Reflections on science and the governance of alcohol policy.

Abstract

To consider, briefly, science's role in informing alcohol policy, and how science could help reframe the present governance of alcohol policy.
Expression of the two project coordinators' reflections based on discussions during project meetings of the Alcohol Measures for Public Health Research Alliance (AMPHORA) project.
Three endeavours are considered important for science's role in informing alcohol policy: modelling studies that help predict the outcomes of differing policy approaches; studying the impact of live policy changes as a powerful set of natural experiments; and, improved study of the impact of integrated, coordinated and joined up alcohol policies, as opposed to the impact of individual alcohol policy measures. Three areas where science can contribute to strengthened alcohol policy governance include: analysis of different governance architectures that might promote joined-up actions between different sectors; the design of better metrics that measure the impact of public and private sector actions on health; and, by identifying incentives that help consumers make choices on the use of alcohol that improve health.
The impact of science on better alcohol policy governance can only happen if there is more and better dialogue between scientists and those who design alcohol policy.

Full text

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Reflections on science and the governance of
alcohol policyadd_3350 67..70
Peter Anderson1& Antoni Gual2
Public Health, Public Health Consultant, Girona, Spain1and Alcohol Unit, Psychiatry Department, Neurosciences Institute, Hospital Clínic, Barcelona, Spain2
ABSTRACT
Aims
present governance of alcohol policy. Design
sions during project meetings of the Alcohol Measures for Public Health Research Alliance (AMPHORA) project.
Results
Three endeavours are considered important for science’s role in informing alcohol policy: modelling studies
that help predict the outcomes of differing policy approaches; studying the impact of live policy changes as a powerful
setof naturalexperiments;and,improvedstudyof theimpactof integrated,coordinatedandjoinedupalcoholpolicies,
as opposed to the impact of individual alcohol policy measures.Three areas where science can contribute to strength-
ened alcohol policy governance include: analysis of different governance architectures that might promote joined-up
actions between different sectors; the design of better metrics that measure the impact of public and private sector
actions on health; and, by identifying incentives that help consumers make choices on the use of alcohol that improve
health. Conclusions
The impact of science on better alcohol policy governance can only happen if there is more and
better dialogue between scientists and those who design alcohol policy.
To consider, briefly, science’s role in informing alcohol policy, and how science could help reframe the
Expression of the two project coordinators’ reflections based on discus-
Keywords
Alcohol policy, European Union, science.
Correspondence to: Peter Anderson, Apartat de Correus 352, 17230 Palamos, Spain. E-mail: peteranderson.mail@gmail.com
Submitted 13 December 2010; final version accepted 15 December 2010
BACKGROUND
The European Union (EU), an integrational entity of 27
Member States, could be viewed as an ongoing political
andeconomicendeavourripeforscientificstudy[1].Cur-
rently, and in health terms, Europe faces at least the fol-
lowing three alcohol-related challenges:
1. A high level of alcohol consumption, alcohol-related
harm and loss of life, compounded by enormous dif-
ferencesinalcohol-relatedlifeexpectancybetweendif-
ferent parts of the Union [2]. The true value of each
year of lost life may be as much as one-third of Euro-
pean gross domestic product (GDP) [3].
2. Anenormoussocialcost,drainingtheproductivity[4]
andsocialcohesionof Europethatmitigatestheobjec-
tives of the Lisbon treaty [5].
3. Alcohol-related harm compounded by the economic
recession [6], leading to an upturn in deaths from
alcohol-use disorders [7].
In these concluding comments, based on reflections
anddiscussionsthatwehavehadinAlcoholMeasuresfor
Public Health Research Alliance (AMPHORA), we briefly
consider, first, science’s role in informing alcohol policy,
and secondly, how science could help to reframe the
present governance of alcohol policy.
SCIENCE’S ROLE IN INFORMING
ALCOHOL POLICY
Theevidencebaseforalcoholpolicyispowerfulandstrong
[8,9],infactprobablymoresothaninmanyotherareasof
publichealthpolicy[10].Wethinkthattheroleof science
is more to advise on how to make and implement current
alcohol policy more effectively rather than what policy to
implement.Sciencehasidentifiedwhattodoandwhatnot
todo;weneedanemphasisonfinetuningandimplemen-
tation. Among other scientific endeavours, we highlight
the following three as important.
Modelling studies
Modelling studies help predict the outcomes of differing
policyapproaches.ClassicexamplesherearetheSheffield
modelling studies for the Department of Health in
England [11], the National Institute for Health and Clini-
cal excellence (NICE) in the United Kingdom [12] and the
CONCLUSION
doi:10.1111/j.1360-0443.2010.03350.x
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Scottish government [13]. For example, the estimates for
theDepartmentof Healthdemonstratethepowerof such
models in comparing the impact of an overall 10%
increase in the price of alcoholic beverages with setting a
minimum price per gram of alcohol [11].
