RCPI Policy Group on Alcohol - 12 November Minutes Minutes

Frederick House 19 South Frederick Street, Dublin 2 Telephone: +353 1 863 9700 Facsimile: +353 1 672 4707 Website: www.rcpi.ie

Minutes- Meeting of RCPI Policy Group on Alcohol Date and Time

12 Nov 2013 at 5pm

Location

RCPI, No 6 Kildare St, Dublin 2 (Winter Hall)

Chair

Prof Frank Murray

Attendees

Prof Joe Barry, Dr Turlough Bolger, Dr Blanaid Hayes, Dr Marie Laffoy, Prof Aiden McCormick, Prof Frank Murray, Dr Stephen Stewart, Prof Bill Tormey RCPI- Kate Healy, Mairead Heffron

Apologies

Dr Declan Bedford, Dr Bobby Smyth, Dr Eimear Smith, Dr Deidre Murphy, Dr Kieran O’Shea

1. Minutes Agenda Item 1.0 Review of Actions of last meetings and update on progress.

Discussion/Agreement/Action Arthur’s day Looking at the success of the Arthur’s day campaign (In particular the difference that a prominent voice makes- Christy Moore), it was suggested that the policy group should try to partner with high profile people, for example engagement with sportspeople. Stephen Stewart spoke about his participation in an event organised by the GAA, and noted that the GAA has a dedicated resource available to members for advice on their drinking.

Action: Kate to investigate how/who to engage with within the GAA on this.

Political engagement Frank Murray and other members of the group met a number of times with Alex White over the last number of months. Frank Murray highlighted how successful this has been, and how it has been welcomed by Minister Alex White. In this engagement, the stated aim has always been that the policy group provides support to Government in making difficult decisions.

Action: This engagement should continue North South engagement was discussed. It was noted that ISG, represented in the policy group by Aiden McCormick, is an all island body. Aiden highlighted that the Minister for Health in NI is very interested in reducing alcohol harm.

Action: More North South engagement to be pursued.

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RCPI Policy Group on Alcohol 12/11/13

Agenda Item

Discussion/Agreement/Action Additional issues raised: Homelessness and Alcohol Harm Bill Tormey highlighted this issue, and proposed that the group look more into this issue, gathering data on this through organisations working with the homeless, including hostels for homeless with alcohol problems.

Other members of the group noted that many people end up homeless as a result of alcohol harm- so action to address alcohol consumption and harm should have a positive impact downstream on reducing homelessness.

The issue of Alcohol and Suicide was also brought up, and suggested that the group should draw attention to this. It was noted that alcohol is often used as a surrogate for counselling.

(Mairead sent information to the group on Alcohol Action Ireland’s conference on Alcohol and Mental Health on Nov 20th) Treatment Services Joe Barry suggested that the group focus on recommendation from the NSMS on services, and look to where the group can make recommendations/suggestions to improve services, for alcohol treatment etc. This would also contribute to reducing the alcohol factor in homelessness. 

Gaps in treatment guidelines:

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At present, doctors give list of treatment centres, but little or no follow up.

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Alcohol nurse specialist needed

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Need to detail what the service would look like

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How follow up is done

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Should look at Kieran Moriarty’s report on Alcohol, related disease from UK for guidance (alcohol structure, liver team)

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ISG has looked at how consultants respond when patient presents with alcohol problems. Whether they refer them for treatment etc. Stephen to share this report

Action : Draft statement on treatment services to be produced Impact of Alcohol Abuse on Children JB proposed the group should also look at this issue. It was mentioned that it would be opportune to release something around Junior Cert results or around national children’s day.

The impact of FASD was also mentioned.

Action: Mairead to work with Turlough Bolger on statement (in advance of International children’s day on 20th Nov)

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RCPI Policy Group on Alcohol 12/11/13

Agenda Item

Discussion/Agreement/Action

Health Warnings 

Provided for in new legislation



Should be of sufficient size (readable)

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JB noted that the current recommendations on labelling (part of the public health alcohol bill) are recommendations dating from 2008.

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The group is not in agreement on the decision of the government to require alcohol content to be described in grams on alcoholic products. Some feel that units is clearer. There is also some disagreement as to whether the new (lower low risk guidelines) are appropriate.

Suggestion that it makes more sense to use UK units (8g) and recommendations.

Toxin Tax BT suggested that the group should lobby for an EU wide toxin tax (EU wide tax on alcohol). It was suggested that contact should be made with Paschal Donohue (FG TD and Minister for European Affairs) on this.

Action: Mairead to investigate how to progress this.

Engagement with Judiciary FM met with Assistant Commissioner John Twomey of the Gardai- Dublin Met Region to discuss enforcement of alcohol related legislation. Ass Comm Twomey stated that the gardai often have difficulty in getting appropriate penalties against premises who break licensing laws (sale to minors etc).

