness of mass media campaigns for
reducing alcohol-impaired driving and alcohol-related crashes identified
seven qualifying studies that found that mass media campaigns were
associated with a median decrease of 13% in total alcohol-related crashes
(interquartile range, 6–4% decrease), and six qualifying studies that found that
mass media campaigns were associated with a median decrease of 10% in
injury-producing alcohol-related crashes (interquartile range, 6–4% decrease)
(85).
The mass media campaigns evaluated had several components in common:
pretested messages; high levels of audience exposure to the message,
generally achieved through paid advertising; and complementary prevention
efforts at the local level such as high-visibility enforcement of laws covering
alcohol-impaired driving. Campaign messages ranged from those focused on
law enforcement activities and the legal consequences of drinking and driving
to the social and health consequences of alcohol-impaired driving. There was
no clear difference in the effectiveness of the two kinds of campaign.
Summary of the evidence of drink–driving policies
What we know


There is consistent evidence that the introduction and/or
reduction of legal BAC levels for driving reduces motor
vehicle accidents and fatalities, when these are enforced.



There is consistent evidence that the introduction of
sobriety checkpoints and random breath-testing reduces
motor vehicle accidents and fatalities.



There is some evidence that lower legal BAC levels for
novice drivers reduce motor vehicle accidents and
fatalities.



There is some evidence that licence suspension can reduce
motor vehicle accidents and fatalities.



There is some evidence that mandatory treatment can
reduce motor vehicle accidents.



There is some evidence that alcohol locks can reduce
motor vehicle accidents.

Drink–driving
page 63



There is some evidence that mass media campaigns
enhance the effectiveness of drink–driving policies.



There are studies that find no evidence for any impact
from designated driver and safe ride programmes in
reducing motor vehicle accidents and fatalities.

What we do not know
⊗

The most effective ways to ensure the existence of
adequate and sustained resources to enforce legal BAC
levels.

Policy implications of drink–driving policies
There is clear evidence that drink–driving accidents would be
prevented were legal BAC levels for driving reduced to
0.2 g/litre and enforced through random breath-testing
programmes, supported by other enforcement measures such as
licence suspension, mandatory treatment and alcohol locks, and
mass media campaigns. There is also good evidence for the
introduction of a 0 g/litre level for novice and young drivers.
Consideration could be given to the use of alcohol locks for all
professional drivers.

Addressing the availability of alcohol
While there are total bans on the sale of alcohol in several countries with
majority Muslim populations, as well as at community level in a number of
indigenous communities, there are also other widely dispersed bans on the use
of alcohol in particular locations and circumstances, such as drinking in parks
or streets, hospitals or at the workplace (7). A licensing system for the sale of
alcohol allows for control, since infringement of the laws can be punished by
revocation of the licence. On the other hand, a licensing system with fees
generated from licences can lead to a proliferation of licensed establishments
as an income-generating mechanism for jurisdictions. Government
monopolies on the sale of alcohol can reduce alcohol-related harm. Such
systems tend to have fewer outlets open for shorter hours than private retailers
(190–192).
The implementation of laws setting a minimum age for the purchase of
alcohol shows clear reductions in drink–driving casualties and other alcoholrelated harms (193). The most effective means of enforcement is on sellers,
who have a vested interest in retaining the right to sell alcohol (194). In
general, the number of alcohol outlets is related to the level of alcohol-related
harm, which is strongest when there are major changes in the number or type
of such outlets. A greater density of alcohol outlets is associated with higher
alcohol consumption among young people (195), with increased levels of
assault and with other harms such as homicide, child abuse and neglect, selfinflicted injury and, with less consistent evidence, road traffic accidents (196–
198). While extending the times of sale can redistribute the times when many
alcohol-related incidents occur, such extensions generally do not reduce the
rates of violent incidents and often lead to an overall increase in consumption
with association problems (199). Reducing the hours or days of sale of
alcoholic beverages leads to fewer alcohol-related problems, including
homicides and assaults (200).
Strict restrictions on availability can create an opportunity for a parallel illicit
market, although in the absence of substantial home or illicit production, this
can in most circumstances be managed with enforcement. Where a large illicit
market exists, licence-enforced restrictions may increase the competitiveness
of the alternative market, and this will need to be taken into account in policymaking.

Availability
page 65

Minimum age for purchase of alcohol
Although legal restrictions on the age at which young people may purchase
alcohol vary widely from country to country, ranging typically from 16 to
20 years of age depending on the beverage type and outlet, almost all
countries legally restrict these sales. A review of 132 studies published
between 1960 and 1999 found very strong evidence that changes in minimum
drinking-age laws can have substantial effects on drinking among young
people and alcohol-related harm, particularly road traffic accidents, often for
well after young people reach the legal drinking age (193). A systematic
review of minimum legal drinking age laws in the United States found that
among 14 studies looking at the effects of raising the minimum legal drinking
age, crash-related outcomes declined by a median of 16% for the targeted age
groups, and that among 9 studies looking at the effects of lowering the
minimum legal drinking age, crash-related outcomes increased by a median of
10% within the targeted age groups (177). The effects were stable over
follow-up times ranging from seven months to nine years. The full benefits of
a higher drinking age are only realized if the law is enforced. Despite higher
minimum drinking age laws, young people do succeed in purchasing alcohol.
In most EU countries in the European School Survey Project on Alcohol and
other Drugs, a majority of students aged 15–16 years thought that getting any
type of alcoholic beverage was fairly or very easy, rising to 70–95% for beer
and wine (201). Such sales result from low and inconsistent levels of
enforcement, especially where there is little community support for
enforcement of the law regarding alcohol sales to minors. Even moderate
increases in enforcement can reduce sales to minors by as much as 35% to
40%, especially when combined with media and other community activities
(193). The most effective means of enforcement is on sellers who, as stated
above, have a vested interest in retaining the right to sell alcohol.

Number of outlets and outlet density
In general, the number of alcohol outlets is related to the level of alcoholrelated harm, which is strongest when there are major changes in the numbers
or types of such outlets. An increased density of alcohol outlets is associated
with reduced social capital (202) and increased levels of alcohol consumption
among young people, with increased levels of assault and with other harms
such as homicide, child abuse and neglect, self-inflicted injury and, with less
consistent evidence, road traffic accidents (198,203).

Interventions to reduce alcohol-related harm
page 66

Studies which have capitalized on natural experiments in alcohol availability
have come largely from the Nordic countries, where access to alcohol has
traditionally been more restricted than in many other developed countries.
These studies have examined substantial changes in alcohol availability such
as the opening of a store in a community that previously had none, or the
introduction of beer into supermarkets. Studies in Finland used the
introduction of outlets in villages and changes to regulations permitting
grocery stores to sell beer to study the impact on changes in consumption
(204). These changes resulted in a marked increase in the consumption of
beer, with marginalized and heavy drinkers affected more than the average.
Swedish studies have focused similarly on the introduction or removal of
medium-strength beer (4.5% by volume) from supermarket shelves, finding
substantial effects on consumption as well as alcohol-related hospitalization,
particularly among teenagers (205). Outside the Nordic countries, studies
have focused on the dismantling of government retail monopolies, generally
resulting in substantial increases in numbers of outlets. The privatization of
the retail wine monopolies in five states in the United States produced
significant increases in wine sales, without substantial changes in beer or
spirits sales (206).
A time-series analysis relating two measures of assault to the density of
outlets selling alcohol on the premises in Norway between 1965 and 1990
found significant associations, suggesting that as the density of outlets in
Norway changed, assault rates changed correspondingly (207).
A number of studies from California have used secondary data to explore the
association between outlet density and alcohol-related harm. A significant
association was found between alcohol-related hospitalization (based on a
rough fractional approach using ICD 9 codes) and total licences across San
Diego zip codes (208). For each unit increase in outlet density per
10 000 persons, there was a 0.48 increase in morbidity per 10 000 persons. In
San Francisco, outlet density measured as the number of licences per
kilometre of roadway was found to be positively related to pedestrian injuries
(209). Child abuse and neglect in census tracts of California have been found
to be positively related to per-capita density of bars, restaurants and offlicences, such that a one unit increase in density resulted in 2.2 additional
cases of abuse (210). After controlling for spatial autocorrelation, off-premise
outlet density was related to substantiated cases of abuse, whereas bar density
was related to neglect. Further evidence of a longitudinal relationship was
found in a study of 6 years of data from 581 Californian postal areas
undertaking time-series analyses of the link between outlet density and assault
(211). The study incorporated a range of environmental controls (e.g. other

