Influence of Societal Restraints on Alcohol Use and Alcohol‐Related Liver Disease

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Abbreviation

DALY

disability‐adjusted life‐year

Worldwide, alcohol is responsible for 3.3 million deaths each year, which represents 5.9% all deaths, and 5.1% of the global burden of disease and injury is attributable to alcohol, as measured in disability‐adjusted life‐years (DALYs).1 Alcohol is associated with more than 60 health conditions, including liver disease, cardiovascular disease, cancers, and a range of mental health problems, and is strongly linked to violence, accidents, self‐harm, suicide, and fetal alcohol spectrum disorder, impacting both individual drinkers and people who do not drink.1 Evidence indicates that the harmful effects of alcohol are disproportionately concentrated in low‐income and vulnerable groups, indicating that alcohol is a driver of inequalities.2

Alcohol is a psychoactive drug with the potential for inducing dependence. This propensity to dependence and the major harm to others have to be set against arguments about the individual’s right to choose when societal restraints are discussed. Most countries accept that alcohol needs to be regulated in some shape or form, and government regulation is the most effective way to minimize alcohol‐related harm.

The key areas for national action are set out in the World Health Organization’s evidence‐based global alcohol strategy.1 These primary prevention measures include regulating alcohol affordability, alcohol availability, and alcohol promotion.3 Information and education programs, although often a popular choice, have largely been shown to be ineffective in isolation but perhaps will have more effect in combination with a suite of regulatory measures, and may even have a part to play in generating community support for effective alcohol policies.4

International evidence strongly supports the regulation of alcohol affordability as the single most effective measure, and this is equally true of other commodities such as cigarettes (Table 1). A 2009 meta‐analysis, including 112 international studies, found that a 10% increase in price/tax produced a 4.4% decrease in average alcohol consumption.5 Price and tax increases are generally politically unpopular and opposed by alcohol industry bodies and by heavier drinkers who tend to favor cheaper alcohol products.6 However, in many countries, alcohol prices are not keeping up with the cost of living, and alcoholic beverages are becoming ever more affordable. In the United Kingdom it has been estimated that alcohol was 61% more affordable in 2012 than it was in 1980 (Fig. 1).7 The government introduced an alcohol excise duty escalator in 2008, keeping the tax rate 2% above the rate of inflation, and for the first time there was a flattening of the rise in liver disease deaths, but it was abandoned by the government in 2014.6 Setting a floor price is an attractive form of price control because it targets the cheapest drinks that are preferred by the heaviest and most vulnerable drinkers. Minimum unit price is a method where a unit of alcohol (8 g, equivalent to about 0.6 US standard drinks) cannot be sold at less than a certain value. There is no impact on beverages sold at more than that price, and it applies almost exclusively to purchases in liquor stores rather than bars. It has been implemented in Scotland since May 2018, and the outcome on alcohol harm is eagerly awaited.

Table 1.

Strength of Various Interventions in Reducing Health Harm

Group	Intervention	Evidence for Effectiveness
Price	Minimum floor price	+++
	Ban multibuy/loss leaders	+++
	Duty/taxation	+++
Availability	Restrict outlet density/hours	++
	Age verification/test purchase	+
	Health as a licensing objective	++
	Raise minimum drinking age	+/−
Marketing	Statutory regulation	++
	Voluntary regulation/partnerships	−
Information/education	School/higher education programs	+/−
	Point of sale information/labeling	++
Drunk‐driving prevention	Reduction of drunk‐driving	+
Alternative drinks	Lower‐strength alcohol	+/−
Partnerships with alcohol industry		−

Figure 1.

Affordability index by beverage type and location 1987‐2016 (1987 = 100) and the impact of adding a duty escalator (from Institute of Alcohol Studies report 2018 “The Rising Affordability of Alcohol.”

Alcohol has become increasingly available in Western countries, often twenty‐four hours a day, seven days a week. There are a number of ways of restricting the availability of alcohol, but the most effective have been shown to be increasing the legal purchase age, reducing trading hours, and restricting numbers of outlets. For example, studies have found positive associations between alcohol outlet densities and a range of harms including assault and mental health disorders.8

Systematic reviews of the evidence show that exposure to alcohol promotion is associated with the commencement of alcohol consumption among young people and increased levels of consumption among young people who already consume alcohol.9 Control of advertising standards is often overseen by self‐regulating bodies, often with links to trade associations. Although there are rules specifying that alcoholic beverage advertisements cannot suggest sexual or sporting prowess, such principles are often honored more in the breach. In the United Kingdom, it is legal to advertise alcohol in cinemas during films certified as suitable for 12‐year‐olds. Sports sponsorship has expanded since tobacco companies have had to withdraw from such deals, and the alcohol industry has huge power, for example, as a “preferred partner” in events such as the soccer World Cup. Nations have been known to suspend their national laws on alcohol availability to win the right to host it.

Secondary prevention for those beginning to show signs of harm or those in treatment programs is also key to any national harm‐reduction strategy. One key area of concern in many countries is access to trained addiction specialists. With the results of misuse of alcohol, drugs, and food comprising most of the workload of a hepatologist, there is surely a strong case for including addiction training in the hepatologists of tomorrow.