Commercial/economic interests may be prioritised over public health interests. He suggested it might be useful for RCPI to engage with judiciary on this.

There was some discussion on legislation and enforcement in relation to purchase etc by minors. Many of the group feel that focus should be on those who sell, rather than the purchasers (criminal conviction for a minor for a one-time infringement of law related to alcohol may be a bit heavy-handed, but repeated infringements should be dealt with in a stronger way). It was however discussed that there is a feeling that infringement of licensing laws and public order (drunkenness) can be done with impunity, and this should be addressed.

Action: Engagement with judiciary to be pursued. BT also mentioned that meetings need to be held with president of district court.

It was suggested that a public meeting where judiciary is invited would also be useful.

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RCPI Policy Group on Alcohol 12/11/13

Agenda Item

Discussion/Agreement/Action

City level action on alcohol 

Galway city alcohol strategy was circulated to those at the meeting. Also available online here



City council should object to licences for premises in certain cases, but does not. This should be addressed.

Action: BT to find out who to influence in city to reduce alcohol harm (who group should engage with).

Communications priorities

2.0 Framework for Future Actions.

3.0 Discussion on future statements

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MUP- political engagement to make progress towards a MUP and preparing public for MUP

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Engagement with sports people/organisations n how to drink without putting yourself in danger.

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Communication with medical professionals re treatment

Framework (see below) to guide the policy group on 

What group wants to say (policy statements)

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Who group says it to

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How the message is communicated.

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Who to partner with to achieve this

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What are the gaps in data/research

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When actions should happen

Proposed future statements a. Development of a recommendation on a MUP b. Number of outlets and outlet densities c. Health Warnings on alcohol d. Alcohol treatment guidelines. e. Alcohol in pregnancy f.

Impact of alcohol on children

g. Advertising and alcohol h. Recommendation on a toxin tax across Europe i.

Alcohol and Homelessness

j.

Other suggestions

Action: Mairead to circulate table of future statements and ask each member to rank the above list according to priority. This subject would then be developed into a paper.

See below (p6-p 9) for summary of evidence on some of Page 4 of 10

RCPI Policy Group on Alcohol 12/11/13

Agenda Item

Discussion/Agreement/Action these issues.

4.0

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Date of next meeting proposed as Tuesday 14th Jan

Frederick House 19 South Frederick Street, Dublin 2 Telephone: +353 1 863 9700 Facsimile: +353 1 672 4707 Website: www.rcpi.ie

2. Framework for Future Actions.

Position Paper

Advocacy and Engagement

Tools

Partnerships

Research

What does the policy group want to say?

(Understand and define the issue)

Who does the group want to reach – and what is the specific message for each group?

How to reach them.

Who to partner with. Could lead to statements of support for initiatives, Joint events, statements?

What are the information gaps/opportunities (RCPI research dept may become involved)

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General Public (raise awareness of alcohol health harm)

    

Alcohol Action Ireland

Research into a recommendation on a MUP

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Recommendations of main policy statement of April 2013 Pre-budget submission Future statements

Government (identify who exactly to influence)

 Eu level and City Council level DoH Gardai Judiciary Media Decision makers in HSE Medical Professionals

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

Traditional Media Social Media Public meetings RCPI Website Meetings with key government stakeholderswhen should this happen.

Engagement with committees.

Meetings with key stakeholders

 Engagement meetings have already been held.  Education for Gardai in general on alcohol harm?

Professional engagement (RCPI as professional body- education etc) Meet with key media contacts to raise their own awareness of alcohol harm.

Meetings with key stakeholders  Educational activities  RCPI internal communication

RCP UK North-South engagement Galway City Alcohol Strategy GAA ISG

Data on alcohol related illnessresearch.

Research partnerships.

Frederick House 19 South Frederick Street, Dublin 2 Telephone: +353 1 863 9700 Facsimile: +353 1 672 4707 Website: www.rcpi.ie

3. Evidence on a MUP  10% increase in the minimum price of alcohol = 3.4% decrease in total alcohol consumption, British Columbia (1), (2)  Introduction of MUP (increase of 10% in MUP) in Saskatchewan reduced alcohol consumption by 8,4% total alcohol consumption (3) Information needed in Ireland: 

   

MUP should reduce consumption, but with bigger impact on hazardous or harmful drinkers than on moderate drinkers. To propose a MUP that will have the required effect on consumption, we need to know: Distribution of alcohol consumption (to determine the % of the population in the different categories of drinker- especially what % are harmful drinkers) The % of alcohol sold at a low price, and who buys it (the category of drinker).