Availability
page 67

retail places) and sociodemographic controls (e.g. median household income)
across the six years, as well as measures of densities of three types of outlet:
bars, restaurants and off-premise retailers. The study found significant
positive effects for both bars and off-premise outlets on violence, and a
negative effect for restaurants. The density of bars in neighbouring regions
was also associated positively with violence, suggesting that new bars
influence violence not only in their local area but in surrounding regions as
well. The authors estimated that an average reduction of one bar in each of the
581 postal codes analysed would have resulted in 290 fewer assaults over the
6 years studied.
A Los Angeles study, focusing on rates of gonorrhea as a measure of risky
sexual behaviour, presented evidence from a natural experiment on the effects
of a reduction in alcohol outlets (212). After the 1992 civil unrest in Los
Angeles, in which many liquor stores were burned, 270 alcohol outlets
surrendered their licences in the wake of a community campaign to prevent
damaged outlets from reopening. The study attempted to differentiate between
alcohol outlets as a causal factor (through alcohol consumption and risky
behaviour) and as a marker of social disorganization. The results of this study
showed a marked impact of alcohol outlets on rates of gonorrhea, suggesting
that outlets play a significant role in the spread of gonorrhea even when social
disorganization was controlled for.
An Australian study into the impact of outlet density of licensed premises on
neighbourhood amenities used an innovative method whereby responses to a
nation-wide survey on crime and safety were linked to locations of licensed
premises in New South Wales (213). The study used two measures of alcohol
outlet concentration: accessibility and density, and examined the impact of
each on reported levels of neighbourhood drunkenness, property damage and
assault in the home. Using geo-coded locations of licensed premises linked to
respondents’ residence, statistical modelling demonstrated that people who
lived closest to licensed premises (relative accessibility) reported the highest
levels of drunkenness and property damage in their neighbourhoods. The
relationship remained significant after statistical adjustment for possible
confounding factors. The study also demonstrated that outlet density was
significantly associated with residents’ reported levels of drunkenness and
related problems in their neighbourhoods.

Interventions to reduce alcohol-related harm
page 68

Days and hours of sale
A number of studies have indicated that although changing either hours or
days of alcohol sale can redistribute the times at which many alcohol-related
crashes and violent events related to alcohol take place, it does so at the cost
of an overall increase in problems (see 9). Around-the-clock opening in
Reykjavik, for instance, produced net increases in police work, emergency
room admissions and drink–driving cases. The police work was spread more
evenly throughout the night, but a change in police shifts was necessitated to
accommodate the new work (199).
A series of studies in Sweden found a net 3.6% increase in alcohol sales when
government alcohol stores opened on Saturdays, although the changes in harm
were not big enough to be significant (214,215).
Following the 2003 Licensing Act in the United Kingdom, which
recommended in general that shops and supermarkets be allowed to sell
alcohol at any time they choose to open (24 hours opening) (216), pubs stayed
open on average only an extra 27 minutes (217,218). No real change in
alcohol-related crimes was found until 03:00, but a 22% increase in crimes
occurred between 03:00 and 06:00. In other words, alcohol-related crimes
were shifted until later in the night (219). In some studies, changes in the
Licensing Act appeared to have little impact on the numbers of people treated
for injuries sustained through assault (220,221), although in other studies,
there were large increases in the number of night-time alcohol-related visits to
accident and emergency departments (222).
A study in Western Australia showed that extending opening hours from
24:00 to 01:00 increased violent incidents at the late-night venues by 70%
(223). The increased problems associated with the late-trading venues
appeared to result from increased alcohol consumption rather than increased
opportunity for crime to occur, since there was no apparent difference
between the two groups after controls for alcohol sales. The BACs of drivers
in road crashes who had been drinking at the extended trading premises were
significantly higher than those drinking at the control premises.
There is also evidence that restricting days and hours of sale reduces
problems. Homicide is a leading cause of death in Brazil, with one of the
highest murder rates occurring in the city of Diadema. To respond to this
situation, local policy measures were introduced which included a new
licensing law in 2002 prohibiting on-premises alcohol sales after 23:00. To
evaluate the effect on restricting alcohol availability through limiting opening

Availability
page 69

hours on homicides and violence, data from the local police archives on
homicides and assaults were analysed. Models were adjusted for contextual
conditions, municipal efforts and law enforcement interventions that took
place before and after the closing-time law was adopted. The introduction of a
limit on opening hours resulted in a significant fall in homicide rates in
Diadema and a 44% decline in the number of murders (200).
Summary of the evidence of addressing the availability of
alcohol
What we know


There is consistent evidence that maintaining and raising
minimum purchasing ages for alcohol can reduce alcoholrelated harm, provided that they are enforced.



There is consistent evidence that government monopolies
on the retail sale of alcohol can reduce alcohol-related
harm.



There is consistent evidence that regulating and limiting
outlet densities can reduce alcohol-related harm.



There is consistent evidence that regulating and limiting
the days and hours of sale can reduce alcohol-related harm.

What we do not know
⊗

The most efficient ways to improve public and political
support for limiting the availability of alcohol.

Policy implications of addressing the availability of alcohol
Consideration should be given to regulating and limiting the
availability of alcohol through enforcing a minimum purchase
age, and regulations and limitations on outlet density and days
and hours of sale. The introduction or maintenance of
government-owned retail monopolies for the sale of alcohol can
limit the level of alcohol-related harm.

Addressing the marketing of alcoholic beverages
This section will show that, despite their methodological difficulties,
econometric studies of the link between alcohol advertising and consumption
have found effects of alcohol advertising on behaviour, although not across all
studies. The strongest evidence comes from longitudinal studies that have
shown an impact of various forms of alcohol marketing, including exposure to
alcohol advertising in the traditional media as well as promotion in the
contents of films and via alcohol-branded merchandise, on when young
people start to drink and on riskier patterns of drinking by young people. The
effects of exposure seem to be cumulative; in markets where alcohol is more
widely advertised young people are more likely to continue to increase their
drinking as they move into their mid-twenties, whereas drinking declines at an
earlier age among those who are less exposed. These findings of the impact
that advertising can have on young people’s behaviour are supported by
experimental studies, and are in keeping with research on young people’s
smoking and children’s food preferences. In some jurisdictions, alcohol
marketing relies on self-regulation by economic operators, including in
advertising, the media and by alcohol producers. Evidence from a number of
studies shows that these voluntary systems do not, however, prevent the kind
of marketing that has an impact on younger people.
It should be noted that a total marketing strategy is multilevel, including not
only marketing and promotional activities but also product development,
pricing, physical availability, and market segmentation and targeting (224).
Further, while alcohol is marketed through increasingly sophisticated
advertising in the mainstream media, it is also promoted by linking alcohol
brands to sports and cultural activities through sponsorships and product
placements, and by direct marketing using new technologies such as the
internet, podcasting and mobile telephones (225).

Advertising and expectancies
Alcohol advertising is one of the many factors that have the potential to
encourage young people to drink. The expectancies of young people who have
not started to drink are influenced by normative assumptions about teenage
drinking as well as through observation of drinking by parents, peers and
models in the mass media. Research has linked exposure to portrayals of
alcohol use in the mass media with the development of positive drinking

Marketing
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expectancies by children and adolescents (226). Young people with more
positive affective responses to alcohol advertising hold more favourable
drinking expectancies, perceive greater social approval for drinking, believe
drinking is more common among peers and adults, and intend to drink more
as adults (227). Fourteen-year-olds who are more exposed to advertisements
in magazines, at sporting and music events and on television are more aware
of them than those with less exposure, as are teenagers who watch more
television, pay attention to beer advertisements and know adults who drink
(228). Among 10–17-year-olds, the perceived likeability of beer
advertisements is a function of the positive affective responses evoked by the
specific elements featured in the advertisements. The liking of specific
elements featured in beer advertisements, such as humour, animation and
popular music, significantly contribute to the overall likeability of these
advertisements and subsequently to the effectiveness of advertising indicated
by intent to purchase the products and brands they promote (229).
Although experimental studies find positive relations between alcohol
expectancies and alcohol use (230), expectancy studies, by themselves, do not
establish whether alcohol advertising actually influences young people’s
drinking behaviour. Further, there is increasing evidence that such prebehaviour cognitions, e.g. expectancies and attitudes, are related to
consumption in a more complex way. For example, for adolescent smoking, it
has been shown that, over time, behaviour can predict attitudes more strongly
than attitudes can predict behaviour (231).

