Memorandum by the British Society of Gastroenterology
and the British Association for the Study of the Liver (AL 20)
1. INTRODUCTION
1.1 This paper is a joint response by the
British Society of Gastroenterology (BSG) and the British Association
for the Study of the Liver (BASL) to the Health Select Committee
Inquiry on Alcohol. Specialist representatives from the BSG and
BASL would welcome the opportunity to give oral evidence to the
Committee.
1.2 The BSG exists to maintain and promote
high standards of patient care in gastroenterology and hepatology
and to enhance the capacity of its members to discover, disseminate
and apply new knowledge to the benefit of patients with digestive
and liver disorders. Founded in 1937, the BSG has over three thousand
members drawn from the ranks of physicians, surgeons, pathologists,
radiologists, scientists, nurses, dietitians, and others interested
in the field.
1.3 BASL has been in existence for 40 years
and has over 400 members. It has a focus on clinical and scientific
aspects of liver disease and is dedicated to understanding of
the biology and pathology of the liver. BASL complements the activities
of BSG and together with the BSG, is the primary body representing
the views of UK hepatologists. BASL membership also reflects the
broad group of clinicians and scientists dedicated to advancement
in liver disease.
2. EXECUTIVE
SUMMARY
2.1 The scale of alcohol related ill health
and mortality in the UK is rising in comparison with other European
countries such as Spain, Italy and France. The costs to the NHS
are estimated to be £2.7 billion. The Government's approach,
through self regulation, has been largely ineffectual despite
the weight of opinion pointing to price being the most effective
driver of change.
2.2 The alcohol industry has been a dominant
force in the debate over alcohol in recent years and has succeeded
in pushing the Government towards education based approaches to
alcohol harm. The effectiveness of such campaigns is debateable
and there is a need to further restrict the marketing and promotion
of alcohol.
2.3 The NHS must prioritise alcohol related
illness through a National Liver Plan as quickly as possible to
ensure specialist liver services are in place and early detection,
intervention and treatment is prioritised.
2.4 The BSG and BASL are calling for a combined
approach of an increase in alcohol duty and a minimum price per
unit of alcohol to protect harmful drinkers and fund alcohol services.
3. THE SCALE
OF THE
PROBLEM
3.1 According to the most recent analysis
published in July 2008[120]
liver disease is the most common cause of alcohol related death
in men and women between the ages of 35 and 75 in England. Death
certification data reveals that more than 80% of UK liver deaths
are due to alcohol related cirrhosis.[121]
Liver disease and liver deaths are the most reliable barometer
of alcohol related ill health and mortality in the UK. While the
wine drinking countries of Southern Europe always had historically
very high levels of liver deaths from alcohol related cirrhosis
(figure1); deaths in these countries have been dropping, whereas
UK deaths are still increasing inexorably.
3.2 The UK finally overtook Spain, Italy
and France for liver deaths in 2004—the year that the UK
Government finally published the long awaited alcohol strategy.
This strategy was criticised by health campaigners at the time
because it appeared to put the interests of alcohol producers
and retailers above the health of UK citizens. At the time of
publication the Cabinet Office's Strategy Unit estimated the cost
of alcohol misuse to the NHS in England at £1.4-1.7 billion.
In 2008 the same team recalculated these costs to the NHS at £2.7
billion.
Figure 1
Liver death rates in the UK compared to France,
Spain and Italy—countries with historically extremely high
liver death rates. Data from the WHO Health For All database.[122]
3.3 Much of the alcohol debate and media
attention has since centred on the problems of binge drinking
amongst young people, and in particular the link between alcohol
use and anti-social behaviour. The degree of loss of life at all
ages caused by alcohol has generally escaped the attention of
the media, and in particular the fact that young people have the
highest proportion loss of life from alcohol related causes—more
than 26% of deaths in males aged 16 to 24 are due to alcohol (figure
2 ).[123]
3.4 The most recent publication by the Office
of National Statistics revealed that since 2004 deaths in males
aged 15 to 34 increased by 2.5%, and in females of the same age
by 24%—for all age groups figures showed an increase of
5% for males, and 7% for females.[124]
Figure 2
The proportion of all deaths that are due to alcohol
at various ages, the levels of deaths in younger patients are
staggeringly high. Data appears on the DH website.[125]
Thus, between 17-27% of all deaths are due to alcohol between
the ages of 16 to 54 years.
4. THE CURRENT
APPROACH BY
GOVERNMENT
4.1 There is no evidence that current Government
approaches have worked so far in terms of reducing either alcohol
related deaths or hospital admissions.
4.2 Alcohol policy has been intensely studied,
and there is a large evidence base for the policies that work.
