Alcohol: A Key Public Health Issue
–Off-licence sales of alcohol have increased
© D. Speirs
The television documentary, When the Party’s Over, presented by Dr Mark Hamilton and broadcast on RTE just before Christmas 2008, provided many memorable images of Ireland’s current drinking habits and of the consequent impact on individuals and society as a whole.
One of the most striking features of the programme was the way it so clearly illustrated the fact that ‘ordinary social drinking’ as it has come to be defined in modern Ireland makes for levels of consumption that are well in excess of the limits for low-risk drinking advised by health authorities. It would appear that many people in Ireland would find themselves readily agreeing with the view of the young woman, quoted in a 2003 article in The Observer, who said: ‘That is not binge drinking. That’s called having a social life.’1
Anecdotal evidence of excessive alcohol consumption is consistently confirmed by surveys on drinking in Ireland. The survey results, in the case of both teenagers and adults, reveal levels of consumption that are high in themselves and high in comparison to other countries. Media and public attention tends to focus on the findings regarding under-age drinking. However, findings on adults’ drinking habits are also a cause for public health concern, not only because of the levels and patterns revealed, but because adults’ drinking plays a crucial role in shaping children’s attitudes regarding what is ‘normal’ in terms of alcohol consumption.
A Eurobarometer study covering twenty-nine countries, which was carried out in October/November 2006 and published in 2007, is just one of several surveys in recent years on the alcohol consumption patterns of adults in Ireland. In this study, Ireland emerged as the country with the highest incidence of binge drinkers, while having the lowest incidence of daily drinkers. The findings showed that a third of Irish people ‘usually’ consumed at least five drinks on any occasion they drank: this was higher than in any other country in the survey, and was significantly higher than the figure for the (then twenty-five member) EU as a whole, which was just 10 per cent. Of the Irish respondents, 54 per cent consumed five drinks or more at least once a week; the overall EU figure was 28 per cent.2
The ESPAD (European School Survey Project on Alcohol and Other Drugs) surveys, which have been conducted at four-yearly intervals since 1995, have consistently revealed a high incidence of under-age drinking and drunkenness in Ireland. The most recent, in 2007, showed that 86 per cent of the Irish sample population (i.e., students who would reach their sixteenth birthday in the year the data was collected) had at some point in their lives consumed alcohol and 78 per cent had done so during the previous twelve months.3
Nearly half (47 per cent) the Irish students said they had been drunk during the previous twelve months; 26 per cent reported being drunk in the previous month, compared to a European average of 18 per cent. This figure meant that Ireland ranked sixth highest among the thirty-five countries in the study in the incidence of students being drunk.4 More girls than boys (44 per cent as against 42 per cent) reported heavy drinking during the previous month.
Aside from the data from surveys which look at patterns of drinking, evidence of potentially harmful drinking is implicit in the figures for overall consumption of alcohol in Ireland.
The drinks industry frequently draws attention to the fact that total consumption of alcohol has been falling since 2001. In that year, consumption peaked at a (per annum) figure of 14.3 litres of pure alcohol per person over fifteen years of age. By 2008, consumption had fallen to around 12.4 litres per capita. What the drinks industry does not highlight is that between 1987 and the peak in 2001, consumption had increased by 46 per cent. Even at current levels, we are still drinking more than 20 per cent above the level of twenty years ago and Ireland has one of the highest adult consumption rates in the EU.
The level of consumption in 2008 is the equivalent of 490 pints, or 129 bottles of wine, or 46 bottles of vodka per person over a year. In terms of weekly consumption, the overall figure for 2008 would translate into around 20 standard drinks consumed per person per week. (The limits for low-risk drinking are 14 standard drinks for women and 21 standard drinks for men, spread out over the week.5) Since around 20 per cent of the population does not drink alcohol at all, and many people drink very moderately, the actual figure for the per capita consumption of those who drink more heavily is inevitably very high indeed.
The WHO has identified alcohol as the third highest risk factor (after tobacco and high blood pressure) for premature death and ill health in developed countries. Alcohol is associated with a wide range of diseases and conditions, including cirrhosis of the liver, a number of different cancers, heart disease, and stroke. Alcohol consumption can lead to dependence and addiction. It can lead also to accidents in the home, the workplace and on the streets and roads, as well as to fights and assaults. The resultant injuries may range from being minor to being so serious that they cause long-term disability or death.