Experimental studies
An experimental study has found that the portrayal of alcohol on television
influences actual drinking behaviour (232). In a naturalistic setting (a bar
laboratory), 40 young adult male pairs (80 participants) watched a film clip
with two commercial breaks for 1 hour and were allowed to drink nonalcoholic and alcoholic beverages. The films American Pie 2 (2001) and
40 Days and 40 Nights (2002) were selected because they were comparable
concerning genre and Motion Picture Association of America rating. In
American Pie 2, characters drank alcohol 18 times and alcoholic beverages
were portrayed an additional 23 times. In 40 Days and 40 Nights, characters
consumed alcohol 3 times and alcoholic beverages were portrayed an
additional 15 times. After 14 and 33 minutes the clips were interrupted by a
commercial break for 3.5 minutes, containing either exclusively neutral
advertisements (e.g. promoting a car or a video camera) or neutral
advertisements combined with alcohol advertisements. Each of the combined

Interventions to reduce alcohol-related harm
page 72

breaks contained two alcohol commercials. The participants were randomly
assigned to one of four conditions varying on type of film (many versus few
alcohol portrayals) and commercials (alcohol commercials present or not).
The results indicated that, independently, participants assigned to the
conditions with substantial alcohol exposure in either the film (F = 4.44;
p<0.05) or commercials (F = 4.93; p<0.05) consumed more alcohol than other
participants, controlling for the participant’s weekly alcohol consumption.
Those in the condition with higher alcohol portrayal in the film and
commercials drank on average three glasses within a period of one hour,
compared to one and a half glasses drunk by those in the condition with little
or no alcohol portrayal.

Econometric studies
Although potentially very important, econometric studies, which look for
correlations between the amount of alcohol advertising and the amount of
drinking taking place in a particular jurisdiction, run into a number of
methodological difficulties. First, measures of the amount of advertising,
which typically use expenditure on advertising, vary in accuracy and
inclusiveness. Second, analysis depends on the construction of a complex
model that ascribes values for all the different variables – including price,
drinking restrictions and disposable income – as well as any advertising that
might be implicated. Third, variations in the amount of advertising tend to be
minor (few comprehensive bans have been introduced) so researchers are
looking for potentially small changes in drinking patterns. Fourth, measures of
the overall amount of advertising do not necessarily give an accurate picture
of exposure by young people.
Not surprisingly, only modest effects have been found in some studies, while
others have found no effects (233). For example, looking at alcohol
advertising expenditure data across states in the United States, it has been
found that, when controlling for alcohol price, income and a number of
sociodemographic variables, advertising expenditure had a modest and
independent effect on adolescent monthly alcohol use and binge drinking. It
could be estimated that a 28% reduction in alcohol advertising would reduce
adolescent monthly alcohol use from 25% to between 24% and 21% (233) and
binge drinking from 12% to between 11% and 8%. In a meta-analysis of
132 studies which provided 322 estimated advertising elasticities, a positive
impact of advertising was found on consumption (co-efficient, 0.029) which,
in a meta-regression procedure controlling for alcohol price and income, was
significantly larger for spirits than for beer (234). On the other hand,

Marketing
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controlling for price, income and minimum legal drinking age across US
states, another study found total alcohol consumption was negatively related
to bans on price advertising (coefficient, -0.009), but positively related to bans
on billboards (coefficient, 0.054) (235).

Cross-sectional studies
Because they cannot show whether exposure preceded drinking uptake, crosssectional studies, which take a snapshot of exposure to advertising (awareness
and/or appreciation) and levels of drinking, leave open the possibility that any
correlation is as likely to reflect drinking encouraging young people to take an
interest in advertising as vice versa. Paying attention to advertising
presupposes that the viewer is getting some benefit or reward from it – most
fundamentally that they are doing the right thing by consuming the product
advertised – and advertisers deliberately design their work to provide such
rewards (236). Thus, cross-sectional data can shed a useful light on the role
alcohol advertising plays in young people’s drinking; and such studies have
consistently reported correlations between increased exposure and greater
likelihood of current drinking (237).

Longitudinal studies
Thirteen longitudinal studies were identified from two systematic reviews
that investigated the impact of marketing communications on young people
beginning to drink and continuing to do so (237,238). The 13 studies, which
followed up a total of over 38 000 young people, were drawn from the
United States (9 studies), Belgium (1 study), Germany (1 study) and New
Zealand (1 study). Three studies reported on the impact of overall alcohol
advertising, one study on brand recall and receptivity, three studies on
television advertisements, two studies on media exposure, three studies on
alcohol use in films, one study on radio exposure, two studies on magazine
exposure, two studies on beer concession stands, two studies on in-store
displays, three studies on ownership of alcohol-branded merchandise, and
one study on outdoor advertisements.
Twelve of the thirteen studies concluded that exposure did have an impact on
subsequent alcohol use, including starting to drink and heavier drinking
among existing drinkers, with a dose–response relationship in all studies that
reported such exposure and analysis. There were variations in the strength of
association and the degree to which potential confounders were controlled for.
The thirteenth study, which tested the impact of outdoor advertising placed

Interventions to reduce alcohol-related harm
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near schools, failed to detect an impact on actual alcohol use but found an
impact on intention to use.
There was no consistent evidence that the size of the impact varied across the
countries. When controlling for exposure to all forms of advertising, the size
of the impact appeared greater for television and media exposure, including
exposure to alcohol use in films, and for ownership of alcohol-branded
merchandise than for exposure to radio, magazines, beer concession stands
and in-store displays. Based on the strength of the associations found, the
consistency of findings across the studies, the confounders controlled for, the
length of exposure, kind of drinking behaviour observed and dose–response
relationships, as well as the theoretical plausibility regarding the impact of
media exposure and commercial communications, it can be concluded that
alcohol advertising and promotion increases the likelihood that adolescents
will start to use alcohol, and to drink more if they are already using alcohol.
These findings of the impact that advertising can have on young people’s
behaviour are in keeping with research on young people’s smoking (239) and
children’s food preferences (240).

Self-regulation
In some jurisdictions, alcohol marketing relies on self-regulation by economic
operators, including advertising, the media and alcohol producers. To be
effective, however, self-regulation needs a clear legislative framework (241).
Furthermore, a self-regulatory system needs sufficient incentive to be
effective. There is no reason to believe that the industry will participate for
selfless reasons just to improve public health (242). A threat of government
adjudication can be a strong incentive (243). In general, a self-regulatory
system works best when pressure from government and civil society and
lawsuits are greatest and least well where there is little advocacy (244). Also,
regulations should cover the entire range of marketing activities to which
young people are exposed in order to avoid advertisers simply using the new
media to avoid the regulations. Interpretations by the general public, and
especially by vulnerable groups such as young people, should be included in
evaluation of the advertisements (242), since evidence from a number of
studies shows that these voluntary systems do not prevent the kind of
marketing that has an impact on younger people (245). Self-regulation can
only be effective as long as there is provision for third-party review of
complaints concerning breaches. Otherwise the interested persons who create
and agree to abide by a code are the same ones who monitor its application.

Marketing
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Sanctions and the threat of sanctions are needed to ensure compliance. An
independent body or a government agency should be responsible for
monitoring alcohol marketing practices and should carry it out systematically
and routinely.
Summary of the evidence of addressing the marketing of
alcohol
What we know


The content of commercial marketing of alcohol has an
impact on the risk of young people consuming alcohol.



The volume of commercial marketing of alcohol increases
the risk of young people consuming alcohol, also in a risky
way.



There is some evidence and experience that the selfregulation of commercial marketing of alcohol does not
prevent the kind of marketing that has an impact on
younger people, particularly when it is not backed up by a
legal framework and effective sanctions.

What we do not know
⊗

The full impact on public health of a ban on the
commercial marketing of alcohol in Europe.

Policy implications of addressing the marketing of alcohol
Consideration could be given to regulating and limiting the
content and volume of commercial communications on alcohol,
ranging from a Europe-wide roll-out of the principles of the
French Evin Law to a ban on all forms of commercial
communications that appeal to children and adolescents.
Statutory regulation of commercial communications seems to be
more effective than self-regulation in limiting inappropriate
exposure of commercial communications to young people.

Pricing policies
This section will show that drinkers respond to changes in the price of alcohol
as they do to changes in the prices of other consumer products. When other
factors are held constant, such as income and the price of other goods, a rise
in alcohol prices leads to less alcohol consumption and less alcohol-related
harm, and vice versa. Given that demand for alcohol is usually found to be
relatively inelastic to price, increasing alcohol taxes not only reduces alcohol
consumption and related harm but increases government revenue at the same
time, noting that in general, alcohol taxes are well below their maximum
revenue-producing potential and that the revenue collected is usually well
below the social costs of alcohol. Beverage elasticities are generally lower for
the preferred beverage in a particular market and tend to decrease with higher
levels of consumption. Controlling for overall consumption, beverage
preferences and time period, consumer responses to changes in the price of
alcoholic beverages are found not to vary by country. Policies that increase
alcohol prices delay the time when young people start to drink, slow their
progression towards drinking larger amounts, and reduce their heavy drinking
and the volume of alcohol drunk on each occasion. Price increases reduce the
harm caused by alcohol, which is an indicator that heavier drinking has been
reduced. Using data from the United Kingdom, this section will show that
setting a minimum price per gram of alcohol can be as effective as an acrossthe-board tax increase, with both options increasing the cost to heavy
consumers far in excess of the cost to light consumers. Natural experiments in
Europe consequent to economic treaties have shown that as alcohol taxes and
prices have been lowered, so sales and alcohol consumption have usually
increased. This section will stress that cross-border issues are not solved by
decreasing alcohol taxes.

