Health impacts of drinking and healthy alcohol policy

1. Health impacts of drinking and healthy alcohol policy Professor Jennie Connor Chair in Preventive and Social Medicine University of Otago New Zealand Institute of Liquor Licensing Inspectors 29 August 2019

2. Global Burden of Disease 2010Top 20 global risk factors for loss of health (DALYs)

3. Properties of alcohol • Intoxicating • Toxic • Carcinogenic • Addictive …and legal.

4. Friday Alcohol Consumptionvolume + pattern Monday Wednesday Sunday Friday Tuesday Thursday Saturday

5. Hazardous drinkers (AUDIT score ≥8) among total population, by age group, 2017/18 Ministry of Health 2017/18: New Zealand Health Survey

6. Hazardous drinkers (AUDIT score ≥8) among total population, by age group, 2014/15 Ministry of Health 2014/15: New Zealand Health Survey

7. Hazardous drinking prevalenceTotal adult population, 2006-2016, by sex, AUDIT ≥ 8 % Ministry of Health 2015/16: New Zealand Health Survey

8. Progressive effects of blood alcohol concentration (BAC) Source: National Institute on Alcohol Abuse and Alcoholism

9. “Three bowls do I mix for the temperate: one to health, which they empty first, the second to love and pleasure, the third to sleep. When this bowl is drunk up wise guests go home. The fourth bowl is ours no longer but belongs to hubris, the fifth to uproar, the sixth to prancing about, the seventh to black eyes, the eighth brings the police, the ninth belongs to vomiting, and the tenth to insanity and the hurling of furniture” Dionysus, in play by Greek poet Eubulus, 4th Century BC

12. Patterns of drinking Average volume Intoxication Toxic effects Dependence Acute social problems Chronic Injuries disease (acutedisease) Chronic social problems Adapted from Rehm et al.

13. What about the benefits for your heart?

14. What about the benefits for your heart? 1. The evidence for reduction in heart disease is weak

15. What about the benefits for your heart? 2. Alcohol is the wrong answer to the question of reducing heart disease

16. What about the benefits for your heart? 3. The possible benefits have been promoted by alcohol companies and their paid scientists for decades

18. What about the benefits for your heart? Evidence is weak If true, only for a small number of older people If true, there are safer remedies with more benefit This is an industry message

19. NZ “Burden of alcohol” study = Summary of health impacts of alcohol at a population level for year 2007 The report on “The alcohol-attributable burden of disease and injury in New Zealand” was commissioned by the Alcohol Advisory Council of NZ and published by the HPA. Connor J, Kydd R, Shield K, Rehm J. The burden of disease and injury attributable to alcohol in New Zealanders under 80 years of age: marked disparities by ethnicity and sex. New Zealand Medical Journal 2015;128:15-27 Connor J, Kydd R, Maclennan B, Shield K, Rehm J. Alcohol-attributable cancer deaths under 80 years in New Zealand. Drug and Alcohol Review 2016; DOI: 10.1111/dar.12443

20. Digestive disorders Cholelithiasis Pancreatitis Alcoholic liver cirrhosis Conditions arising during pregnancy Spontaneous abortion Low birth weight Fetal alcohol syndrome Injuries Road traffic injuries Alcohol poisoning Other poisonings Falls Drownings Other unintentional injuries Suicide and self-harm Violence Infectious diseases Tuberculosis HIV Cancers Mouth and oropharyngeal cancers Oesophagus cancer Liver cancer Laryngeal cancer Breast cancer Diabetes Diabetes mellitus Neuro-psychiatric disorders Alcohol use disorders Unipolar depressive disorders Epilepsy Cardiovascular disorders Hypertensive heart disease Ischaemic heart disease Cardiac arrhythmias Oesophagealvarices Stroke, ischaemic or haemorrhagic Conditions included

21. Men (n= 537) Women (n= 265) Premature deaths due to alcohol in NZ in 2007 (802 deaths under 80 years of age) Cancer Injury Other chronic conditions Connor J, Kydd R, Shield K, Rehm J. The burden of disease and injury attributable to alcohol in New Zealanders under 80 years of age: marked disparities by ethnicity and sex. NZMJ 2015;128(1409):15-27

22. pancreas prostate skin (melanoma) stomach Cancer Research UK

23. Risks for heavy drinkers (50g alcohol per day or more) compared with non-drinkers 5x 3x 5x 1.6 x 2x 1.4 x

24. Effects of light drinking • Million women cohort study (Allen, 2009) • 5% increase in total cancer • 13% increase in breast cancer for women drinking 1-2 drinks a day on average compared with none, over 7 years. • Meta-analysis (Bagnardi, 2013) • Increased risk of mouth, pharynx, oesophagus, breast • Not for colorectal, liver, laryngeal cancer • Two U.S. cohort studies (Cao, 2015) • Increased total risk of alcohol-related cancers • Largely due increased breast cancer risk from 1 drink per day

26. Social harms from alcohol Physical harms from alcohol Violence Physical violence Sexual violence risk of violence when perpetrator ± victim is intoxicated severity of family violence and sexual violence when alcohol involved Police report a third of violent offenders have been drinking Harm due to other people’s drinking Traffic injuries, fires Child abuse and neglect Well being of drinkers’ families Property crime, neighborhoods