There is emerging evidence of the harm which alcohol may do to the developing brain during adolescence, potentially resulting in damage to the area of the brain involved in learning and to the area involved in self-regulation, judgement and impulse control. Harmful alcohol consumption may also affect health in the wider sense of general wellbeing by, for example, damaging individuals’ financial security, relationships, and ability to avail of educational and employment opportunities.
In addition to the impact which alcohol may have on the life of the individual drinker, there is also what Sir Liam Donaldson, Chief Medical Officer for England and Wales, has called the ‘collateral damage of alcohol’ – the harmful effects on other individuals and on society as a whole.6 Such damage includes injuries and death as a result of road accidents, assaults and fights, and emotional and financial damage to marriage and other relationships. The harmful consumption of alcohol by parents and carers can have an extremely negative effect on children in terms of financial and emotional insecurity and it may even be a factor in abuse and neglect.
Data for Ireland on mortality and morbidity reveal a rising scale of health-related damage from alcohol. For example, between 1995 and 2004, there were 1,775 alcohol-related deaths in Ireland; the incidence of such deaths per 100,000 of the population aged over fifteen increased from 3.8 to 7.1 in this period. It is generally accepted that these figures are an underestimation of the true extent of alcohol related mortality.
Hospital admission figures show that large numbers of patients are treated for alcohol-related injuries and illness on both an outpatient and inpatient basis. The findings of a national study, covering six major acute hospitals, which profiled attendances at accident and emergency departments over a week, showed that more than a quarter (28 per cent) of attendances because of an injury were alcohol-related. Half these patients were in the 18–29 age group and three-quarters were male. Between 1995 and 2004, the numbers of admissions for inpatient treatment of alcohol-related conditions almost doubled, from over 9,000 to over 17,000.7
Alcohol-related disorders constitute one of the most common reasons for admission to inpatient psychiatric care. Less readily quantifiable but no less real are the complex social and psychological alcohol-related harms to drinkers and their families that result in additional demands on social work, psychological and family support services.
In sum, harmful alcohol consumption in Ireland causes immeasurable damage to the health and wellbeing of individual drinkers and of many others who are affected in varying ways and to varying degrees. It also places significant additional demands on an overstretched health service and an underdeveloped social support system.
In the face of the mounting evidence regarding alcohol-related damage to health and well-being, and of the reality of significant additional demands being placed on health and other services as a consequence, the policy responses in Ireland over the past two decades have been seriously inadequate and often contradictory. Weak public health measures have been overshadowed by other measures that have made alcohol cheaper and more easily available.
A National Alcohol Policy was published in 1996 and set out an overall public health approach to dealing comprehensively with alcohol issues.8 However, the specific legislative changes, policies and structures that should have followed did not materialise. Likewise, there was no active, co-ordinated, government response to the recommendations of the Strategic Task Force on Alcohol in 20049 and no plan or mechanism for the progressive implementation of these recommendations was put in place.
The introduction of randomised breath testing in July 2006 stands out as a rare example of significant policy reform. However, Ireland still retains a drink driving limit that is higher than that in the great majority of EU countries. The National Road Safety Authority has recommended a reduction of the limit to 50 mgs of alcohol per 100 mls of blood, with a lower limit of 20 mg for learner and professional drivers.
Three Key Areas
Internationally, three policy areas are recognised as being essential to an effective public health approach to preventing alcohol-related harm: these are pricing, availability and marketing. In Ireland, policy in respect of all three has been weak and ineffectual.
Prior to every Budget, media commentators speculate on the likelihood of additional taxes being imposed on ‘the old reliables’, which are assumed to include alcohol. The reality is, however, that until the increase in excise duty on wine in the October 2008 Budget, alcohol taxes had not increased since 2002. In that year, the duty on spirits (and in particular alcopops) was increased – and a notable drop in consumption followed. In 2001, the duty on cider was raised but that on beer has not increased since 1994.
In reality, then, there have been just three increases in duty in fifteen years. Even in the depth of the current crisis in the public finances, when raising additional revenue has become a priority, no increases in alcohol duties were imposed in the Supplementary Budget of April 2009.