Price and the use of alcohol
Drinkers respond to changes in the price of alcohol as they do to changes in
the prices of other consumer products. When other factors are held constant,
such as income and the prices of other goods, a rise in alcohol prices leads to
less alcohol consumption and less alcohol-related harm, and vice versa
(246,247). A meta-analysis of 132 studies found a median price elasticity for
all beverage types of -0.52 in the short term and -0.82 in the long term,
elasticities being lower for beer than for wine or spirits (234). An elasticity of
-0.52 means that for every 10% increase in price, consumption would fall by

Pricing
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5.2%. Another meta-analysis of 112 studies found mean price elasticities for
beer of -0.46, for wine of -0.69, and for spirits of -0.80 (248).
The price elasticities for different beverages and over time are not uniform.
Beverage elasticities are generally lower for the preferred beverage (beer,
spirits or wine) in a particular market than for the less-preferred beverages,
and tend to decrease with higher levels of consumption (249) Controlling for
overall consumption, beverage preferences and time period, consumer
responses to changes in the price of alcoholic beverages are found not to vary
by country (249) Consumers tend to shift to more expensive beverages if
relative prices decrease, either within the same beverage category or across
beverage categories (250). If prices are raised, consumers reduce their overall
consumption and tend to shift to cheaper beverages, with heavier drinkers
tending to buy the cheaper products within their preferred beverage category.
The impact of an increase in alcohol price tends to be stronger in the longer
rather than the shorter term which, from a public health perspective, is more
important (251).
Influencing the prices of the cheapest drinks on the market by raising floor
prices has a larger impact on total consumption than does increasing the prices
of more expensive drinks. Using the empirical results obtained in their study of
the Swedish alcohol monopoly from 1984 to 1993, the study’s authors predicted
the impact of a 10% increase in average beverage prices on sales under three
scenarios: a flat price increase across all beverages led to a 1.7% drop in sales, a
price increase affecting mainly higher-quality beverages led to a 2.8% increase
in sales, and a price increase affecting lower-quality beverages led to a 4.2%
drop in alcohol sales (250).
A natural experiment occurred in Switzerland with its reform of spirits taxes,
which came into effect on 1 July 1999 (252). Previously, the tax rate per litre
of pure alcohol for domestic spirits was CHF 26.00 and for foreign spirits
between CHF 32.00 and 58.00, according to the type of beverage and its
alcohol content. The fiscal reform also liberalized the import of spirits. The
result was a reduction of between 30% and 50% in the retail price of foreign
spirits, while the prices of domestic spirits did not change. The consumption
of spirits rose significantly (by 28.6%) in the total sample, especially among
young males and individuals who were low-volume drinkers at baseline. The
consumption of alcohol overall, or of wine or beer, did not change
significantly. No indication of effects of substitution was found. Alcoholrelated problems also increased significantly, an effect that disappeared when
the consumption of spirits was controlled for. This suggests that the increase

Interventions to reduce alcohol-related harm
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in alcohol-related problems at follow-up was directly associated with
increased consumption of spirits.
Increasing alcohol taxes not only reduces alcohol consumption and related
harm, but increases government revenue at the same time, especially since in
general, alcohol taxes are well below their maximum revenue-producing
potential (253) and that the revenue collected is usually well below the social
costs of alcohol (254). The existence of a substantial illicit market for alcohol
complicates policy considerations regarding alcohol taxes; in such
circumstances, tax changes require efforts to bring the illicit market under
effective government control.

Price and younger drinkers
Policies that increase alcohol prices delay the time when young people start to
drink, slow their progression towards drinking larger amounts, and reduce
their heavy drinking and the volume of alcohol drunk on each occasion (255).
Although alcoholic beverages appear to behave in the market like most other
consumer goods, the demand for alcoholic beverages among some consumers
may differ from the demand for other products because of the addictive nature
of alcohol. This addictive nature implies that an increase in past consumption
of alcohol would raise current consumption, so that price elasticity in the short
term, which holds past consumption constant, would be smaller in absolute
value than price elasticity in the long term, which allows past consumption to
vary. For example, a price increase in 2004 would reduce consumption in
2004, with consumption in previous years held constant. Because of the
addictive nature of alcohol, it would be expected that consumption in 2005
and in all future years would also fall. Consequently, the reduction in
consumption observed over several years (i.e. in the long term) after the price
increase would exceed the reduction observed in 2004 (i.e. in the short term).
A study of the relationship between price and alcohol consumption by young
adults aged 17 to 29 years has found this to be the case (256). Ignoring
previous years’ consumption (and thus the addictive aspects of alcohol), the
price elasticity of demand for alcohol was -0.29. When previous years’
consumption (and thus the addictive aspects of alcohol) was taken into
account, the estimated long-term price elasticity of demand was more than
twice as high at -0.65, indicating that price had a much greater influence on
alcohol consumption. This also means that about half of the reason that young
adults who drink heavily do not reduce their consumption is the difficulty
(costs) of overcoming the addictive nature of alcohol.

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In the United States, binge drinking by young people is highly responsive to
state taxes on alcohol. An increase in local alcohol price reduces the occasions
when binge drinking occurs, and thus the individual is less likely to become a
binge drinker (257). A 5% increase in the price of pure alcohol decreases an
individual’s probability of heavy binge drinking by 0.22. Further, the direct
effect of a one-unit increase in the latent binge-drinking variable is a decrease
in the individual’s annual earnings by 4.7%.
Increases in the prices of alcohol and beer lead to a reduction in road traffic
accidents and fatalities among people of all ages, particularly younger drivers.
Increases in alcohol prices also reduce death rates from cirrhosis, intentional
and unintentional injuries, workplace injuries and sexually transmitted disease
rates. Higher beer prices have been shown to lead to reductions in rapes and
robberies, homicides, crime, child abuse, wife abuse, violence at universities
and violence-related injuries (255).

Price and heavier drinkers
Price increases reduce the harm caused by alcohol, which also indicates that
heavier drinking has been reduced (247). Cirrhosis mortality is responsive to
small changes in price: in the United States, increases in taxes have been
shown to lead to an immediate reduction, which doubles over the long run
(258). More recent estimates found that a 10% increases in tax in the United
States was associated with a 32% decrease in the death rate from cirrhosis
(247).
Consistent with this, studies have reported that increases in the price of
alcohol result in a reduction in heavy drinking and alcohol dependence. A
study of survey data of 43 000 adults in the United States found a price
elasticity for heavier drinking of -1.325 (p=0.027), for physical and other
consequences of drinking of -1.895 (p=0.003), and for alcohol dependence of
-1.487 (p=0.012) (259). Studies in Alaska found statistically significant
reductions in the numbers and rates of deaths caused by alcohol-related
disease beginning immediately after alcohol tax increases in 1983 and 2002
(260).

Price and alcohol-related harm
The United Kingdom has extended the work of cost–effectiveness analysis to
model the impact of specified policy changes on a wider range of outcomes
beyond the health service (261). For example, estimates suggested that a 10%

Interventions to reduce alcohol-related harm
page 80

increase in the price of alcoholic beverages would lead to a reduction in
consumption of 4.4% (a reduction of 5.5 g alcohol per week), and more for
harmful drinkers (-25 g per week) than for moderate drinkers (-4 g per week).
Deaths were estimated to fall by 232 per annum in the first year up to1681
after 10 years. Hospital admissions were estimated to fall by 10 100 in the
first year, up to 50 800 after 10 years. Crime was estimated to fall by 65 000
offences overall, and the direct costs of crime were estimated to fall by
£70 million per year. Harm in the workplace was estimated to fall, with
12 800 fewer unemployed people and 310 000 fewer sick-days. The estimated
social value of these reductions in harm was £7.8 billion in total (when
discounted) over the 10-year period modelled. In the first year, they were
estimated as follows: reductions in health service costs (£43 million), value of
QALYs saved (£119 million), costs of crime avoided (£70 million), value of
crime QALYs saved (£98 million) and employment-related harm avoided
(£330 million). The cost impact of the policy on consumers varied
substantially between different types of drinker. The overall estimate was £33
per drinker per annum, £116 per annum for harmful drinkers and £17 per
annum for moderate drinkers. If drinkers did not change their alcohol
consumption, the effect on their pockets would be £223 per annum for
harmful drinkers and £26 per annum for moderate drinkers.
In the United Kingdom, in 59% of off-licence trade and 14% of trade on
licensed premises, alcohol is currently sold at less than 5 pence per gram of
alcohol. Setting this minimum price was estimated to reduce overall
consumption by 2.6% (3.4 g per week), with harmful drinkers affected (25 g)
much more than moderate drinkers (0.01 g/week). Deaths were estimated to
fall by 157 in the first year, up to 1381 after 10 years. Hospital admissions
were estimated to fall by 6300 in the first year up to 40 800 after 10 years.
Crime was estimated to fall by 16 000 offences overall. Harm in the
workplace was estimated to fall, with 12 400 fewer unemployed people and
100 000 fewer sick-days. The social value of these reductions in harm was
estimated at £5.4 billion in total over the 10-year period modelled. In the first
year, the estimated social value of the reduction in harm was as follows:
reductions in health service cost (£25 million), value of QALYs saved
(£63 million), crime costs avoided (£17 million), value of crime QALYs
saved (£21 million) and employment-related harm avoided (£312 million).
The cost impact of the policy on consumers varied substantially between
types of drinkers. The overall estimate was £22 per drinker per annum, £106
per annum for harmful drinkers and £6 per annum for moderate drinkers. If
drinkers did not change their alcohol consumption, the effect on their pockets
would be £138 per annum for harmful drinkers and £6 per annum for
moderate drinkers.

