Reducing alcohol-related liver disease – what works and the barriers to

implementation Integrated Treatment for ARLD: Making it happen.

Southampton 2nd February 2017

Ian Gilmore, University of Liverpool, Chair, UK Alcohol Health Alliance

Declaration of Interests

None

Outline of talk • the way we drink

•Internationally v Europe v UK •Patterns by country and age

•The harm it causes, particularly to the liver •The harm to whom and when? •The evidence base of what works to prevent harm •What about education and information – the CMO guidelines? •Levers for change?

WHO Global Status Report 2011

China –the new global market for alcohol

Recorded adult per capita consumption age 15+– (unrecorded 1+l/person)

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PHE Report Dec 2016

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Sheron and Gilmore, BMJ 2016 Messages:

•Hazardous, Harmful and Extreme groups make up make up 20%

drinkers but consume 70% of alcohol (Pareto Principle)

• Harmful and extreme drinkers make up 4.5% of total drinkers but

consume 55% strong cider / lager / beer

Based on a study of a sample of 160 patients admitted to Glasgow and Edinburgh hospitals with alcohol-related illnesses in 2011-12 and 449 patients attending alcohol treatment services in the same cities Clinical Medicine 2016

Drinking 5 or more days a week by age

ONS 2012

Men more than women

16-24yr olds binge more

ONS 2012

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PHE Report Dec 2016

Drinking with meals in the EU 15 Source Eurobarometer 2003

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Alcohol Related Admissions for Liverpool PCT (residents) 2002/03 to 2008/09

by Condition Group.

0

500

1000

1500

2000

2500

3000

3500

2002/2003 2003/2004 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009

Ra

te p

er

10

0,0

00

Chronic Conditions Rate

Wholly Attributable Rate

Acute Consequences Rate

CHRONIC

CONDITIONS

DEPENDENCE

DALYs lost attributable to 10 leading risk factors for the age group 15–59 years globally

WHO Global Status Report on alcohol and health 2011

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PHE Report Dec 2016

Male alcohol-related deaths by age group, England

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PHE Report Dec 2016

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PHE Report Dec 2016

Lancet Commission 3rd report, December 2016

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Remarkable differences in alcoholic cirrhosis deaths over time within Europe

Bhattacharya et al., The Gorbachev anti-alcohol campaign & Russia’s mortality crisis, Am Econ J: Appl Econ 5:232-260, 2013; Allamani & Prina, eds., Why the decrease in consumption of alcoholic beverages in Italy?... Contemp Drug Probs 34:187-378, 2007 Bhattacharya et al., The Gorbachev anti-alcohol campaign & Russia’s mortality crisis, Am Econ J: Appl Econ 5:232-260, 2013;

Allamani & Prina, eds., Why the decrease in consumption of alcoholic beverages in Italy?... Contemp Drug Probs 34:187-378, 2007 Bhattacharya et al., The Gorbachev anti-alcohol campaign & Russia’s mortality crisis, Am Econ J: Appl Econ 5:232-260, 2013; Allamani & Prina, eds., Why the decrease in consumption of alcoholic beverages in Italy?... Contemp Drug Probs 34:187-378, 2007

Austria

Belg

DenFin

France

Germy

Greece

Icelnd

Irelnd

Italy

Luxmb

Nether

Norway

Spain

Sweden

Switz

UK E&W

UK NI

UK Sco

05

10

15

Fe

male

rate

pe

r 1

00

,00

0

0 10 20 30Male rate per 100,000

Liver cirrhosis mortality : Western EuropeAge-standardised rates by sex and country 2004-9

30 Leon and Collier 2010

Austria

Belg Bulg

CzechDen

Est

Fin

France

Germy

Greece

Hungary

Icelnd

Irelnd

Italy

Latvia

Lithu

Luxmb

NetherNorway

Poland

Romania

Russia

SlovakSloven

Spain

Sweden

Switz

UK E&WUK NI

UK Sco

010

20

30

Fe

male

rate

pe

r 1

00

,00

0

0 10 20 30 40 50 60 70Male rate per 100,000

Liver cirrhosis mortality : EuropeAge-standardised rates by sex and country 2004-9

31 Leon and Collier 2010

Countries with markedly rising cirrhosis rates in last twenty years

• Bulgaria

• Denmark

• Estonia

• Finland

• Baltic countries

• Poland

• Russia

• UK + Ireland

Tend to be:

