European Economic and Social Committee

SOC/340 Alcohol related harm

Brussels, 30 September 2009

OPINION
of the European Economic and Social Committee on How to make the EU strategy on alcohol related harm sustainable, long-term and multisectoral (Exploratory opinion) _____________ Rapporteur: Ms van Turnhout _____________

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Rue Belliard/Belliardstraat 99 1040 Bruxelles/Brussel BELGIQUE/BELGI Tel. +32 25469011 Fax +32 25134893 Internet: http://www.eesc.europa.eu

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In a letter dated 18 December 2008, in the context of the forthcoming Swedish Presidency of the European Union, the Swedish Minister for European Affairs asked the European Economic and Social Committee to draft an exploratory opinion on the following subject: How to make the EU strategy on alcohol related harm sustainable, long-term and multisectoral. The Section for Employment, Social Affairs and Citizenship, which was responsible for preparing the Committee's work on the subject, adopted its opinion on 1 September 2009. The rapporteur was Ms van Turnhout. At its 456 plenary session, held on 30 September 2009 and 1 October 2009 (meeting of 30 September 2009), the European Economic and Social Committee adopted the following opinion by 128 votes to 5 with 4 abstentions. * * 1. 1.1 Summary and recommendations Drawn up in response to a request by the Swedish Presidency to the EESC, this exploratory Opinion focuses on how to make the EU strategy on alcohol related harm sustainable, longterm and multisectoral1. The goal of the Swedish Presidency is to support the implementation of the horizontal EU alcohol strategy and the establishment of long-term preventive work at both EU and national level. This Opinion builds on the previous EESC Opinion on alcohol related harm, which looked at five priority themes: protecting children; reducing alcohol related road accidents; preventing alcohol related harm among adults and in the workplace; information, education and raising awareness; and common evidence base2. The Opinion highlights the following four priorities of the Presidency: the impact of advertising and marketing on young people; the influence of price on the development of damage; children in focus specifically foetal alcohol spectrum disorder and children in families; and
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Multisectoral is defined as "covering several sectors, including civil society, trade unions and business". EESC opinion of 30.05.2007 on "An EU strategy to support Member States in reducing alcohol related harm", rapporteur Ms van Turnhout, Co-rapporteur : Mr Janson, OJ C 175 of 27.7.2007.

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-3 the effects of harmful alcohol consumption on healthy and dignified ageing.

to achieve a comprehensive approach, all of the themes dealt with in both opinions and other relevant matters should be taken together. 1.4 Drinking patterns vary significantly across countries, but most consumers drink responsibly most of the time (see 3.2)3. Having said that, the EESC is concerned that 15% of the EU adult population are estimated to drink at harmful levels on a regular basis, and that children are the most vulnerable to the harms caused by alcohol. Policy measures should be designed to reach those already drinking at harmful levels. Alcohol marketing is one of the factors that increases the likelihood that children and adolescents will start to use alcohol, and will drink more if they are already using alcohol. Given this, the EESC calls for a reduction in the exposure of children to alcohol marketing. Appropriately designed alcohol pricing policies can be effective levers in reducing alcohol related harm, particularly among low income and young people. The EESC believes that regulation governing the availability, distribution and promotion of alcohol is needed; selfregulation in this area is not enough. To raise awareness about the risk of Foetal Alcohol Spectrum Disorder (FASD), the EESC supports national and EU level awareness-raising campaigns. The EESC believes that more information is needed about the effects of harmful alcohol consumption on healthy and dignified ageing at an EU level. The EESC recognises that alcohol policies should be comprehensive and include a variety of measures for which there is evidence of reducing harm. Background The European Union has competence and responsibility to address public health problems related to harmful and hazardous alcohol use on the basis of article 152 (1) of the Treaty 4, which states that Community action shall complement national policies. Following the Council Recommendation of 2001 on the drinking of alcohol by young people5, it invited the Commission to follow and assess developments and the measures taken, and to report back on the need for further actions.
Konnopka, A & Knig, H-H, The Health and Economic Consequences of Moderate Alcohol consumption in Germany 2002, in: Value in Health, 2009 Treaty establishing the European Community. Council recommendation of 5 June 2001 (2001/458/EC).