Pricing
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There is also evidence that people in low socioeconomic groups may be even
more responsive than other groups to changes in the affordability of alcohol,
most likely because alcohol would take up a greater proportion of their
income. In other words, increases in the price of alcoholic beverages lead to
greater decreases in consumption among these groups than among others
(262).

Affordability of alcohol
The real value of excise duty rates for most alcoholic beverages has gone
down since 1996 in the vast majority of EU member states (263). Notable
exceptions are Italy and the United Kingdom, which have seen an increase in
the real value of excise duty rates for beer and, in the United Kingdom, an
increase for wine. There has also been a decline in the EU minimum excise
duty rates in real terms for alcoholic beverages since 1992 as they have not
been adjusted for inflation.
The affordability of alcohol is a composite measure looking at the net effect
of price and income. The affordability of alcoholic beverages has increased
in all European countries examined, apart from Italy. In six countries
(Estonia, Finland, Ireland, Latvia, Lithuania and Slovakia) the affordability
of alcohol increased by 50% or more. Across the EU, 84% of the increase in
alcohol affordability results from increases in income and only 16% to
changes in alcohol prices. This is primarily because while incomes went up
considerably across the EU, the relative price of alcoholic beverages has
remained relatively stable or fallen more slowly than incomes have
increased. There is a statistically significant positive relationship between
alcohol affordability and consumption across the EU, with a short run
elasticity of 0.22 and long-run elasticity of 0.32 (suggesting a total increase
in consumption of 0.32% following a 1% increase in affordability).

Price and cross-border trade
Effective alcohol policies can be eroded by international trade and trade
agreements and cross-border issues. For example, there is substantive
evidence that the introduction of a single market for alcohol in the EU
resulted in significant tax competition between countries and thus lower tax
rates than would have occurred without a single market (264). Natural
experiments in Europe consequent to economic treaties have shown that as
alcohol taxes and prices have been lowered, so sales and alcohol consumption

Interventions to reduce alcohol-related harm
page 82

have usually increased (265,266), although this is not always reflected in
survey and panel data (267).
Total alcohol consumption (recorded and unrecorded) in Sweden rose from
1989 until 2004; from then until 2007 there was a slight drop in consumption
to an estimated 9.7 litres of pure alcohol per person aged 15 years or older per
year (268). In 2007, cross-border purchases of alcoholic beverages were the
source of almost a fifth of all alcohol consumption in Sweden. Starting from
slightly below average consumption, the southern Swedish counties
considerably increased their alcohol consumption until around 2003, while the
northern counties experienced only a slight increase. Both the increase until
2004 and the subsequent slump in consumption in the southern counties in
2005 were largely due to the cross-border purchase (and smuggling) of
alcohol from Denmark and Germany (269,270). In addition, it seems that the
increased consumption of imported alcoholic beverages also resulted in
increased alcohol-related morbidity and mortality (266). Further, the closer a
hospital to the Danish border, the higher the costs for alcohol-related
diagnosis were for inpatient treatment (271).
Finland, which joined the EU in 1995, was allowed to continue to restrict
alcohol imports until 2003. After that, alcohol imports were expected to
increase heavily, due not only to opening borders but also because
neighbouring Estonia, well-known for its low alcohol prices, was scheduled
to join the EU in 2004. The Finnish government therefore decided to lower
alcohol taxes: on 1 March 2004, the alcohol excise duty rate was reduced by
an average of 33% to prevent excessive imports and thereby losses in
alcohol tax revenues (272). The reduction in tax was greatest on distilled
spirits (-44%) and more moderate on wines (-10%) and beer (-32%). In
2004, both imports of alcohol from Estonia and retail sales of alcohol in
Finland went up. The total consumption of alcohol per capita increased by
10% from 9.4 litres in 2003 to 10.3 litres in 2004, with recorded
consumption increasing by 6.5% from 7.7 litres to 8.2 litres per capita, and
unrecorded – and thus untaxed – consumption by an estimated 25% from
1.7 litres to 2.1 litres per capita. The recorded consumption of spirits
increased by 18%, but the increase in sales did not cancel out the effects of
the tax cuts on tax revenues. The impact on health associated with Estonia
joining the EU was not statistically significant, but the impact of alcohol tax
cuts in March 2004 was significant, resulting in an estimated eight
additional alcohol-positive deaths per week, which was a 17% increase
compared with the weekly average in 2003 (273). Overall alcohol-related
mortality increased by 16% among men and by 31% among women; 82% of
the increase was due to chronic causes, particularly liver diseases (272). The

Pricing
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increase in absolute terms was greatest among men aged 55–59 years and
women aged 50–54 years. Among people aged 30–59 years, it was greatest
among the unemployed or early pensioners and those with low education,
social class or income. Those in employment and those aged over 35 years
did not suffer from increased alcohol-related mortality during the two years
after the change. In response to the worsening situation, alcohol taxes were
raised in Finland at the beginning of 2008 by an average of 11.5%. The
example of Finland illustrates (274), as with tobacco (275), that cross-border
issues are not solved by lowering taxes.
Summary of the evidence of addressing pricing of alcohol
What we know


There is extensive and consistent evidence that raising the
price of alcohol reduces alcohol-related harm.



There is consistent evidence that, to be effective, rises in
the price of alcohol need to account for changes in income
and the prices of other commodities.



There is consistent evidence that price has an impact on
younger and heavier drinkers.



There is some evidence from economic models that setting
a minimum price of alcohol could reduce alcohol-related
harm.



There is some evidence from economic models that price
increases and setting a minimum price affect the
consumption and expenditure of heavier drinkers to a
much greater extent than lighter drinkers.



There is some evidence that the EU economic treaties have
led to lower alcohol taxes.



There is some evidence that lowering taxes to reduce
cross-border trade can lead to increased alcohol-related
harm

What we do not know
⊗

The most efficient way to obtain public and political
support for raising taxes or introducing a minimum price.

Interventions to reduce alcohol-related harm
page 84

Policy implications of addressing pricing of alcohol
Consideration should be given to ensuring that taxes set the price
of alcohol at a level that reduces alcohol-related harm,
accounting for changes in inflation, income and the prices of
other commodities. Setting a minimum price per gram of alcohol
can be considered as a policy option to reduce the availability of
low- and cut-priced alcohol. Lowering taxes on alcohol to offset
cross-border trade or an illicit market in alcohol can bring the
risk of extra alcohol-related harm.

Drinking environments
This section will review the evidence for the impact of policies and
programmes that can reduce harm from drinking environments, including
enforcement of existing laws governing licensing and alcohol-servers, server
training programmes and bar design. The relationship between drinking and
alcohol-related harm can be both affected and mediated by the physical and
social context of drinking and by the succeeding contexts while the drinker is
intoxicated. Interventions in drinking environments can be important, since
the problems potentially averted commonly harm others than the drinker,
including the consequences of drink–driving and violence. Unfortunately, the
evidence shows that such interventions have limited impact unless they are
backed up by adequate enforcement.

Design of premises
Licensed drinking environments are associated with drunkenness, drink–
driving and problem behaviours such as aggression and violence, with some
licensed premises being associated with a disproportionate amount of harm
(276). Aspects of the bar environment that increase the likelihood of alcoholrelated problems include serving practices that promote intoxication, an
aggressive approach taken to closing-time by bar staff and local police, the
inability of bar staff to manage problem behaviour, general characteristics of
the environment such as crowding and permissiveness on the part of bar staff,
the general type of bar and physical comfort, the degree of overall
permissiveness in the bar, the availability of public transport and aspects of
the ethnic mix of customers (see 9).

