1

Report fortheDepartment ofHealth

AlcoholLiteratureReview

By

DrAnn Hope

Target Health Ltd

June2014
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Department of Health

Alcohol LiteratureReview

DrAnnHope,Target HealthLtd.

This briefing document has been prepared in response to arequest from the Department

of Health toconductan alcohol literature reviewand updatetheevidencecontained in the

NationalSubstanceMisuse Strategy,inthecontextof thedraft Public Health(Alcohol) Bill.

Thereport incorporatesthelatest Irishand International research evidenceonalcohol

consumption and harm. It alsopresents the latestresearch evidenceontheregulationof

alcohol marketing and health labelling.

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Table of Contents

1. UpdateofIrishevidence
Alcohol consumption ......... ........ ........ ....... 4
Costtosociety of problemalcohol usein Ireland . . . . . . . . . . . . 6
New relevantIrish research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

2. UpdateofInternationalEvidence
Alcohol consumption . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 17
Burden of Disease/Alcohol-related harm . . . . . . . . . . . . . . . . . 18
Effectivemeasures toreduce alcoholrelated harm . . . . . . . . . 20
Global monitoring framework . . . . . . . . . . . . . . . . . . . . . . . . . . 20

3. RegulationofAlcoholmarketing
Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Reviewof researchevidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
o Effects of alcoholmarketing
o Alcohol branded sportssponsorship
o Digital marketing
Enforcementmechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

4. HealthLabelling
Reviewof researchevidence . . . . . . . . . . . . . . . . . . . . . . . . . . 31
o Health warning labels
o Low-risk drinking guidelines

5.References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

6.Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
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1.1AlcoholconsumptioninIreland

During thelast30 years,alcohol consumption percapita(15+ years) of purealcohol

increased from 9.5 litres in 1984 toa high of 14.3 litresin 2001 (Figure1). In 2003,alcohol
consumption dropped by 6% following a substantial taxincrease on spirits. Afurther
reduction was observed during the early phaseof the recession years (2008-2009).
Alcohol consumption again increased in2010 and 2011. In 2013,alcohol consumption
was 10.6 litres per capita (15+),a decline of 7.7% fromtheprevious year. While this
reduction inconsumption is to bewelcomed,itis importanttorecognise that Ireland’ s
alcohol consumption remains in thetop five among EU28 Member States and theWHO
European Region hasthehighest consumption in the world (WHO 2014).

Alcohol consumption per adult in Ireland, 1984-2013

16.0

14.0

12.0

10.0 Beer
litres of pure alcohol

Spirits
8.0
Wine
6.0 Cider

4.0 Total

2.0

0.0
84

86

88

90

92

94

96

98

00

02

04

06

08

10

12
19

19

19

19

19

19

19

19

20

20

20

20

20

20

20

In Ireland,the mostrecentnationalalcohol survey shows that morethanhalf (54%) of

adult drinkers (18-75 years) inthepopulation areclassified as harmfuldrinkers,using the
WHO AUDIT-Cscreening tool(Long &Mongan 2013). Theseresults are similartothose in
theSLAN2007 survey. Harmful drinking is morecommon among men than women. The
vast majority (three in every four) of young adult drinkershavepositiveAUDIT-Cscores.
Whentheproportion of survey respondents who are classified as harmfuldrinkers is
applied tothepopulation,thisequates withbetween 1.3 and 1.4 million harmful drinkers.
Whilealcohol percapita (15+) declined between 2007 and 2013,it still remains high and
 5

thedamaging dominanceof a harmful drinking patternin Ireland remains very highby

European standards and is a major public health concern.

Youth drinking patterns

Alcohol use in last month Youth drinking was examined, based on the
HBSC four surveys between 1998 and 2010,
80
using two drinking measures - alcohol use in
60
last 30 days (current drinkers), drunkenness
%
40 ever. The most meaningful discussion is by
gender and age. When examined by gender
20
and age, the findings show there was an
0
girls boys girls boys girls boys
increase in alcohol engagement as age
1998 4 18 17 26 51 58 increased, with lowest engagement in the
2002 3 6 12 16 50 54
youngest age group (10 to 11 yrs) and the
2006 1 4 12 16 47 48
2010 1 3 9 12 39 41 highest in the older age group (15-17 yrs), in
terms of current drinkers and drunkenness.
Boys were more likely to be current drinkers
Drunkenness - ever drunk
thangirlsup toageof 14 years. Inthe older age
70 group, gender difference diminished over time
60 for both measures (Figure 2). Between 1998
50 and 2010, some reductions (mainly among
40
% boys) were seen but the pattern was
30
inconsistent. In2010, 40%(two out of five) of
20
15 to 17 year olds were current drinkers and
10
over half (53%) reported drunkenness (Figure
0
girls boys girls boys girls boys 2). Inthe 12 to 14 age group, 15% of girlsand
1998 5 15 17 28 49 57
2002 3 7 17 22 56 60
18% of boys reported drunkenness. While
2006 2 7 16 22 56 57 some decline has taken place, the drinking
2010 3 5 15 18 52 53 pattern of children continues to pose serious
 6