27. Harm to the drinkers: physical, mental , social • Harm to others by the drinkers: physical, mental, social • Harm to community “amenity”: safety, fear, noise, aesthetics, divisions • Economic harm: increased costs of health services, police, justice system, prisons…. Reduced productivity. Lost opportunities. 3% GDP; $7-8 billion per year

28. What can we do? Reduction in hazardous drinking by individuals is needed to reduce harm…… but individual-level targeted strategies will not be sufficient • Determinants of drinking patterns are not just individual • Connection between population average and hazardous drinking (total consumption model) • Effective individual interventions are unlikely to be offered to, or taken up by, 720,000 hazardous drinkers (i.e. generally not scalable) • Focusing on individuals can be stigmatising • Drinking at lower levels also causes harm

29. The most effective strategies • Pricing and taxation • Regulating availability of alcohol • Regulating alcohol promotion • Drink-driving countermeasures • Treatment and early intervention • and not education and persuasion [Babor et al, 2010]

30. Education and persuasion? Evaluations have been conducted of • Alcohol education in schools • College student education • Public service messages • Warning labels May raise awareness and knowledge but have NO SUSTAINED EFFECT ON DRINKING BEHAVIOUR Useful for increasing acceptance of restrictions and enforcement

32. Increase price Regulate promotion Regulate advertising and sponsorship Increase purchase age to 20 Reduce opening hours Improved treatment

33. The price of alcohol “The public is not in the mood for more taxes” Excise tax (Law Commission 2010) 50% tax increase = 10% increase in price of all alcohol products = 5% reduction in consumption Minimum Unit Pricing (Ministry of Justice 2014) e.g. $1.20 minimum per standard drink Only affects cheap alcohol $9 for a bottle of wine

34. Pricing and taxation Consumption of alcohol in the UK relative to its price 1960-2002

35. Minimum Unit Pricing (MUP) Scotland 3% drop in 2018 the first year of 50p MUP

36. Regulating availability • Reduced hours and days of sale • Limits on density of outlets • Restricting places of sale • Increasing minimum legal purchase age

37. The Newcastle ‘experiment” +2% -34% Hamilton - postcode area 2303 (control site) CBD - postcode area 2300 (intervention site) Kypri et al (Addiction 2010)

38. Purchase age Imposing an age law, or raising it, results in less consumption and fewer car crashes in those affected by the change. Enforcement is needed [Babor et al, 2000] Law Commission recommended 20 years, as it was prior to 1999, because of evidence of harm since then. Car Crashes:  Increases in the incidence of traffic injury attributable to male 15- to 19-year-old alcohol-impaired drivers, short-term and up to 10 years later. Smaller short-term effects in women. Weekend hospitalized assaults: Lowering the minimum alcohol purchasing age increased weekend assaults resulting in hospitalization among young males 15 to 19 years of age. No effect seen in women Kypri K, Davie G, McElduff P, Langley J, Connor J. Long‐term effects of lowering the alcohol minimum purchasing age on traffic crash injury rates in New Zealand. DAR 2017;36:178-85. Kypri K, Davie G, McElduff P, Connor J, Langley J. Effects of lowering the minimum alcohol purchasing age on weekend assaults resulting in hospitalization in New Zealand. AJPH 2014; 104:1396-401.

39. Regulation of marketing • There have been major changes and intensification of marketing in the last 20 years, particularly social media • Policy is usually self-regulation, with voluntary codes for content but not for amount of exposure (as in NZ) • Research shows exposure of children to marketing of alcohol is harmful, and it contravenes the UN Convention on the Rights of the Child. • The Law Commission recommended staged process of getting rid of all promotion except product information, after extensive public support (2300 out of 3000 submissions) • The Ministerial Forum on Alcohol Advertising and Promotion (2014) recommended major change

42. Sale and Supply of Alcohol Act (2012) I want to reduce harm, especially crime and victimisation, caused by heavy episodic drinking. I do not, however, want to unduly inconvenience low and moderate drinkers. My reform proposals therefore target those who drink excessively, particularly at licensed premises and in the public domain. [Simon Power in cabinet paper on reform] No increased tax (or price control) Minor changes to availability No control of supermarket sales No policy on purchase age No major change to on-licence hours Minor restriction to off-licence hours No control of promotion or marketing [No reduction in adult legal BAC limit]

43. Health Sponsorship Council Survey 2010 %

44. The most effective strategiesWhat are we using? • Pricing and taxation • Regulating availability of alcohol • Reduced hours and days of sale • Limits on density of outlets • Restricting places of sale – supermarkets and convenience stores • Increasing minimum legal purchase age • Regulating alcohol promotion • Drink-driving countermeasures • Lower BAC and enforcement • Treatment and early intervention [Babor et al, 2010]

45. Why aren’t we doing this? Motivation • Large burden of physical, mental, social, economic harm • Systematic differences between Māori and non-Māori • Failure to protect children Strategies • Outlined in Law Commission report (2010); MFAAS (2014) Barriers • Political (neoliberal) ideology and coalition government • Industry influence • Trade treaties

46. jennie.connor@otago.ac.nz