Training of alcohol servers
Responsible beverage service
Nearly all evaluations of training bar staff in responsible beverage service,
backed up with enforcement, have demonstrated improved knowledge and
attitudes on the part of the participants (see 9). These studies have also shown
some effects on serving practices, although not always. While servers are
usually willing to intervene with customers who are visibly intoxicated, they
will generally not intervene with individuals solely on the basis of the
customer’s estimated BAC or number of drinks consumed. In addition,

Interventions to reduce alcohol-related harm
page 86

training tends to discourage bad serving practices such as pushing drinks, and
encourage “soft” interventions such as suggesting food or slowing service. In
terms of the effects on customer intoxication, several studies have found that
training servers results in lower BAC levels among customers generally and
fewer customers with high BAC levels. Moreover, time-series analyses of
mandatory server training suggest that such training is associated with fewer
visibly intoxicated customers and fewer single-vehicle night-time injuryproducing crashes (277). Studies of the impact of adhering to bar policies for
avoiding intoxication have also found modest effects in reducing heavy
consumption and high-risk drinking, but these were not as successful as
originally expected (276).
Responsible beverage service programmes are frequently included in broadbased interventions that have shown reductions in violence. For example, the
Safer Bars programme developed in Canada includes a risk assessment and a
training component for owners, managers and all staff (278). The programme
was designed to increase early intervention by staff, improve teamwork and
staff abilities in managing problem behaviour, and reduce the risk of injury to
patrons. The Safer Bars training was shown to be highly valued by bar staff
and managers and demonstrated a significant impact on knowledge and
attitudes. There was also a significant effect in reducing both moderate
aggression (e.g. pushing and holding) and severe aggression (e.g. punching
and kicking). The effects were lessened when there was a high turnover of
managers and door and security staff.
A systematic Cochrane review found no reliable evidence that interventions as
regards alcohol servers are effective in reducing injury (279). One study that
investigated server training estimated that there was a reduction of 23% in
single-vehicle night-time crashes in the experimental area (controlled for
crashes in the control area). Another study examined the impact of a drink–
driving service and reported a reduction of 15% in road crashes resulting in
injury in the experimental area, with no change in the control; no difference
was found for fatal crashes. A study investigating the impact of a policy
intervention reported that before the intervention the serious assault rate in the
experimental area was 52% higher than in the control area; after the
intervention, the serious assault rate in the experimental area was 37% lower
than in the control. A study investigating the impact of an intervention aimed
at reducing crime on drinking premises found a lower rate of all crime in the
premises covered by the experiment (rate ratio 4.6, 95% CI 1.7–12, p = 0.01);
no difference was found for injury (rate ratio 1.1, 95% CI 0.1–10, p = 0.093).
Since compliance with interventions appears to be a problem, mandated
interventions may be more likely to show an effect.

Drinking environments
page 87

Active enforcement
The impact of responsible beverage service is greatly enhanced when there is
active and continuing enforcement of laws prohibiting the sale of alcohol to
intoxicated customers (see 9). Increasing the perceived risk of apprehension
for an offence can deter individuals from future violations of the law: a cost–
effective intervention in which the benefits greatly exceed the costs.
Enforcement also seems to be a necessary component if voluntary codes of
responsible beverage service are to be successful. One study found that a
programme combining stricter enforcement of alcohol sales laws and training
in responsible beverage service had a significant effect in reducing the rate of
violent crimes between 20:00 and 06:00 (144). There is some evidence from
specific establishments, with limited diffusion to the whole community, that
enforcement checks prevent alcohol sales to minors (280); most of the
enforcement effect decayed within three months, however, suggesting that a
regular schedule of enforcement is necessary to maintain deterrence. Further,
there is some evidence that enforcement activity focuses more on breaches
committed by patrons or minors, rather than on licensees or vendors who are
in breach of the intoxication provisions of the liquor laws.
For example, the goal of the Surfers Paradise project was to reduce violence
and disorder associated with the high concentration of licensed establishments
in the resort town of Surfers Paradise in Queensland, Australia (281). The
project involved three major strategies: (i) the creation of a community forum
including the development of task groups and a safety audit; (ii) the
implementation of risk assessments, model house policies, and a code of
practice; and (iii) regulation of licensed premises by police and spirits
licensing inspectors. This project and its replications in three North
Queensland cities (Cairns, Townsville and Mackay) resulted in significant
improvements in alcohol policy enforcement, in the bar environment, in bar
staff practices and in the frequency of violence. Following the intervention,
the number of incidents per 100 hours of observation dropped from 9.8 before
the test to 4.7 in Surfers Paradise, and from 12.2 before the test to 3.0 in the
replication sites. The initial impact of the project was, however, not sustained.
Two years following the intervention in Surfers Paradise the rate had
increased to 8.3, highlighting the need to find ways to maintain the gains
achieved from community action projects.

Interventions to reduce alcohol-related harm
page 88

Summary of the evidence of drinking environments
What we know


There is some evidence that increased enforcement on
sales to intoxicated and underage drinkers can reduce
alcohol-related harm.



There is some evidence that responsible serving practices
do not on their own consistently reduce alcohol-related
harm.



There is some evidence that interventions delivered in
drinking environments do not consistently reduce alcoholrelated harm.



There is some evidence that interventions aimed at
reducing underage access to alcohol do not on their own
consistently reduce alcohol-related harm.

What we do not know
⊗

The most effective ways that drinking environments can
reduce the harm done by alcohol.

Policy implications of drinking environments
Interventions in drinking environments on their own are unlikely
to have a substantial impact in reducing alcohol-related harm.
Consideration can, however, be given to increased enforcement
on restrictions of sales to intoxicated and under-age drinkers,
perhaps as part of comprehensive community action, also to
reduce the harm done by alcohol to people other than the drinker
(see under Community Action).

Reducing the public health impact of unrecorded
alcohol
This section will note that unrecorded alcohol, defined as home-made,
illegally produced or smuggled alcohol products as well as surrogate alcohol
that is not officially intended for human consumption (mouthwash, perfumes
and eau-de-colognes) could have health consequences due to a higher ethanol
content and contamination with methanol and lead, for which many poisoning
outbreaks and fatalities have been recorded internationally (282), and possibly
also from some higher alcohols, which have been attributed to higher rates of
alcoholic liver disease. For example, it has been suggested that the large
differences in cirrhosis mortality rates between Hungary, Romania and
Slovenia and the rest of Europe could be due to the composition of
unrecorded alcohol products (283) rather than differences in the volume of
consumption (284) (Fig. 4). Illegally traded alcohol can bring a health risk due
either to contamination during the trading process or to a lower cost than legal
alcohol leading to higher consumption. Little is known about the scale of
smuggling in Europe, although an estimate made for the EU15 in 1996
suggested that fraud cost the equivalent of around 8% of total alcohol excise
duty, similar to tobacco fraud for which, at the time, one third of cigarettes
traded were estimated to be smuggled.

Unrecorded alcohol
Despite concern about the potential harm to health from the chemical
composition of unrecorded alcohol, there are surprisingly few data in Europe.
A small study of samples collected from markets in Hungary and Lithuania
only found problems with surrogate alcohols, which contained high levels of
ethanol (60% by volume) and some of which contained hepatatoxic levels of
coumarin (285). Although the stone fruit spirits (cherries, plums, mirabelles
and apricots) from Hungary contained higher levels of methanol and ethyl
carbamate, these were not found at levels toxic to human health.
For unrecorded and surrogate alcohols that can have a high methanol content,
the complete removal of methanol from denatured spirits is probably the most
significant measure to reduce methanol-attributable morbidity and mortality.
Some countries, including Australia, have abolished the use of methanol to

Interventions to reduce alcohol-related harm
page 90

Standardized rates per
100 000 person-years

Fig. 4. Trends in liver cirrhosis mortality in different parts of Europe in the
group aged 20–64 years, 1958–2003

Notes: SCEE: southern central and eastern European countries (Hungary, Romania, Slovenia);
Baltic countries: Estonia, Latvia, Lithuania; other EU10 countries: Bulgaria, Czech Republic,
Poland, Slovakia.
Source: Zatonski et al (68).

denature alcohol, with a subsequent significant reduction in cases of toxicity
(286). Many European countries also do not allow methanol (or methanolcontaining wood alcohol) to be used as a denaturing agent (287). For
cosmetics, the simplest way is to use the perfume oils that are part of the
recipe as a denaturing agent. Other surrogate alcohols, for example those for
automobile products, could also be treated with bittering agents to avoid
consumption. Rigorous controls on the sale of medicinal alcohol and only
permitting small container sizes have been shown to reduce potential harm
from medicinal alcohols in the Nordic countries (288).