It is true, as the drinks industry frequently points out, that alcohol taxes in Ireland are higher than in many European countries. Overall, however, alcohol has become significantly more affordable in Ireland since the mid-1990s. A recently published survey on the ‘affordability’ of alcohol in twenty EU countries shows Ireland to be one of eight where alcohol became at least 50 per cent more affordable over the period 1996 to 2004.10
The greater affordability of alcohol is, to a large extent, attributable to the steep rise in incomes in the decade from the mid-1990s onwards. Disposable incomes are now falling but the effect of the other key factor in affordability – the sharp decline in the cost of alcohol sold for ‘off-premises’ consumption – still prevails. The abolition in 2006 of the Groceries Order (which had prohibited the below-cost selling of products, including alcohol) opened the way for the undercutting of competitors’ prices and for supermarkets and other stores to use promotions of very cheap alcohol as a way of attracting customers. The result is the widespread availability of alcohol at a price less than that for bottled water.
Section 16 of the Intoxicating Liquor Act 2008 provided that the Minister for Justice, Equality and Law Reform could introduce regulations to prohibit or restrict retail outlets advertising or selling alcohol at reduced prices. However, no such regulation has yet been introduced.
(It might be noted that in February 2009 the Scottish Government stated its intention to introduce statutory regulations to control low-cost selling of alcohol, including setting a minimum price for a unit of alcohol.11 And in March 2009, the Chief Medical Officer for England and Wales, Sir Liam Donaldson, called for the setting of minimum pricing, suggesting a figure of 50 pence per unit of alcohol.12)
As a result of the Intoxicating Liquor Act 2008, there has been a reduction in the hours during which alcohol can be sold in off-licences and ‘mixed trading premises’ (supermarkets, convenience stores, garage forecourts, for example).
Scope for some further restriction on the availability of alcohol was provided by Section 9 of the Act. This allowed the Minister for Justice, Equality and Law Reform to introduce regulations that would require mixed trading stores to structurally separate the location of alcohol, so that it would be sold only in a specific section of the shop, which would be separated by a wall or similar barrier and accessible by a gate or door.
However, as a result of lobbying by the drinks industry, the commencing of Section 9 has been put on hold. In mid-May 2009, there was the formal launch of a voluntary Code of Practice which had been agreed between the Department of Justice, Equality and Law Reform, the Department of Health and Children and representatives of ten of the major retailers operating in Ireland. The retailers involved have created a new body, Responsible Retailers of Alcohol in Ireland (RRAI), which will communicate and monitor the implementation of the Code and establish a customer complaints procedure.
The provisions of the Code in terms of the physical separation of alcohol in supermarkets and other stores are much weaker than those envisaged in the legislation. Furthermore, not only is the Code voluntary, but its monitoring, while claimed to be independent, will ‘be under the auspices of the RRAI’.13 And the reality is that as much as 20 per cent of alcohol sales for off-premises consumption is by retailers not involved in the RRAI. All this serves to indicate a significant retreat from the provisions of the 2008 legislation.14
Even if statutory regulation as provided for in the 2008 Act had been brought into effect, it would still have represented only a very minor rolling back of the process of liberalisation of availability that characterised the previous decade. This resulted in a vast increase in the number and range of outlets for the off-licence sale of alcohol. For example, the number of off-licences and of ‘mixed trading’ premises authorised to sell the full range of alcohol products increased by almost 70 per cent between 2001 and 2007; there was a significant increase also in the number of premises authorised to sell wine only.15 Alcohol is now, therefore, not only a great deal cheaper but far more readily available than it was just a decade ago.
A comprehensive review (published in January 2009) of the findings of longitudinal studies on the impact of alcohol advertising and promotion on young people underlines why marketing is considered to be such a key area of alcohol policy. The review, by an international group of alcohol experts, found ‘consistent evidence’ that:
exposure to alcohol advertising and promotion increases the likelihood that adolescents will start to use alcohol and to drink more if they are already using alcohol.16
Given the high levels of consumption of alcohol by Irish teenagers and the very young age at which many of them begin to drink, the extent to which they are exposed to alcohol advertising clearly ought to be cause for serious concern and strong policy reaction. In fact, however, this is yet another area where ‘light touch’ regulation rather than forceful legislation has been adopted.