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In its Conclusions of June 2001 and of June 2004, the Commission was invited to put forward proposals for a comprehensive Community strategy aimed at reducing alcohol-related harm which would complement national policies6. In 2006, the Commission adopted the Communication: An EU Strategy to support member states in reducing alcohol related harm7. It aims to "map actions" put in place by the Commission and Member States, and explains how the Commission can further supports and complements national health policies. The EESC believes that the Communication falls far short of a comprehensive strategy8 as it does not provide a comprehensive and transparent analysis of all the relevant policy areas and of the difficulties some Member States have experienced in maintaining quality public health alcohol policies due to EU market rules9. The Strategy also fails to acknowledge that alcohol is a psychoactive drug, a toxic substance when used to excess, and, for some, an addictive substance. The European Court of Justice has repeatedly confirmed that reducing alcohol related harm is an important and valid public health goal, using measures deemed appropriate and in accordance with the principle of subsidiarity10. The EESC acknowledges the work performed by all relevant stakeholders within the European Alcohol and Health Forum since its launch in 2007. The EESC welcomes similar developments at local levels. Overview of harmful effects Globally, the European Union is the region where most alcohol is consumed, with 11 litres of pure alcohol consumed per person each year11. Overall consumption declined between the 1970s and mid-1990s, since when it has remained relatively stable; however there are still

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Council Conclusions of 5 June 2001on a Community strategy to reduce alcohol-related harm (OJ C 175, 20.06.2001, p. 1) and Council Conclusions of 1 and 2 June 2004 on alcohol and young people (not published in the OJ). COM(2006) 625 final. See footnote 2. Ibid. Franzen case (C-89/95), Heinonen case (C-394/97), Gourmet case (C-405/98), Catalonia (joined cases C-1/90 and C179/90), Loi Evin (C-262/02 and C-429/02). "Alcohol in Europe, a public health perspective" Report for the European Commission by P. Anderson and B. Baumberg, Institute of Alcohol Studies, June 2006.

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-5differences between countries in terms of both consumption and harm, also in terms of the form the harm takes12; however, harmful drinking patterns remain significant13. 3.2 Most consumers drink responsibly most of the time. However, the EESC is concerned that 55 million adults in the EU (15% of the adult population) are estimated to drink at harmful levels on a regular basis14. Harmful alcohol consumption is estimated to be responsible for approximately 195 000 deaths a year in the EU due to accidents, liver disease, cancers and so forth. Harmful alcohol use is the third biggest cause of early death and illness in the EU15. The EESC believes that harmful alcohol consumption by individuals is not a problem that develops in isolation, but rather one that can have a variety of causes including poverty, social exclusion, family environment, and work-related stress. While different cultural habits related to alcohol consumption across Europe exist, it can also be observed that different cultural habits related to harmful and hazardous alcohol consumption, including among children and adolescents, exist16. The EESC urges the Commission and the Member States to take account of these national and local patterns when defining policies. Children are particularly vulnerable to harms caused by alcohol. It is estimated that in the EU 5 to 9 million children in families are adversely affected by alcohol. Alcohol is a causal factor in 16% of cases of child abuse and neglect, and an estimated 60 000 underweight births each year are attributable to alcohol17. Harmful alcohol consumption can cause harm not only to the individual but also to third persons. Alcohol-related harm should also be addressed in the workplace, in the framework of health and safety regulations, which is primarily the responsibility of the employer. Workplace alcohol policies could help reduce alcohol-related accidents, absenteeism and increase working capacity. The EESC urges employers, trade unions, local authorities and other relevant organisations to closely cooperate and to undertake joint actions to reduce alcohol-related harm in workplaces.