Smuggled alcohol
By its nature, it is obviously difficult to obtain reliable statistics on the illicit
trade in alcohol, which makes it difficult to estimate the scale of smuggling in
Europe and monitor trends in the illegal trade. The only existing estimate for
the EU15 comes from the European High Level Group on Fraud, which

Unrecorded alcohol
page 91

estimated that €1.5 billion was lost due to fraud in 1996, equivalent to around
8% of total alcohol excise duty at the time (289). In comparison, for tobacco
products member states estimated the loss in 1996 at approximately
€3.3 billion (or 7.5% of total excise duty receipts on tobacco products).
Although the single market and greater passenger movement may be expected
to increase the possibilities for fraud, the indications are that there are
different trends in Europe. France, Ireland and the United Kingdom, for
example, believe that they have experienced increased diversion fraud,
whereby goods moving from one member state to another under suspension of
excise duty are diverted en route, often to member states applying relatively
high levels of duty. Portugal, on the other hand, has seen more evasion of duty
(290).
Although any heavily-taxed product will be susceptible to fraudulent activity,
this does not mean that lower, uniform tax rates will reduce the level of
smuggling. In fact, smuggling of tobacco (which has been analysed in more
detail) was more likely to occur from the expensive north of Europe to the
cheaper south (291), probably related to less transparent government in
southern Europe (292). Price differentials do increase the incentive to
smuggle goods (especially for small-scale smuggling by individuals in single
vehicles), but any highly-taxed item such as alcohol is susceptible to
smuggling. This makes the chances of being caught of key importance for the
large-scale, organized smuggling operations that make up the bulk of the
problem for alcohol. Improved enforcement is, therefore, an effective tool
against smuggling (290).
Other member states have reported an increase in the smuggling of alcohol
from third countries (as in Finland) or increases in home distilling and
confiscation of alcoholic beverages brought into the country illicitly from
other member states (as in Sweden) (290). As stated above, member states
applying relatively low levels of duty (such as Portugal) have reported
increasing fraud in the alcohol and alcoholic beverage sector, mainly
evasion of duty. The Commission has also become aware of an increasing
number of cases, signalled by individual companies in the alcohol sector, of
non-clearance of movements within the European Community or from the
Community towards third countries, whereby these companies are held
liable for payment of the duty on goods which have not reached their
destination. Following the recommendations of the High Level Group on
Fraud, the Commission and member states have taken a number of
initiatives in order to combat fraud. Examples are the adoption of a
Commission Recommendation concerning warehouse-keepers, and the
computerization of the movement and surveillance system of excisable

Interventions to reduce alcohol-related harm
page 92

products. These initiatives will improve the efficiency of existing regulatory
and control systems, and facilitate the fight against fraud and evasion.
Summary of the evidence of drinking environments
What is known


There very limited studies that have been undertaken
suggest that the chemical composition of unrecorded
alcohol is unlikely to pose a substantial health hazard; the
exception to this is surrogate alcohols.

What is not known
⊗

The full extent of unrecorded and, in particular, smuggled
alcohol.

⊗

The full extent to which the chemical composition of
unrecorded alcohol presents a health risk.

Policy implications of unrecorded alcohol
Consideration should be given to obtaining better estimates of
the size of the unrecorded market, including smuggled products,
and the size of the potential health risk from unrecorded alcohol.
A range of measures listed in the chapter can be used to reduce
the risk of surrogate alcohol. Electronic recording systems and
tax stamps can be used to track traded alcohol, and licit alcohol
producers can take a responsibility in supporting reduced illicit
trade.

Overview of effectiveness and
cost–effectiveness
Summarizing the previous sections, this section will note that there is a
substantial evidence base on the effectiveness of different policies in reducing
the harm done by alcohol. Essentially, those policies that regulate the
environment in which alcohol is marketed (economic and physical
availability) are effective in reducing alcohol-related harm. Enforced
legislative measures to reduce drinking and driving are effective, as are
individually-directed interventions to already at-risk drinkers. On the contrary,
the evidence shows that information and education-type programmes do not
reduce alcohol-related harm, although they have a role in providing
information, reframing alcohol-related problems, and increasing attention to
and acceptance of alcohol on the political and public agendas.
Adding a cost component to the assessment of the health impact of alcohol
policies creates an opportunity to identify those strategies that offer the greatest
(or least) value for money. For example, devoting scarce resources to
interventions that do not discernibly reduce the harm done by alcohol, as is the
case for information and education aimed at changing behaviour, can be argued
as an inefficient use of scarce resources. At the other end of the spectrum,
changes in taxation cost relatively little to implement but lead to substantial
health returns. In fact in all parts of the EU, all of the population-based
interventions represent a cost–effective use of resources (against the
international yardstick of per capita income), and compare favourably to
treatment strategies for disease and injury that may result from harmful alcohol
use. Brief interventions for the treatment of individual high-risk drinkers also
compare favourably to such treatment strategies but are harder to scale up
because of their associated training and personnel needs.

Summary of effectiveness
Based on Anderson et al (293), the evidence for the impacts of the policy
measures described in this report are summarized below in order of levels of
evidence for, and potential for impact from, those interventions for which
there is evidence that they reduce alcohol-related harm (Table 2). What is
clear about the change in evidence over time is that there are now many more
publications of systematic reviews and meta-analyses which have

Interventions to reduce alcohol-related harm
page 94

strengthened the conclusions of previous reviews. Policies that limit the
economic and physical availability of alcohol reduce harm, whereas
educational-type policies do not. No-one can now dispute the impact of prices
when a meta-analysis of 1003 estimates from 112 studies (248), and a metaanalysis of 1172 estimates from 132 studies (234) convincingly show an
impact of price on consumption, with the effect greater in the longer than the
shorter run. No-one can now argue that more school education or prevention
among young people is the solution when a systematic review of
14 systematic reviews could only identify 6 out of 59 high-quality school
programmes that were able to demonstrate any evidence for effectiveness
(72), and a systematic review of 25 reviews could only identify 12 out of 127
high-quality interventions that showed promising evidence (77).
Table 2. Summary of the evidence of the effectiveness of alcohol policies
Degree of
evidence

Evidence of action that reduces
alcohol-related harm

Evidence of action that
does not reduce alcoholrelated harm

Convincing

Alcohol taxes
Government monopolies for retail sale
Restrictions on outlet density
Restrictions on days and hours of sale
Minimum purchase age
Lower legal BAC levels for driving
Random breath-testing
Brief advice programmes
Treatment for alcohol use disorders

School-based education and
information

Probable

A minimum price per gram of alcohol
Restrictions on the volume of
commercial communications
Enforcement of restrictions of sales to
intoxicated and under-age people

Lower taxes to manage
cross-border trade
Training of alcohol servers
Designated driver campaigns
Consumer labelling and
warning messages
Public education campaigns

Limitedsuggestive

Suspension of driving licences
Alcohol locks
Workplace programmes
Community-based programmes

Campaigns funded by the
alcohol industry

Cost–effectiveness
page 95

Cost–effectiveness of alcohol policies
This section reports the results of WHO’s CHOICE (CHOosing
Interventions that are Cost–effective) model, which provides estimates of
the impact and cost of implementing policies in reducing DALYs due to
harmful alcohol use (123), re-calculated for the EU. The CHOICE model
determines the effectiveness of an intervention via a state transition
population model, taking into account births, deaths and the impact of
alcohol. Two scenarios are modelled over a lifetime (100 years): (i) no
interventions available to reduce hazardous and harmful alcohol use
(defined in the CHOICE model as more than 20g alcohol a day for women
and more than 40g alcohol a day for men); and (ii) the population-level
impact of each specified intervention, implemented for a period of 10 years.
The difference represents the population-level health gain resulting from the
implementation of the intervention, discounted at 3% and age-weighted.
Population-level costs associated with the implementation of interventions –
which include legislation, enforcement, administration and training costs, plus
inpatient and outpatient services where indicated – have been updated from
2000 to 2005 international dollar price levels, and now include estimates for
school-based education and mass media awareness campaigns. (An
international dollar has the same purchasing power as the US dollar has in the
United States and is used as a means of translating and comparing costs from
one country to the other using the US dollar as a common reference point.)
Intervention health effects expressed in DALYs saved, relative to an
epidemiological situation of no alcohol control measures in the population,
have also been updated in order to reflect underlying demographic changes in
regional populations since 2000, and have been extended to include the
impact of a sustained campaign of tax enforcement on reducing levels of
unrecorded production and consumption. Non-health effects of alcohol policy
measures, such as reduced damage to property or enhanced work productivity,
are not considered in this analysis.
A summary of the estimated cost and impact of different interventions,
compared to a Europe with none of these policies is shown in Table 3, with an
estimate of the cost per DALY saved. For information and education, and
community action, the costs of school-based education and mass-media
awareness campaigns have been estimated respectively. Although these
interventions are not expensive, they do not notably alter consumption levels
or health outcomes. Such interventions are therefore not effective or cost–
effective strategies to pursue in terms of reducing health-related harm due to