Draft legislation providing for the control (though not the banning) of alcohol advertising was abandoned by the Government in 200517and substituted by voluntary guidelines agreed by the alcohol and advertising industries and the Department of Health and Children. In August 2008, revised and somewhat strengthened Codes of Practice to Control Alcohol Marketing, Communications and Sponsorship were published. And the new Code of Practice of the RRAI, referred to earlier, also contains some stipulations regarding advertising.
The fundamental weakness of the approach that has been adopted in Ireland to controlling alcohol advertising is that it is voluntary, largely self-regulated, and without any real penalties attaching to infringements.
An underlying assumption of the voluntary codes is that the restrictions imposed will reduce the likelihood that advertisements for alcohol `will be targeted at children. However, research has shown that advertisements do not have to be specifically targeted in their content or in where they are placed in order for them to be seen by and have an influence on children and teenagers.18
Another assumption is that restrictions on when and where advertisements may be placed will result in a lowering of the numbers of children and young people exposed to alcohol advertising. This, in effect, implies that it is acceptable that tens of thousands will see, and be influenced by, alcohol promotional material, just as long as the number does not exceed a certain percentage. Such an approach is completely at variance with the UN Convention on the Rights of the Child, to which Ireland is a signatory, which provides that every child under eighteen has an equal right to have his or her health protected from harm.
In September 2008, the Irish College of Psychiatrists called for a complete ban on alcohol advertising, arguing in particular that the high incidence of drinking among young people, and the seriousness of the potential harm to them, warranted this level of response.19 The Government has in the past argued that a ban on alcohol would be contrary to EU law in regard to the free movement of goods and services.20 However, the European Court of Justice has upheld the right of the French Government to pursue a very restrictive approach to alcohol advertising.21
Why Such Permissive Policies?
The very pervasiveness of a culture of heavy drinking in Ireland may, paradoxically, serve to lessen rather than strengthen the willingness of government to take decisive action in terms of putting in place effective policies and implementation structures.
With regard to the public, the concern that does exist has not been of sufficient ‘volume’ to translate into concerted, forceful demand for change. The findings of a public opinion survey commissioned by the HSE in early 2008 give an insight into public attitudes that do nothing to challenge the present inadequate policy response to alcohol problems. Over 90 per cent of the adults questioned acknowledged that teenage drinking was a problem, but only 50 per cent thought they could do something to stop teenagers obtaining alcohol. Even more revealing was the finding that only 15 per cent thought that their own drinking habits influenced young people around them, and just 40 per cent said they would be willing to make changes in these habits in order to pass on a message of responsible drinking to the younger generation.22
With regard to politicians, it can be expected that some will share the widespread permissive attitude towards the typical, but dangerous, pattern of Irish social drinking; other politicians may be concerned about the level and patterns of alcohol consumption but fear that calling for the type of measures which are known to be more effective will not be popular with many sections of the public. However, it is important to note that TDs and Senators who have been part of Joint Oireachtas Committees which have examined aspects of the alcohol issue have been prepared to sign up to strong recommendations regarding the development of policy.23
Irish governments for more than a decade have adopted a ‘partnership approach’, including the involvement of the drinks industry, to addressing alcohol issues. Partnership has also been espoused in other countries – and indeed in the EU. In Ireland, however, the existence of a formal Social Partnership process, which has a significant social policy dimension, has given particular backing to the notion of partnership in relation to alcohol issues and has facilitated the input of the industry.
There are serious drawbacks to this approach. The desire to agree positions acceptable to all partners lessens the chances that strong policy positions will be adopted. Under the Sustaining Progress Partnership Agreement, for example, a Working Group on Alcohol Misuse was established – but its terms of reference precluded it from making the kind of recommendations in regard to pricing, availability and marketing that would have an impact on overall consumption. Furthermore, the partnership approach can give the impression that the Government is but one of several partners in the task of addressing alcohol issues, rather than the body that has ultimate responsibility and authority for framing legislation and policy.
Role of Drinks Industry
The drinks industry has a strong presence in Ireland in terms of investment and employment. As is the case in other countries, as well as at a global level, the industry here has a vested interest in influencing policy on alcohol – and considerable resources to pursue this objective.