The subject has been subjected to a number of independent expert
reviews commissioned by; the World Health Organisation,[126]
the European Commission[127]
and the UK Academy of Medical Sciences.[128]
The findings of these reviews are all entirely consistent and
show universally that the key drivers to alcohol related harm
are cheap alcohol, easy availability of alcohol, and the promotion
and marketing of alcohol by industry. There are also underlying
cultural differences in the patterns of alcohol related harm,
which in many cases are centuries old.
4.3 More recently the UK Government have
commissioned further expert reviews on self regulation by the
alcohol industry,[129]
the role of price and promotions[130]
and the effectiveness of education based approaches to change
harmful drinking behaviours.[131]
The findings of these studies are also entirely consistent with
the previous expert reviews. Self regulation does not work, and
low prices and cheap promotions are the key reversible factor
in the dramatic increases in alcohol related harm seen in the
UK.
4.4 For liver disease—the evidence
linking UK liver deaths to the affordability of alcohol is incontrovertible—the
correlation between the two is 0.98—as can been seen in
figure 3, the two are clearly linked. This direct link is the
result of two factors in the clinical evolution of alcohol related
liver disease.
4.5 First, one needs to drink a lot of alcohol,
the equivalent of more than 4 bottles of wine a week, for more
than 10 years to get liver disease.
4.6 Second, many liver deaths occur largely
as a result of alcoholic hepatitis, and therefore a reduction
in drinking has an immediate effect on mortality.
Figure 3
Changes in UK liver death rates are closely related
to the affordability of alcohol .[132]
5. EDUCATION,
SOCIAL MARKETING
AND THE
ROLE OF
INDUSTRY
5.1 As reviewed most recently by NICE—there
is very little evidence, even in young people, that education
based approaches promoted by the alcohol industry and favoured
by the Government reduce alcohol related harm.[133]
The somewhat cynical view being that this is the precise reason
that they are so favoured by the alcohol production and retail
industries. According to the DH, 25% of the UK population are
hazardous or harmful drinkers, but this minority consumes 75%
of alcohol sales. This phenomenon is well described in other countries,[134]
, [135]and
means that the alcohol production and retail industries rely on
hazardous and harmful drinkers to supply three-quarters of their
profitability. One therefore has to question the motivation of
the alcohol industry to reduce alcohol related harm, and their
central role in policy making so far.
5.2 The role of education and social marketing—namely
the use of commercially derived marketing approaches to improve
health related behaviours—is however somewhat paradoxical.
On one side of the health debate, industry claims that education
based approaches are effective, but that their own promotional
activities do not increase the consumption of alcohol. Whereas
the health lobby claims that education based approaches are completely
ineffective, but that the promotional activity of industry has
deleterious consequences in terms of alcohol, consumption, and
in particular teenage drinking. It is likely that the truth lies
between these two polarised positions, there is a mounting body
of evidence that when used correctly, social marketing is an effective
tool.[136]
It is only recently that the government has tried to stigmatise
drinking in the same way that smoking is now stigmatised with
adverts showing the shameful and embarrassing effects of being
drunk. Similarly a large body of evidence shows that alcohol marketing
has a deleterious effect on the drinking behaviour of young people.[137],
[138]The
independent Science Group of the EU Commission recently reviewed
the impact of alcohol marketing communications on young people
and the verdict was clear:[139]
"it can be concluded from the studies reviewed that alcohol
marketing increases the likelihood that adolescents will start
to use alcohol and to drink more if they are already using alcohol".
5.3 The largest fall in EU liver deaths
has occurred in France which has tight restrictions on alcohol
marketing—the "Loi Evin". Alcohol advertising
is banned on TV, in cinemas and at sporting events, print advertising
is permitted but "messages and images should refer only to
the qualities of the products such as origin, composition and
means of production".
6. THE ROLE
OF THE
NHS AND OTHER
SERVICES
6.1 Services for patients with liver disease
have developed in an unplanned manner as an offshoot of general
gastroenterology, and many liver patients are managed at District
General Hospital level by general gastroenterologists, many of
whom have had no training in a specialised liver unit. The service
structure developed at a time when liver disease and death from
liver was relatively uncommon and the 10 fold increase in young
liver deaths over the last 30 years[140]
has not been matched by the development in services needed to
cope. The DH is aware of the situation with regard to liver services
and there appears to be agreement within the DH that a Liver Strategy
is urgently needed. The BSG and BASL are currently drafting a
National Plan for Liver Services which it is hoped will feed into
this new strategy when commissioned.
6.2 As reviewed in the recent NAO report[141]
health services for alcohol misuse are, if anything, in a worse
state than liver services. This is largely the result of two factors.