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EESC opinion of 30.05.2007 on "An EU strategy to support Member States in reducing alcohol related harm", rapporteur Ms van Turnhout, Co-rapporteur : Mr Janson, OJ C 175 of 27.07.2007 See footnote 11 More than 40 g of alcohol, i.e. 4 drinks a day, for men and over 20 g, i.e. 2 drinks a day, by women. Alcohol-related harm in Europe - Key data October 2006, Brussels, MEMO/06/397, 24 October 2006. ESPAD survey, 2007 See footnote 11.

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-63.7 Alcohol is an important commodity in the Europe creating jobs, generating revenue through taxes and contributing to the balance of trade. However, harmful alcohol drinking also affects the economy, due to increased health care and social costs, and loss of productivity. The cost of alcohol related harm to the EUs economy was estimated at EUR 125 billion for 2003, equivalent to 1.3% of GDP18. The impact of advertising and marketing on young people The EESC urges the Commission to acknowledge the WHO European Charter on Alcohol 19 adopted by all EU Member States in 1995 and, in particular, the ethical principle that all children and adolescents have the right to grow up in an environment protected from the negative consequences of alcohol consumption and, to the extent possible, from the promotion of alcoholic beverages. The EU Council recommendation urged Member States to establish effective mechanisms in the field of promotion, marketing and retailing and to ensure that alcohol products were not designed or promoted to appeal to children and adolescents. Binge drinking by young adults (15-24 years) is a growing concern at EU and Member State level; 24% of drinkers in this age group reported binge drinking at least once a week in 200620. Beer (40%) and spirits (30%) are the most often consumed alcoholic drinks among teenagers21, followed by wine (13%), alcopops (11%)22 and cider (6%). Alcohol sales promotions such as "happy hour" and "two for one" promotions also increase alcohol consumption and the likelihood of binge drinking among youth23. As a step forwards, the stricter enforcement of legal drinking age by authorities is required. 4.4 Alcohol advertising and marketing are influential in shaping young peoples attitudes to and perceptions of alcohol, and encouraging positive expectations of alcohol use amongst young people24. A review of longitudinal studies by the Science Group of the European Alcohol and Health Forum found consistent evidence to demonstrate an impact of alcohol advertising on the uptake of drinking among non-drinking young people, and increased consumption among

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DG SANCO World Health Organisation European Charter on Alcohol (1995). See footnote 11 The 2007 ESPAD Report (2009). Alcopop is a term used to describe bottled alcoholic beverages that resemble drinks such as soft drinks and lemonade. Independent Review of the Effects of Alcohol Pricing and Promotion (2008). Scientific Opinion of the Science Group of the European Alcohol and Health Forum (2009) and Impact of Alcohol Advertising and Media Exposure on Adolescent Alcohol Use: A Systematic Review of Longitudinal Studies (2009).

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-7their drinking peers. This finding is all the more striking, given that only a small part of a total marketing strategy has been studied25. 4.5 The EESC is concerned that alcohol marketing attracts underage drinkers 26, and draws attention to consistent findings that exposure to television and sponsorship that contains alcohol predicts the onset of youth drinking and increased drinking27. The WHO Expert Committee considered that voluntary systems do not prevent the kind of marketing which has an impact on younger people and that self-regulation seems to work only to the extent that there is a current and credible threat of regulation by government28. Actors in the alcohol beverage chain have declared their willingness to be more proactive in enforcing regulatory and self-regulatory measures29. They have a role in working together with the Member States to ensure their products are produced, distributed and marketed in a responsible manner, contributing to reduce alcohol related harm. The Audiovisual Media Services Directive helps set minimum standards for alcohol advertising. It specifies that "[]alcohol advertisements shall [...] not be aimed specifically at minors, shall not link the consumption of alcohol to enhanced physical performance, social or sexual success and shall not claim that it is a stimulant, a sedative or a means of resolving personal conflicts"30. The EESC believes that this Directive alone is not sufficient to fully protect children from alcohol marketing. The EESC urges that a reduction in the exposure of children to alcohol products, advertising and promotions be stated as a specific objective by the Commission, and that tighter regulation in this area be introduced. The influence of price on alcohol related harms There is increasing pan-European interest in measures to combat alcohol related harms. Alcohol is an important commodity in Europe, creating jobs, generating revenue through taxes and contributing to the EU economy through trade. However, an estimated 15% drinks