The industry argues that the ‘misuse’ of alcohol is not in its interest, and that it wishes to play a constructive role in regard to alcohol policy. It has set up and funds MEAS, which can be described as a ‘social aspects organisation’ of the type the alcohol industry has established in many countries (and at EU and global level) to represent the industry’s interests in policy debate and to undertake information and education initiatives.24
However, the key policy areas in terms of reducing overall consumption – namely, increasing price, restricting availability and limiting marketing – must of necessity involve measures that are not in the interests of the alcohol industry. The industry has consistently displayed its opposition to such measures. It has strongly resisted legislation and regulations in these areas, has argued that it should be allowed to implement and monitor voluntary codes for self-regulation and has promoted policy options which research has shown to be of limited impact. Meanwhile, it has continued to vigorously market and promote alcohol and to maximise sales through reduced pricing.
At a fundamental level, then, there is an unavoidable clash between what must be the core aims of the alcohol industry – to sell its products and maximise its profits – and the demands of public health.
This reality needs to be acknowledged as a starting point in any dealings between government and the drinks industry regarding legislation and policy in respect of alcohol. The duty of government is to protect and promote the right to health of all its citizens, which it has guaranteed to do in signing up to international human rights agreements, such as the Convention on the Rights of the Child and the International Covenant on Economic, Social and Cultural Rights. A further duty is to ensure the efficient use of limited health care resources – and this has to include taking steps to prevent levels of alcohol consumption that lead to illnesses and injuries which place additional demands on services.
Good News at Last?
In 2006, an Oireachtas Joint Committee proposed that alcohol should be included in a new ‘national substance misuse strategy’– in other words, that there be a combined strategy to address issues relating to both alcohol and illicit drug use. Such an approach, the Committee said, ‘would have the effect of cementing alcohol policy at the Governmental level.’ 25
The Committee reached its conclusion on the basis of arguments put forward in a consultants’ report it had commissioned. This highlighted the absence of any permanent structures to give effect to recommendations of official reports on alcohol and the fact that, in contrast, there existed an explicit National Drugs Strategy and an accompanying integrated framework for implementation.26 Within this framework, specific responsibilities regarding the Drugs Strategy are assigned at Cabinet, interdepartmental and departmental levels and there are in existence national, regional and local structures.
For a long time, there seemed little likelihood that this proposal would be accepted, in particular because the drinks industry strongly opposes such an approach. However, on 31 March 2009, it was announced that the Government had approved a proposal, brought to Government by the Department of Community, Rural and Gaeltacht Affairs and the Department of Health and Children, that there be ‘a combined substance misuse policy to include alcohol and drugs’.27
After more than a decade of reports and recommendations but no officially defined policy and no implementation and accountability structures this seems a very positive development. Obviously, it will take time to develop and put in place a combined strategy. And it is more than likely that there will be concerted attempts to delay and modify the proposal.
Now is a time for those politicians, statutory organisations, voluntary and community groups, and ordinary members of the public who share a concern about the current impact of alcohol on Irish society to make known their desire that the promised integrated strategy be put in place as soon as possible, and that the strategy be based on clear public health principles.
The development and implementation of the strategy will require determination and co-operation on the part of government ministers, and across different government departments and statutory agencies. The effectiveness of any strategy will ultimately depend on the willingness of the public to accept the kind of changes required if harmful alcohol consumption – one of the most pervasive and persistent of the country’s health and social problems – is to be tackled.
1. Anushka Asthana and Jamie Doward, ‘Binge Drinking: Do They Mean Us?’, The Observer, Sunday, 21 December 2003.
2. TNS Opinion and Social, Attitudes Towards Alcohol, Special Eurobarometer, 272, Brussels: European Commission, 2007.
3. Björn Hibell, Ulf Guttormsson, Salme Ahlström, Olga Balakireva, Thoroddur Bjarnason, Anna Kokkevi and Ludwig Kraus,The 2007 ESPAD Report: Substance Use Among Students in 35 European Countries, Stockholm: The Swedish Council for Information on Alcohol and other Drugs, 2009. (www.espad.org)
4 Ibid., p. 73.
5. One standard drink is a half-pint of beer or ale, or a glass of wine, or a single measure of spirits.
6. 150 Years of the Annual Report of the Chief Medical Officer: On the State of Public Health 2008, London: Department of Health, 2009.
7. Ann Hope, Alcohol Related Harm in Ireland, Dublin: Health Service Executive, 2008.
8. Department of Health, National Alcohol Policy – Ireland, Dublin: Stationery Office, 1996.
9. Strategic Task Force on Alcohol, Second Report, Dublin: Department of Health and Children, September 2004. The Task Force produced an Interim Report in May 2002.