The model estimated that a 10% increase in the price
of alcoholic beverages would reduce alcohol consump-
tion by 4.4%, an average reduction of 5.5 g alcohol per
week, with a significantly greater reduction of 25 g per
week for harmful drinkers (defined as men who drink
morethan400 galcoholperweekandwomenwhodrink
more than 280 g/week) than the 4 g/week reduction for
moderate drinkers (men who drink up to 168 g alcohol
per week and women who drink up to 112 g/week). The
model estimated that in England (population 51 million)
the annual number of deaths would fall by 232 within
the first year and by 1681 after 10 years. In addition,
hospital admissions would decline by an estimated
10 100 in the initial year, reaching full effect after 10
years with 50 800 avoided admissions annually. The
model also predicted that a 10% price increase would
reduce the number of criminal offences by 65 000 over
the course of a decade, with savings in the direct costs of
crime of €80 million per year. In the work-place, it was
anticipated that the same intervention would mean
12 800 fewer unemployed people and 310 000 fewer
sick days over 10 years. The estimated total value of this
price increase is €8.9 billion over the 10 years modelled.
The direct cost to consumers would vary significantly
among different types of drinkers. The overall figure is
€38 per drinker per annum, ranging from an estimated
€132 annually for harmful drinkers to €19 for moderate
drinkers. The effect ‘on the pocket’ if there were no
change in consumption was estimated at €254 per year
for harmful drinkers and €30 for moderate drinkers.
In England, 59% of the alcohol sold for consumption
elsewhere (‘off trade’) and 14% of the alcohol sold for
consumption on the premises (‘on trade’) is sold for less
than €0.06/g of alcohol. The Sheffield model was able to
estimatethatsettingaminimumpriceof €0.06/galcohol
would reduce overall consumption by 2.6% (3.4 g reduc-
tion per week), affecting harmful drinkers tremendously
more (25 g/week) than moderate drinkers (0.01 g/
week). The model estimated the value of these harm
reductions to society as €6.2 billion over 10 years. If no
changes were made to consumption, such a minimum
price would cost harmful drinkers an estimated addi-
tional €157 per annum and moderate drinkers €7.
Natural experiments
Studying the impact of policy changes is a powerful set of
natural experiments. Unfortunately, and perhaps shame-
fully,naturalexperimentsarerarelyandpoorlystudied.A
classic exception to this has been cross-border trade in
Finland [14,15]. Finland joined the EU in 1995, and was
given until 2003 to lift its restrictions on alcohol imports.
Afterthatdate,alcoholimportswereexpectedtoincrease
heavily, not only because the borders were opening, but
alsobecauseneighbouringEstonia,withitsloweralcohol
prices, was scheduled to join the EU in 2004.The Finnish
government therefore decided to lower the alcohol taxes
byanaverageof 33%inMarch2004.Totalconsumption
of alcohol per capita increased by 10%, from 9.4 litres in
2003 to 10.3 litres in 2004. Recorded consumption
increased by 6.5%, from 7.7 litres to 8.2 litres per capita,
while unrecorded—and thus untaxed—consumption
increased an estimated 25%, from 1.7 litres to 2.1 litres
percapita.Whilethehealthimpactof Estonia’saccession
was not significant for Finland, the health impact of the
Finnishalcoholtaxcutswere,resultingina17%increase
in alcohol-positive deaths per week [14], with the largest
number of deaths occurring among the underprivileged
[15]. Tax revenues also dropped by 17%. In 2008,
Finland again raised its alcohol taxes.
Integrated alcohol policy
Policydocumentscallrepeatedlyforcomprehensive,inte-
grated, coordinated and joined-up alcohol policy [16].
However, and surprisingly, we actually have very little
evidence for the impact of the interactions between dif-
ferent alcohol policy elements and the added value of
joined-upalcoholpolicy.Europeisanidealtestingground
for such studies, given the heterogeneous and changing
nature of alcohol polices between European Member
States. Where this has been studied is the United States,
which also provides a natural setting of heterogeneous
alcohol policies between the states. Since the repeal of
Prohibition in 1933, two different kinds of alcohol
control systems have restricted the alcohol market in the
United States. Control states adopted more restricted
control systems, which included state-owned monopolies
on segments of the market. Licence states adopted less
regulated control policies, in which all parts of the
marketwerelicensedtoprivatecompanies.Controlstates
usually provide fewer outlets for retail sales, often restrict
credit card purchases and concurrent sales of alcohol
with other commodities (e.g. forbidding sales in grocery
and convenience stores) and sometimes restrict days of
sale and operating hours. In the past, control states have
also set significantly higher minimum legal drinking
ages.
Thus, one might expect that the price elasticity of the
demand for alcohol is lower in control states, which leads
to higher transaction costs in association with purchases
of alcohol, implying that the full price of an alcoholic
beverage (i.e. the transaction cost plus the nominal cash
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Peter Anderson & Antoni Gual
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price of the beverage) is higher in this type of market
compared to a less regulated and restricted market. Con-
sequently, higher transaction costs are likely to lead to
lower price elasticities, as consumers are assumed to
react primarily to changes in the full price of the bever-
ages. This has been found to be the case. A study of
alcohol price elasticities in control and licence states in
theUnitedStatesfortheperiod1982–1999foundsignifi-
cant price elasticities of –0.25 for spirits and –0.07 for
beer, but not for wine (-0.02) in the licence states, but
insignificant elasticities in the control states (0.014 from
spirits, 0.001 for beer and 0.03 for wine) [17].The differ-
ences in elasticities for spirits and beer between control
and licence states were significant.