• Northern and Eastern European

• Beer/spirit drinking

• Binge pattern

• Starting from lower levels

Countries with markedly falling cirrhosis rates in last twenty years

• Austria

• France

• Germany

• Greece

• Italy

• Portugal

• Spain

Tend to be:

• Southern European

• Wine drinking

• With meals

• Starting from high levels

Three decades of evidence

• Alcohol control policies in public health perspectives –Bruun et al , 1975 • Alcohol policy and the public good – Edwards et al 1994 • Alcohol: no ordinary commodity – Babor, Edwards et al 2003 and 2010

International evidence shows consumption and harm are driven by:

• price of alcohol

• promotion by the alcohol producers and retailers

• availability

Lancet Commission 3rd report, December 2016

What to do about price

(centrally and locally)?

• increase duty / VAT

• use duty to promote lower strength

• tackle discounting / bulk offers

• minimum unit price

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Stockwell data from British Columbia •2011 addiction paper showed real life 10% increase in price led to 16% reduction in consumption of alcoholic beverages compared to non-alcoholic ones •2013 paper shows increase in MUP in British Columbia led to both immediate and delayed falls in alcohol-attributable deaths •Furthermore benefits in real life exceeded those predicted by the Sheffield model •A 10% increase in MUP was associated with a 31% fall in wholly alcohol-attributable mortality

Stockwell et al, Addiction 2011 Zhao et al, Addiction 2013

Availability

Includes: • hours of opening • home deliveries • density and site of outlets • the siting of alcohol in-store • the ability to take account of public health in licensing decisions • regulation and enforcement of sales to the underage and drunk

Nakamura et al, Social Science and Medicine, 2014

Impact of placing alcoholic and non-alcoholic products at end-of-aisle

• Beer sales increased by 23% • Wine by 37% • Spirits by 46%

Availability

Includes: • hours of opening • home deliveries • density and site of outlets • the siting of alcohol in-store • the ability to take account of public health in licensing decisions • regulation and enforcement of sales to the underage and drunk

Journal of Epidemiology and Community Health 2014

mass media

advertising

television press

billboards

other marketing

communications

point of

sale

packaging

internet

sponsor-

ship

product

placement

brand

stretching

free

samples

consumer

marketing

product

design

distribution

price

stakeholder

marketing

corporate

social

responsibility

Comp

analysis

media

know-

how

corporate

affairs

social

marketing

What is marketing?

Gerard Hastings, Univ of Stirling

Alcohol and Sports Sponsorship

• All studies indicate exposure to alcohol sports sponsorship is associated with increased levels of consumption and risky drinking amongst schoolchildren and sports people, although the effect size varies across the studies.

• Already bans in France and Norway, and NZ + Ireland on the way

• F1 worst offender

• 11 promotional refs / min

• Mainly spirits . Vermouth

(Eurocare et al, May 2015)

Are the public behind alcohol regulation?

Figure 9.1 Assessment of the British people’s

relationship with alcohol 76%

71%

65%

64%

63%

61%

61%

59%

54%

54%

53%

53%

15%

24%

23%

29%

28%

30%

30%

30%

37%

39%

38%

38%

9%

5%

12%

6%

9%

10%

9%

10%

10%

7%

9%

10%

Northern Ireland

Scotland

North East

North West

London

South East

East of England

Yorkshire and the Humber

South West

Wales

East Midlands

West Midlands

unhealthy relationship neutral healthy relationship

Figure 9.3 Respondents’ support for specific minimum prices for alcohol

products based on a minimum unit price of 50p per unit of alcohol.

46%

46%

43%

43%

41%

40%

29%

29%

28%

32%

29%

29%

26%

25%

29%

25%

30%

31%

£1.98 for a 440 ml can of super strength lager

£13.13 for a 70cl bottle of branded vodka

£7.50 for a 2 litre bottle of strong cider

£0.88 for a 440 ml can of normal strength beer

£4.69 for a 750ml bottle of wine

£13.13 for a 70cl bottle of supermarket value vodka

support neutral object

• Our central finding is that non-regulatory measures used in isolation, including “nudges”, are less likely to be effective.

Nemtsov Addiction 1999

The benefits of reducing consumption can be rapid – even for cirrhosis

Statement by Margaret Chan, Director General of WHO:

• In the view of WHO, the alcohol industry has no role in the formulation of alcohol policies, which must be protected from distortion by commercial or vested interests

BMJ, 2013