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See footnote 24, part 1 See footnote 11. Ibid. WHO Expert Committee on problems related to Alcohol Consumption, 2nd Report, 2007. COM(2006) 625 final. The affordability of alcoholic beverages in the European union: understanding the link between alcohol affordability, consumption and harms (2009).

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-8at harmful levels generating harm for individuals and societies. In 2003, the cost of alcohol misuse in the EU was estimated at EUR 125 billion, equivalent of 1.3% GDP31. 5.2 Based on the RAND study, there is a trend across the EU towards more off-trade alcohol consumption, which tends to be cheaper than alcohol sold on-trade32. However, it should be noted that the study focused only on off trade alcohol prices and did not compare off trade prices to on trade prices. Studies show that alcohol became more affordable across the EU between 1996 and 2004, in some countries by more than 50%33. Evidence shows that there is a positive relationship between alcohol affordability and alcohol consumption in the EU34. 5.4 Young people are sensitive to alcohol price increases, which lead to reduced frequency of drinking among young people and, to smaller quantities drunk in each drinking event35. However, other studies show that young people may turn to more harmful drinking patterns in response to price increase, e.g. pre-drinking36 where people consume cheaper alcohol at home before going out. This finding has important implications for alcohol policy in the EU, particularly given the increase in harmful youth drinking. An estimated 3.8% of all global deaths and 4.6% of global disability-adjusted life-years are attributed to alcohol. There is a positive relationship between alcohol consumption and traffic injuries and traffic deaths37. Alcohol is the sole cause of some diseases such as alcoholic liver disease and alcohol-induced pancreatitis, and is a contributory cause of other diseases and injuries (e.g. certain types of cancer, heart disease and strokes and liver cirrhosis) 38. Harmful alcohol consumption is a contributory factor for crime, violence and family deprivation, risky sexual behaviour and sexually transmitted disease39.
DG SANCO 2006. See footnote 11. On-trade refers to pubs, clubs, restaurants and other retailers selling alcohol for consumption in the venue; off-trade refers to supermarkets and off-licences, selling alcohol for consumption elsewhere. Affordability is measured by looking at the net effect of price and income. See footnote 30. Modelling the Potential Impact of Pricing and Promotion Policies for Alcohol in England: Results from the Sheffield Alcohol Policy Model Version 2008(1-1).. Alcohol Price and Consumer Behaviour. Market Research, by IPSOS Belgium (2009). See footnote 30. "Global burden of disease and injury and economic cost attributable to alcohol use and alcohol use disorders", The Lancet, (2009). "Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol", The Lancet (2009).