REFRAMING ALCOHOL POLICY
GOVERNANCE
With regard to reducing the harm caused by alcohol,
there is a puzzling asynchronization when it comes to the
governance and implementation of effective alcohol
policy.Ononehand,poorhealthandprematuredeath(of
which some 8% is due to alcohol) present a threat to
European wellbeing and development, and the financial
burden that these impose diverts essential monies that
could have dealt with other risks facing the EU.They also
continue to be grossly undervalued in their centrality to
human, business and social capital development. On the
other hand, there is little evidence that different sectors
arecooperatingtoachieveimprovedhealthandtoreduce
theharmcausedbyalcohol.Theconceptof ‘stewardship’
implies an obligation to provide conditions that allow
people to be healthy and, in particular, to take measures
to reduce health inequalities [18]. Science can also con-
tribute to strengthened alcohol policy governance. We
mention a list of three possible areas.
Architecture
As the paper in this supplement by Kønig & Segura [19]
has shown, for an action plan to reduce alcohol-related
harm to be effective it is necessary to ensure that the
requisite infrastructure for policy development, priority-
setting,monitoringandsurveillance,researchandevalu-
ation, work-force development and programme delivery
is all in place. Despite some advances in building core
infrastructure for action on alcohol, it can be argued that
there continues to be insufficient political will and invest-
ment by both the private and the public sector in many
Member States, and ensuring that this infrastructure is
sufficiently large and capable remains a challenge. There
is also evidence that good infrastructure can facilitate
the effective implementation of an alcohol action plan,
while its absence can be an obstacle. Although vested
interests—whether from the political, business, health-
care or academic sectors—can also be barriers to action,
they can be overcome by effectively utilizing existing
infrastructure or developing new infrastructure. This
may require new forms of alcohol policy governance
architecture to ensure policy coherence and joined-up
actions between different sectors that can be analysed
and studied from a policy science perspective [20].
A health footprint
Healthandwellbeing,andalcohol’scontributiontothese,
are grossly undervalued as central and crucial to human
productivity and individual and social capital develop-
ment and there is an enormous awareness gap [3,4]. One
of the problems is that individuals, communities, busi-
nesses and countries have no ready, simply understood
metric of the impact of their actions and inactions on
promotingornegatinghealth,andalcohol’skeycontribu-
tion to this. A health footprint, modelled on the carbon
footprint (which is the total set of greenhouse gas emis-
sionsfromanindividualororganization,eventorproduct,
expressed in the metric carbon dioxide equivalent) could
be developed as a summary metric from existing metrics
produced by science [21] including, for example, global
burden of disease, population health modelling and the
chronic disease model of the National Institute for Public
HealthandtheEnvironmentof theNetherlands.Thefoot-
print could measure how much alcohol-related health
and wellbeing is being created or diminished, and could
act as an incentive and measurement tool for change.
Measurementandpublicdisplayof alcohol-relatedhealth
impacts could act as an incentive to create new ways of
working by countries, municipalities and producers.
Incentives
Incentives and stimuli are needed to help realign the
actions of all government sectors, international organi-
zations, the private sector and individuals towards
alcohol-related healthier outcomes. Building on many
of the recognized incentives across sectors, stimuli for
change are needed to support governments in their
alcoholpolicyreformulationandactions,helpingthemto
realign existing resources to ensure that subsidies do not
distort alcohol consumption patterns in a way that affect
health and wellbeing negatively [5]. Governments also
need to create frameworks and incentives for healthier
products and services and healthier choices throughout
the whole value chain to reduce alcohol-related harm.
Governments and businesses outside the alcohol sector
canbestimulatedtoutilizescience,newtechnologiesand
social entrepreneurship to improve health literacy and
developmetresandgaugesforindividualusethatprovide
real-time feedback on purchasing decisions and daily
Reflections
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actions that promote health and wellbeing. For example,
a universal system of symbols backed by rigorous metrics
to inform shoppers about the health footprint of alcohol
products on the shelves and an intelligent shopping-
basketthatmonitorsthehealthimpactof alcohol-related
shopping choices could be designed to help nudge people
in the direction of healthier choices and to improve an
individual’s alcohol-related health footprint [22].
CONCLUSIONS
AMPHORA’s scientific studies will inform alcohol policy,
and hopefully lead to better alcohol policy governance in
Europe. One of AMPHORA’s strengths which will con-
tribute particularly to this process is a series of science
policy dialogues. Research appears to be most influential
in setting a policy agenda and considering policy alter-
natives, less influential when amending draft laws and
least influential in decision-making. We hope that the
science policy dialogues, meeting-grounds between the
AMPHORAscientistsandthosewhoworkinministriesof
health, the first of which will take place in Spain during
June 2010, the second in Switzerland in 2011 and
the third in Denmark in 2012, will help to address this
imbalance.
Declarations of interest
None.
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Addiction, 106 (Suppl. 1), 67–70