Interventions to reduce alcohol-related harm
page 96

alcohol use (particularly since there exist other actionable strategies that are
very cost–effective).
In relation to the health sector response, brief interventions have been studied
extensively. The cost–effectiveness of such interventions is not as favourable
as the population-level policy instruments summarized below because they
require direct contact with health care professionals and services. Although
brief interventions are the most expensive to implement, it should be noted
that within health service expenditure, brief interventions for hazardous and
harmful alcohol consumption are one of the most cost–effective of all health
service interventions in leading to health gain. Where drink–driving policies
and countermeasures are concerned, there is good evidence for the
effectiveness of drink–driving laws and their enforcement via roadside breathtesting and checkpoints. The estimated cost–effectiveness of such
countermeasures ranged from I$ 781 (in Eur-C countries) to I$ 4625 (in Eur-B
countries).
The impact of reducing access to retail outlets for specified periods of the
week and implementing a comprehensive advertising ban have the potential to
be cost–effective countermeasures, but only if they are fully enforced (each
healthy year of life restored costs between I$ 567 and I$ 2509).
Table 3. Costs, impact and cost–effectiveness of different policy options in Europe
Target area, Coverage
(%)
specific
intervention(s)

WHO subregion (exemplar countries)
Eur-A
(e.g. Spain, Sweden)
Annual
cost per
million
persons
a

Raising awareness and
political
commitment
School-based
education
Health sector
response
Brief
interventions
for heavy
drinkers

Annual
effect
per
million
persons
(DALYs
saved)

I$ per
DALY
savedb

Eur-B
(e.g. Bulgaria, Poland)
Annual
cost per
million
persons

Annual
effect
per
million
persons
(DALYs
saved)

I$ per
DALY
savedb

a

Eur-C
(e.g. Russian Federation,
Ukraine)
Annual
cost per
million
persons

Annual
effect
per
million
persons
(DALYs
saved)

I$ per
DALY
savedb

a

80

0.84

–

N/Ac

0.70

–

N/Ac

0.34

–

N/Ac

30

4.20

672

6256

0.77

365

2100

1.78

667

2671

Cost–effectiveness
page 97
Target area, Coverage
(%)
specific
intervention(s)

WHO subregion (exemplar countries)
Eur-A
(e.g. Spain, Sweden)
Annual
cost per
million
persons
a

Community
action
Mass media
campaign
Drink–driving
policies and
countermeasure
s
Drink–driving
legislation and
enforcement
(via random
breath-testing
campaigns)
Availability of
alcohol
Reduced
access to retail
outlets
Marketing of
alcoholic
beverages
Comprehensiv
e advertising
ban
Pricing policies
Increased
excise taxation
(by 20%)
Increased
excise taxation
(by 50%)
Tax
enforcement
(20% less
unrecorded)
Tax
enforcement
(50% less
unrecorded)

Annual
effect
per
million
persons
(DALYs
saved)

I$ per
DALY
b
saved

Eur-B
(e.g. Bulgaria, Poland)
Annual
cost per
million
persons

Annual
effect
per
million
persons
(DALYs
saved)

I$ per
DALY
b
saved

a

Eur-C
(e.g. Russian Federation,
Ukraine)
Annual
cost per
million
persons

Annual
effect
per
million
persons
(DALYs
saved)

I$ per
DALY
b
saved

a

80

0.83

–

N/Ac

0.95

–

N/Ac

0.79

–

N/Ac

80

0.77

204

3762

0.74

160

4625

0.72

917

781

80

0.78

316

2475

0.56

414

1360

0.47

828

567

95

0.78

351

2226

0.56

224

2509

0.47

488

961

95

1.09 2301

472

0.92

726

1272

0.67

1759

380

95

1.09 2692

404

0.92

852

1083

0.67

1995

335

95

1.94 2069

939

1.26

706

1780

0.87

1741

498

95

2.21 2137

1034

1.34

790

1692

0.93

1934

480

a
Implementation cost in 2005 international dollars (millions); b cost–effectiveness ratio, expressed in terms of
international dollars per DALY saved; c not applicable because the effect size is not significantly different from zero
(the cost–effectiveness ratio would therefore approach infinity).

In the category of pricing policies, there is consistent evidence showing that
the consumption of alcohol is responsive to an increase in final price, which
can be effectuated via higher excise taxes on alcoholic beverages. Tax
increases (of 20% or even 50%) are highly cost–effective throughout
Europe. Even accounting for longer life, and thus potentially increased social
welfare costs, taxation remains a highly cost–effective alcohol policy option
(294). As discussed above, the effect of alcohol tax increases could be
mitigated by illegal production, tax evasion and illegal trading, which
accounts for approximately 12% of all consumption in Eur-A countries and
40% in Eur-B and Eur-C countries. Reducing this unrecorded consumption
(by 20–50%) via concerted tax enforcement efforts is estimated to cost 50–
100% more than a tax increase but produces similar levels of effect. In
settings with higher levels of unrecorded production and consumption,
increasing the proportion of consumption that is taxed (and therefore more
costly to the price-sensitive consumer) may represent a more effective
pricing policy than a simple increase in excise tax, which may only
encourage further illegal production, smuggling and cross-border purchases.
Fig. 5. Expansion path of cost-effectiveness in Eur-A countries

Cost–effectiveness
page 99

Fig. 6. Expansion path of cost-effectiveness in Eur-B countries

Legend for Figs. 5-7 plot the total costs and effects of each single and
combined intervention on an expansion curve (the solid line)

Interventions to reduce alcohol-related harm
page 100

Fig. 7. Expansion path of cost–effectiveness in Eur-C countries

Figs. 5–7 plot the total costs and effects of each single and combined
intervention on an expansion curve. The lower right boundary of this plot
represents the increasing incremental cost of saving one additional DALY and
indicates the most efficient way of combining different strategies. Interventions
to the north-west of this cost–effectiveness frontier or expansion path are
“dominated”, i.e. they are less effective and/or more costly than (a combination
of) other interventions. The most cost–effective options are those that occur on
the inflections of the expansion path. In all three sub-regions of Europe, the most
cost–effective option is increased taxation (current + 50%), followed by
increased tax and scaled-up tax enforcement in Eur-A and Eur-C countries and
increased tax and reduced access in Eur-B countries, followed by increased tax,
scaled-up tax enforcement and reduced access in all three sub-regions, followed
by increased tax, scaled-up tax enforcement, reduced access, an advertising ban
and brief advice in all three sub-regions.
It is also important to note that country contextualization can change the cost–
effectiveness ratios. For example, compared with Eur-C countries, costs per
DALY averted in Estonia were cheaper for taxation, an advertising ban and
roadside breath-testing, and more expensive for reduced access and brief
advice in primary care (295). Thus, in Estonia, in contrast to Eur-C countries,
an advertising ban became more cost–effective than reduced access, and
roadside breath-testing than brief advice in primary care.

Cost–effectiveness
page 101

Finally, it should be noted that a comprehensive policy that combines
individual elements can be far more cost–effective than the individual policy
elements alone. For example, current taxation plus a 50% increase, which lies
at the first inflexion of the expansions path in Eur-A countries, has an
incremental and average cost–effectiveness of I$ 404/DALY averted. The
next inflection (increased tax and scaled-up enforcement) has an incremental
cost–effectiveness of I$ 991 and an average cost–effectiveness of I$ 647. The
third inflection (increased tax, scaled-up enforcement and reduced access) has
an incremental cost–effectiveness of I$ 2252 and an average cost–
effectiveness of I$ 776. The final point (increased tax, scaled-up enforcement,
reduced access, advertising ban and brief advice) has an incremental cost–
effectiveness of I$ 6923 and an average cost–effectiveness of I$ 1517.
Importantly for policy discussions, it should be noted that the current
intervention mix does not appear on any of the expansion paths, indicating
room for improvement from a cost–effectiveness point of view and that more
DALYs could be saved by increasing the taxation level, improving coverage
of interventions and better enforcement, possibly even in the current
budgetary range using resource re-allocation.

Summary of the evidence of drinking environments
What is known


The most cost–effective policy option to reduce alcoholrelated harm is taxation.



The next most cost–effective policy option is taxation
combined with scaled-up tax enforcement.



The next most cost–effective policy option is increased
tax, scaled-up tax enforcement and reduced access.



The next most cost–effective policy option is increased
tax, scaled-up tax enforcement, reduced access, an
advertising ban and brief advice.



Current intervention mixes could be more cost–effective.

What is not known
⊗

The specific expansion paths in individual member states,
apart from Estonia.

Interventions to reduce alcohol-related harm
page 102

⊗

The impact of policies in reducing the avoidable social
cost burden of alcohol in Europe, although this has been
done, for example in Australia (296) and Canada (297).

Policy implications of the evidence related to
cost–effectiveness
Policy-makers would be advised to model expansion paths in
their own countries. Consideration could be given to adjustment
of policies towards those most favourable from a cost–
effectiveness perspective in reducing alcohol-related harm.

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