10. Lila Rabinovich, Philipp-Bastian Brutscher, Han de Vries, Jan Tiessen, Jack Clift and Anais Reding, The Affordability of Alcoholic Beverages in the European Union: Understanding the Link between Alcohol Affordability, Consumption and Harms, Prepared for the European Commission DG SANCO, Cambridge: RAND Corporation, 2009, p. 27.
11. The Scottish Government, Changing Scotland’s Relationship with Alcohol: A Framework for Action, Edinburgh: The Scottish Government, February 2009, p. 11.
12. 150 Years of the Annual Report of the Chief Medical Officer, op.cit., p. 23.
13. Responsible Retailers of Alcohol in Ireland, ‘RRAI Code Implementation’, n. 7. (www.rrai.ie)
14. See Editorial, The Irish Times, 14 May 2009, commenting on the failure to introduce regulations under Section 9 of the Intoxicating Liquor Act 2008.
15. Report of the Government Alcohol Advisory Group, Dublin, 31 March 2008, par. 3.6, p. 11. (www.justice.ie)
16. Peter Anderson, Avalon de Bruijn, Kathryn Angus, Ross Gordon and Gerard Hastings, ‘Impact of Alcohol Advertising and Media Exposure on Adolescent Alcohol Use: A Systematic Review of Longitudinal Studies’, Alcohol and Alcoholism, January 2009, p. 1; p. 14.
17. Documentation obtained under the Freedom of Information Act by the National Youth Federation of Ireland and reported in the media supports the widespread view that this change followed representation by the drinks industry. (The Irish Times, 12 December 2005.)
18. The one Irish study on the impact of advertising found that children and teenagers under eighteen were not just very familiar with alcohol advertisements but ranked them as their favourites. The appeal of the advertisements for the young people lay not in the alcohol product being promoted but in the fact that they were stylish, action-filled, humorous, and portrayed a desirable lifestyle. See Cindy Dring and Ann Hope, The Impact of Alcohol Advertising on Teenagers in Ireland, Dublin: Health Promotion Unit, Department of Health and Children, 2001, p. 38.
19 Irish College of Psychiatrists, Calling Time on Alcohol Advertising and Sponsorship in Ireland: Supporting a Ban on Alcohol Advertising in Ireland, Protecting Children and Adolescents, Policy Paper Prepared by the Faculty of Addiction Psychiatry of the Irish College of Psychiatrists, September 2008. (www.irishpsychiatry.ie)
20. ‘Proposal to Ban Alcohol Adverts is Ruled Out’, The Irish Times, 16 June 2004.
21. Judgments of the European Court of Justice, C-429/02 and C-262/02. (www.europa.eu.int/jurisp)
22. Fiach Kelly, ‘Adults Won’t Change their Habits to Stop Teen Drinking’, Irish Independent, 20 May 2008.
23. Joint Committee on Health and Children, Report on Alcohol Misuse by Young People, 2004; Oireachtas Joint Committee on Arts, Sport, Tourism, Community, Rural and Gaeltacht Affairs, Ninth Report: The Inclusion of Alcohol in a National Substance Misuse Strategy, July 2006; Thirteenth Report: The Relationship between Alcohol Misuse and the Drinks Industry Sponsorship of Sporting Activities, March 2007. (www.oireachtas.ie)
24. See Peter Anderson,The Beverage Alcohol Industry’s Social Aspects Organizations: A Public Health Warning, A Report for EUROCARE (The European Alcohol Policy Alliance), 2004. (www.eurocare.org)
25. Oireachtas Joint Committee on Arts, Sport, Tourism, Community, Rural and Gaeltacht Affairs, Ninth Report: The Inclusion of Alcohol in a National Substance Misuse Strategy, July 2006.
26. The Drugs Strategy has five ‘pillars’ – supply reduction; prevention (which includes education and awareness campaigns); treatment; research; rehabilitation.
27. Department of Community, Rural and Gaeltacht Affairs, ‘Alcohol and Drugs to be Joined in a National Substance Misuse Strategy’, 31 March 2009. (www.pobail.ie)
Margaret Burns is Social Policy Officer with the Jesuit Centre for Faith and Justice.