Firstly, subjects with substance misuse issues are not seen as
coming under the remit of general mental health services—but
are seen as needing specialist addiction services. Secondly, specialist
addiction services under the control of the National Treatment
Agency and the associated network of Drug Action Teams are all
geared almost entirely to the treatment of drug misuse. The pooled
treatment budget for these services in 2009-10 will be £406
million.[142]
This has resulted in a bizarre situation in which the waiting
time for treatment for drug offences is two to three weeks, whereas
for patients with potentially fatal alcoholic liver disease the
waiting time for an assessment is over six months. This effectively
means that alcohol treatment services do not exist in many areas.
Figure 4
As can be seen from the survival curves in subjects
with liver cirrhosis, there are two phases of liver deaths. Early
deaths within the first few weeks can only be prevented by preventing
liver disease from developing in the first place. Whereas late
deaths after the first year are almost entirely related to continued
drinking behaviour, and can be decreased by improved treatment
of alcohol addiction.[143]
7. THE EFFECTIVENESS
OF DETECTION,
INTERVENTION AND
TREATMENT SERVICES
7.1 Figure 4 illustrates that many patients
with liver disease die before they get the chance to stop drinking;
if the DH are serious about decreasing the rising tide of liver
deaths in the UK we need to prevent people from developing serious
liver disease. There are two evidence based methodologies for
doing so: making alcohol less affordable through increases in
taxation, or early intervention in heavy drinkers before they
develop problems.[144]
The latter is the more expensive option, and combinations of the
two options, together with restrictions on alcohol promotions/availability
and increased measures against drink driving are the most effective
on a global scale.
Figure 5
Modelling of effective alcohol policy by the World
Health Organisation[145]
8. WHAT WOULD
AN EFFECTIVE
UK ALCOHOL STRATEGY
LOOK LIKE?
8.1 The distinction between the Northern
European culture of binge or feast drinking and the Southern European
culture of regular heavy drinking with meals has been long recognised.[146],
[147]There
is no precedent for actively changing the drinking culture of
one nation into that of another, although in the UK at the present
time we have superimposed a regular drinking Mediterranean culture
on top of our underlying Anglo-Saxon binge drinking culture, and
we are reaping the consequences in terms of liver deaths.
8.2 The recent increase in alcohol related
problems in the UK can largely be explained by the reduction in
the relative price of alcohol, combined with the massively increased
marketing of alcohol—largely directed at young people—that
occurred from the early 1990's onwards. The UK alcohol industry
currently spends around £800 million on promotion—compared
with tiny sums on social marketing. Much tighter regulation of
promotion is urgently needed with serious consideration given
to a UK version of the French "Loi Evin".
8.3 The increased burden of alcohol related
health issues has put an intolerable strain on the provision of
alcohol services, and the increase in services that are required
should be matched by additional funding either from general taxation,
from a reduction in other NHS services, or from an increase in
levels of duty on alcohol.
9. RECOMMENDATIONS
9.1 Increase in the duty on alcohol
A gradual year on year increase in the duty
on alcohol would solve both problems. As we have already seen,
three quarters of the alcohol sold is drunk by hazardous and harmful
drinkers, and so duty increases would fall predominantly on those
at risk whose consumption in any case needs to be reduced. The
impact of duty increases on truly moderate drinkers would be negligible—even
more so when staged over a number of years.
Figure 6
Modelling of the reductions in illness and deaths
that would result from various levels of minimal price/unit of
alcohol.[148]
9.2 Minimum price for a unit of alcohol
Recent increases in alcohol duty have on the
whole not been passed on to customers by the large retailers,
including supermarkets—suppliers have been squeezed instead.
Increasing duty on its own does not ensure that the problem of
cheap booze will be remedied. The solution to this would be to
introduce a minimum price for a unit of alcohol. This policy option
has been extensively modelled for the Department of Health, and
has also been proposed by the Scottish Government. It has the
merit of protecting revenues of the alcohol industry, but the
disadvantage of not raising the additional revenue for the NHS
and other services. A combination of the two options, stepped
duty increases and a minimum price, provides the most comprehensive
solution to the UK alcohol problem, and restores a much needed
level of control to the health consequences of the alcohol free-market.
There is a delicate balance between the price of alcohol and the
cost of alcohol to UK society—the balance simply needs to
be redressed.
9.3 National Plan for Liver Services
BSG and BASL strongly support the decision to
develop a National Liver Plan and urge that the management of
patients with alcoholic liver disease is at its heart.
9.4 Improved alcohol support services
The time of first presentation is a period of
opportunity for personal reform. There is a desperate need to
invest in effective support services for alcoholics, particularly
at a time of first diagnosis. Revenue from increased duty on alcohol
should be used for this purpose, whether or not the tax is specifically
hypothecated.
This response was drafted on behalf of the British
Society of Gastroenterology (liver section) and the British Association
for the Study of the Liver. This response has been co-ordinated
with the formal responses from the Royal College of Physicians,
and the Alcohol Health Alliance. Specialist representatives from
the BSG and BASL would welcome the opportunity to give oral evidence
to the Committee.
March 2009
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