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It is estimated that across the EU heavy episodic drinking contributes to 2 000 homicides, 17 000 traffic deaths (or one in three of all traffic fatalities), 27 000 accidental deaths and 10 000 suicides40. Alcohol pricing policies can be effective levers in reducing alcohol related harms 41. The EESC nevertheless believes that pricing policy should be considered when developing strategies to address alcohol related harm in a long-term, sustainable and multi-sectoral way. Alcohol policies should be comprehensive and include a variety of measures for which there is evidence of an impact in reducing harm, such as drink drive policies and primary health based interventions. The EESC recognises that no single measure can solve alcohol related harm. The EESC believes that efficient enforcement of regulation governing the availability, distribution and promotion of alcohol is needed. Self-regulation in this area is part of the solution, but in itself not sufficient. Restrictions on sales below cost and on sales promotions should be possible without being trade restrictive or in contravention with EU law. Children in focus specifically foetal alcohol spectrum disorder and children in families The destiny of Europe depends on a healthy and productive population. The evidence that a higher proportion of the disease burden from harmful and hazardous alcohol consumption is experienced by young people is therefore of grave concern to the EESC42. The Commission recognises that children have a right to effective protection against economic exploitation and all forms of abuse43. The EESC strongly supports this position. The EESC notes that harmful and hazardous alcohol consumption impacts negatively not only on the drinker but on people other than the drinker, especially in relation to accidents, injuries and violence. In families, the EESC recognises that the most vulnerable group at risk are children. It is estimated that 5 to 9 million children in families are adversely affected by alcohol, that alcohol is a contributing factor in 16% of cases of child abuse and neglect, as well as

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See footnote 11. WHO Global Status Report: Alcohol Policy, (2004). See also "Paying the tab. The costs and benefits of alcohol control (2007)", and footnotes 35 and 37 See footnote 11 COM(2006) 367 final.

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- 10 contributing to an estimated 60 000 underweight births each year44. Further negative effects for children include poverty and social exclusion, which can affect their health, education and well-being both now and in the future. 6.6 Domestic violence, a serious problem in many countries45, is strongly linked to problems of heavy drinking by the perpetrator46. While domestic violence can occur in the absence of alcohol, heavy drinking can contribute to violence among some people. A reduction in heavy drinking benefits the victims and perpetrators of violence, and the children living in such families. 6.7 Alcohol can affect children even before they are born. Foetal alcohol spectrum disorder (FASD) describes a continuum of permanent birth defects (physical, behavioural and cognitive) caused by maternal consumption of alcohol during pregnancy. Awareness about FASD and its effects is low. Disseminating evidence-based examples of preventive programmes to reduce alcohol harm during pregnancy is critical. The EESC supports the use of targeted EU and national Government campaigns to raise awareness about the risk of FASD. The effects of harmful alcohol consumption on healthy and dignified ageing Older people are more sensitive to the effects of alcohol. Specific problems include balance and risk of falling and the onset of health problems that can make older people more susceptible to alcohol. About a third of older people develop drinking problems for the first time in later life, often due to bereavement, physical ill-health, difficulty getting around and social isolation47. Harmful alcohol consumption can affect older peoples mental health in the form of: anxiety, depression and confusion. Alcohol Use Disorders are common among older people, particularly among males who are socially isolated, and living alone48. Problematic alcohol use is associated with widespread impairments in physical, psychological, social and cognitive health. Around 3% of those over
See footnote 11. EESC own-initiative opinion of 16.03.2006 on "Domestic violence against women" rapporteur Ms Heinisch, OJ C 110 of 09.05.2006 and EESC own-initiative opinion of 14.12.2006 on "Children as indirect victims of domestic violence" rapporteur Ms Heinisch, OJ C 325 of 30.12.2006. See footnote 11. See Royal College of Psychiatrists, UK, http://www.rcpsych.ac.uk/mentalhealthinfoforall/problems/alcoholanddrugs/alcoholandolderpeople.aspx
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"Alcohol use disorders in elderly people: redefining an age old problem in old age", British Medical Journal, (2003).

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- 11 65 years suffer from these disorders49, though many cases may go undetected as diagnostic criteria and screening are directed at younger adults. However, treating older people for alcohol problems is often easier than treating younger adults. 7.4 Alcohol can add to the effects of some medications, and reduce the effects of others. Raising awareness among care professionals, informal carers and older citizens of potential interaction between medication and alcohol is important. The EESC believes that more needs to be done to address the wellbeing of the ageing population in the EU, including information about the effects of harmful alcohol consumption on healthy and dignified ageing at an EU level.

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Brussels, 30 September 2009. The President of the European Economic and Social Committee

Mario Sepi

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Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders) project, (2004).

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