Big Alcohol Knocks Back Medical Clout on Drinking

Ingrid Hein

March 25, 2019

VIENNA — Alcohol should carry warning labels about health risks, the marketing of alcohol directly to the public should be banned, and it should be more expensive, according to specialists in liver disease.

"Cost is the only way you can reduce alcohol consumption," said Roger Williams, MD, from the Foundation for Liver Research in London. "Everyone has tried education; nothing works."

In the fifth report of the Lancet Standing Commission on Liver Disease in the UK (Lancet. 2018;392:2398-2412), Williams and his coauthors ask the British government for a "reintroduction of the alcohol duty escalator, which was highly effective during the 5 years it was in place." They also ask for "the introduction of minimum unit pricing in England, targeted at the heaviest drinkers."

The government has been reluctant to introduce any taxes on alcohol, because the drinks-industry lobby is very powerful. In fact, "it appears the lobby has more sway over government than medical opinion," Williams told Medscape Medical News.

The report and its recommendations, along with other strategies to reduce alcohol consumption, will be discussed at the upcoming International Liver Congress (ILC) 2019.

Alcohol is still the biggest contributor to liver disease in Europe, followed by obesity and hepatitis B and C infection, according to the European Association for the Study of the Liver (EASL) HEPAHEALTH project (J Hepatol. 2018;69:718-735).

Harmful Use of Alcohol Causes 3 Million Deaths Annually

Last September, the World Health Organization reported that alcohol causes 3 million deaths globally every year, which is one death every 10 seconds. To combat alcohol-related health risks, the WHO outlined five high-impact strategies to reduce alcohol consumption: restricting availability, raising taxes, banning advertising, enhancing drunk-driving laws, and facilitating treatment.

The heaviest drinkers are now "the 40- to 50- and 50- to 60-year olds," Williams said, adding that the number of women who drink heavily is rising.

People in these age groups are also at risk for obesity. "If you're overweight or obese, alcohol-related liver disease is worse," he pointed out. "The two are synergistic."

Fortunately, once government does take the lead, it really can be effective, he said. "Smoking is a good example of how policy can affect change."

The duty escalator — introduced in the United Kingdom in 2008, but then repealed for beer in 2013 and for wine, cider, and spirits in 2014 — automatically increased alcohol duties by 2% above inflation every year.

The Duty Escalator, Minimum Unit Price

When the duty escalator was in place, rates of mortality related to alcohol consumption improved in Scotland and, to some extent, England, an analysis of the policy showed (BMJ. 2016;353:i1860). Immediately after the repeals, however, rates started climbing.

Just 4% of the population accounts for almost one-quarter of the alcohol industry's sales, and many of these people drink harmful quantities, according to the Lancet report.

"Then there's the 5% of those who are poor and in a bad environmental situation and are drinking 100 units a day or more," said Williams. "These are the ones we have to target with the minimum unit price; it stops them from drinking all those cheap ciders."

In Scotland, legislation that established a minimum unit price was introduced in 2012, over legal challenges launched by the Scotch Whiskey Association.

Interventions should be targeted at higher-risk groups, said Peter Rice, MD, steering group chair of Scottish Health Action on Alcohol Problems (SHAAP), a project of the Royal College of Physicians of Edinburgh.

In fact, policy interventions that have the greatest effect on populations most in need "may be more useful than the traditional alcohol policy field conceptualizations of whole population and targeted measures," he writes in a recent review of alcohol policies in Europe (Alcohol Alcohol. 2019;ii: agz013).

A minimum unit price specifically targeted at the extreme drinker who develops cirrhosis has a higher likelihood of being effective than tax or duty, Rice explains.

"If we can affect the heaviest drinkers, we can affect the rest of the population," he told Medscape Medical News.

Policy is effective, he said. "We need restrictions on price, availability, and marketing; we cannot treat our way out of Scotland's liver disease."

Clear advice from a physician is a powerful tool.

Rice, who will speak at the congress, said he hopes to inspire advocacy from medical professionals. He said he believes that having doctors get used to having direct conversations with patients about drinking is important.

"Clear advice from a physician is a powerful tool," he said.

But nothing beats doctors getting involved in campaigning. "We need to get busy to advocate for effective prevention. Physicians have effective voices," said Rice. Doctors, physiatrists, and hepatologists really made a difference "in our own debates in Scotland."

He and his colleagues continue to work to ensure that the minimum price keeps up with inflation and market changes. "The government is now committed to reviewing price at a 2-year interval," he reported.

Next, his team will look at pushing for a ban on alcohol marketing. "We increasingly see how sports sponsorship has an effect on people's normalization of consumption," he explained. "We would like to see regulations in sports."

Today, outcomes for patients treated for liver disease are good. "Those who quit drinking do pretty well, as long as there is good support and treatment for them," said Rice.

But, he added, "like most things in medicine, prevention is better than a cure."

Editor's note: This story was updated to correct an error in the death rate cited, which is one every 10 seconds.

Price is the steering group chair of Scottish Health Action on Alcohol Problems. Williams is medical director of the UK Foundation for Liver and heads the Lancet Commission into Liver Disease in the UK .

Follow Medscape Gastroenterology on Twitter @MedscapeGastro and Ingrid Hein @ingridhein

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