Price elasticity for different categories of drink It’s also necessary to use a risk function to determine alcohol harms associated with decreased levels of consumption.

In the UK, through the UK modelling by the University of Sheffield (England and UK), they used the General Lifestyle Survey (GLF) and the Living Cost and Foods Survey (LCF) to get this information (including expenditure diaries). In Scotland, the Scottish Health survey was also used to look at consumption distribution.

In the Republic, alcohol consumption figures have largely been drawn from Revenue Commissioners’ alcohol clearances data. The CSO Household Budget Survey also has information:  From the HBS, we know average household expenditure on different types of alcohol, broken down by rural and urban households; drink consumed at home and out; by income deciles; by region; by household tenure. This is published in a report (HBS 2009-2010).  There are research papers proposing how HBS could be used to estimate food consumption (4). The same could be done for alcohol. Note: Expenditure info is recorded by inclusion of receipts.

The minister for Health has said that a health impact assessment has been commissioned “in conjunction with Northern Ireland, is being commissioned as part of the process of developing a legislative basis for minimum unit pricing. The assessment will study the impact of different minimum prices on a range of areas such as health, crime and likely economic impact”.

1. Zhao J, Stockwell T, Martin G, Macdonald S, Vallance K, Treno A, et al. The relationship between minimum alcohol prices, outlet densities and alcohol-attributable deaths in British Columbia, 2002-09. Addict Abingdon Engl. 2013 Jun;108(6):1059–69.

2. Stockwell T, Auld MC, Zhao J, Martin G. Does minimum pricing reduce alcohol consumption? The experience of a Canadian province. Addict Abingdon Engl. 2012 May;107(5):912–20.

3. Stockwell T, Zhao J, Giesbrecht N, Macdonald S, Thomas G, Wettlaufer A. The raising of minimum alcohol prices in Saskatchewan, Canada: impacts on consumption and implications for public health. Am J Public Health. 2012 Dec;102(12):e103–110.

4. http://www.cso.ie/en/media/csoie/surveysandmethodologies/documents/pdfdocs/Expanding_HBS_Jul_06.pdf

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RCPI Policy Group on Alcohol 12/11/13 4. Evidence on Alcohol Control, Outlet Density and Alcohol Harm There is evidence that that availability of alcohol and control of alcohol sales, and number of outlets has an effect on  Consumption  Alcohol harm  Violence related to alcohol A number of systematic reviews have been conducted on this in recent years: 

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A 2012 review (1) published in the American Journal of Preventative medicine concluded from reviewing 17 studies assessing the impact of privatisation (where government control of alcohol sales is relaxed) of alcohol sales that the privatisation of alcohol sales leads to an increase in alcohol consumption. Across the 17 studies, there was a 44.4% median increase in the per capita sales of privatized beverages in locations that privatized retail alcohol sales.

Another 2012 (2)review of 26 studies, while stating that findings were not conclusive, and advising that further study be carried out, concluded that there was some indication that higher outlet density and greater exposure to advertising in a local community may be associated with an increase in alcohol use, particularly among adolescents.

A 2009 (3)review of forty-four studies on density of alcohol outlets and 15 studies found that that alcohol outlet density and hours and days of sale had an impact on one or more of the three main outcome variables, such as overall alcohol consumption, drinking patterns and damage from alcohol.

A 2007 study (4)reviewing literature on effect of outlet density, show that outlet density and bunching are likely to have effects on rates of binge drinking on alcohol related injuries and violence, and other short term consequences. The same study does not find clear evidence on effects of outlet density on alcohol consumption levels and long term alcohol related health problems.

Other recent studies showed links between outlet density and alcohol harm 

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A 2013 British Columbia study (5)looking at both MUP and outlet density found that increases in the minimum price of alcohol in British Columbia, Canada, between 2002 and 2009 were associated with immediate and delayed decreases in alcohol-attributable mortality. By contrast, increases in the density of private liquor stores were associated with increases in alcoholattributable mortality. A 10% increase in private liquor stores was associated with a 2.45% in acute, chronic and total AA mortality rates Another 2013 (6)of 1,816 Block Groups in Philadelphia showed that a strong and positive association between alcohol outlet density and violence remained after controlling for alcohol expenditures and the density of other retailers thus arguing that the association is not due solely to alcohol availability or to retail density. The authors suggest that there is something unique about alcohol outlets or their density that makes them crime generators and links them to violence.

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RCPI Policy Group on Alcohol 12/11/13 1. Hahn RA, Middleton JC, Elder R, Brewer R, Fielding J, Naimi TS, et al. Effects of alcohol retail privatization on excessive alcohol consumption and related harms: a community guide systematic review. Am J Prev Med. 2012 Apr;42(4):418–27.

2. Bryden A, Roberts B, McKee M, Petticrew M. A systematic review of the influence on alcohol use of community level availability and marketing of alcohol. Health Place. 2012 Mar;18(2):349–57.

3. Popova S, Giesbrecht N, Bekmuradov D, Patra J. Hours and days of sale and density of alcohol outlets: impacts on alcohol consumption and damage: a systematic review. Alcohol Alcohol Oxf Oxfs. 2009 Oct;44(5):500–16.

4. Livingston M, Chikritzhs T, Room R. Changing the density of alcohol outlets to reduce alcohol-related problems. Drug Alcohol Rev. 2007 Sep;26(5):557–66.

5. Zhao J, Stockwell T, Martin G, Macdonald S, Vallance K, Treno A, et al. The relationship between minimum alcohol prices, outlet densities and alcohol-attributable deaths in British Columbia, 2002-09. Addict Abingdon Engl. 2013 Jun;108(6):1059–69.

6. Grubesic TH, Pridemore WA, Williams DA, Philip-Tabb L. Alcohol outlet density and violence: the role of risky retailers and alcohol-related expenditures. Alcohol Alcohol Oxf Oxfs. 2013 Oct;48(5):613–9.

5.

Evidence on Health Warnings on Alcohol The new Irish legislation- labelling on alcohol to include: “ Health warnings and advice (including for pregnancy) on all alcoholic drink containers (bottles, cans etc.) and on promotional materials, and the amount of pure alcohol as measured in grams and the calorie count contained in each container/measure on the label/container. There are no plans at the moment to stipulate that any additional information be displayed on the label.”

WHO- Global Status Report on Alcohol (2004) says “research regarding warning labels on bottles is rather ambiguous at this stage, with most of the evidence (primarily from the United States, Canada and Australia) suggesting no change in the perception of risk among people who have taken note of the label, and only few studies suggesting behaviour change that could be attributed to the label (Edwards et al., 1994). Some studies show that warning labels do raise levels of awareness. However, the impact of the current warning labels on perceptions of risk and drinking habits is modest, partly due to poor label designs and weak wording” NSMS recommendation is for clear health warnings, and health warnings on consumption of alcohol in pregnancy, and information on calorific content. A 2007 Eurobaromenter report on public attitude towards alcohol shows strong public support for alcohol warnings.

In 20 countries warnings on labels are mandatory, and vary in type and size. Thailand has proposed graphic warnings linking alcohol and suicide, for example (yet to be passed by government) Research papers on Health Warnings  A 2013 paper published in the European Journal of public health (1) said “Current evidence seems to support prompt inclusion of a list of ingredients, nutritional information (usually only kcal) and health warnings on labels. Standard drink and serving size is useful only when combined with other health education efforts. A definition of 'moderate intake' and recommended drinking guidelines are best suited to other contexts”

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RCPI Policy Group on Alcohol 12/11/13   

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Another 2013 study in (2)Germany concluded that warning labels had an influence on the college-aged people they participating in the study.

A 2012 paper(3) found little conclusive evidence that labeling is effective in changing alcohol-related beliefs and behaviours in adolescents.

A 2009 study (4)highlighted that alcohol warning labels are an increasingly popular alcohol policy initiative but can be ineffective. However, the authors suggested that based on the tobacco experience, effective warning labels are possible.

An older study in Detroit in 1993 (5) of over 4000 pregnant women found that warning labeling resulted in lighter drinkers consuming less alcohol, but pregnant risk drinkers did not reduce their consumption significantly.

1. Martin-Moreno JM, Harris ME, Breda J, Møller L, Alfonso-Sanchez JL, Gorgojo L. Enhanced labelling on alcoholic drinks: reviewing the evidence to guide alcohol policy. Eur J Public Health. 2013 May 8; 2. Glock S, Krolak-Schwerdt S. Changing Outcome Expectancies, Drinking Intentions, and Implicit Attitudes toward Alcohol: A Comparison of Positive Expectancy-Related and Health-Related Alcohol Warning Labels. Appl Psychol Heal Well-. 2013 Jul 29; 3. Scholes-Balog KE, Heerde JA, Hemphill SA. Alcohol warning labels: unlikely to affect alcohol-related beliefs and behaviours in adolescents. Aust N Z J Public Health. 2012 Dec;36(6):524–9.

4. Wilkinson C, Room R. Warnings on alcohol containers and advertisements: international experience and evidence on effects. Drug Alcohol Rev. 2009 Jul;28(4):426–35.

5. Hankin,J.R.,Firestone, I.J.,Sloan,J.J.,Ager,J.W.,&etal.(1993).The impact of the alcohol warning label on drinking duringpregnancy. Journal of Public Policy&Marketing,12(1),10-10

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