1.2 CosttoSocietyofproblemalcoholuseinIreland

1.2.1 Theprincipalsocialcostsofproblemalcoholuse.

Thelinks between problem alcoholuse and the social costs to which it gives rise are
complex and just someof the costs canbeestimated with some degree of reliability.
Problemalcohol usegives risetothreetypes of costs:direct costs, indirect costs and
intangiblecosts. Direct costs arebornebythegovernment and therefore by taxpayers
and includecoststothehealth care,criminal justiceand welfare systems. Indirectcosts
include lostoutput through alcoholrelated absenteeismand output lostduetopremature
deathordisability. Intangiblecosts are mainly pain and suffering experienced by those
whoexperience alcoholrelated problemsand are the mostdifficultcategoryof coststo
measure.

As thesocial costs of problemalcohol usearevery significant to individuals and tosociety,

therearelargepotentialsavings not only inmoney terms butalsoit terms of reduced
suffering and improved qualityof life,if those costs can bereduced. Estimates of thecost
of problemalcohol useareusefulin formulating effectivealcohol policies,can identify
gaps in national statisticalreporting systemsand enable cross nationalcomparisons. But
thereareothersocial costs which are moredifficult toestimate. These includethe
suffering imposed on the families of problemdrinkers. McKeonetal (2002) found that of a
largesampleof married couples seeking counselling,40% of menand 20% of women,
wereabusing alcohol. Alcohol is a factorin up to70% of domestic violenceagainst
women (National CrimeCouncil of Ireland,2006). As only about5% of domestic violence
cases are prosecuted,thecost of domestic violence does not appear in thecost of crime
figures.

In estimating thecost of problemalcohol use,it is importanttorecognisethatdependant

drinkers whoareusually thoughtof as alcoholicsdonotimpose the largest share of costs
on society. Whiledependentdrinkers aremorelikely tohavethelargest number health,
socialand other problems,they account for a relatively small share of thetotalcost of
problem alcoholuse to society.

Thepattern of drinking as well as overallconsumption affects the social costof problem

alcohol use. In Ireland,a largeproportion of thepopulation engage inheavy episodic
drinking (HED) known as ‘ bingedrinking’ (Long &Mongan 2014),which leads tohigh
costsin termsof violence and accidents. Inaddition,problem alcoholuse imposescosts
on peoplewhosuffer asa result of thedrinking of others. Research by Hope (2014) shows
thatin Ireland overonequarter of survey respondents reported that they had experienced
harmin the previous year as a result of someone else’ sdrinking. Theseharms included
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family and money problems,assaults,property vandalised and being apassenger with a

drunk driver. Estimating thefull costof harmtoothers is difficult due to the variety of
coststhat may beincurred and is notattempted in this paperbutwill beestimated in future
research.

1.2.2 Studiesofthesocialcostofproblemalcoholuseforothercountries

Beginning in the1970s,many governments in developed countries began torecognise

thecoststosociety of problemalcoholuseand commissioned studies of these costs.
Thestudiesfromwhich theestimates are derived vary widelyin termsof methodology and
reliability of data. In theirreporttotheEU Commission;
,Anderson and Baumberg (2006) reviewed 21 European studies of the social
costsof alcohol. Summarising theconclusions of these studies,Anderson and Baumberg
arrived at a totaltangible cost of alcoholtotheEuropeanUnion of 1.3% of GDPwitha
rangeof 0.9% to2.4% for individual countries. The costs included in Anderson and
Baumberg’ s reportare: costs to the health care system,the costof alcoholrelated
crime,thecost of alcohol related traffic accidents,thecost of alcohol induced
unemploymentand absenteeismand the costof alcoholrelated prematuremortality.

Thecost studies from other countries most relevanttoIreland are thosefortheUKand

Northern Ireland as the patterns of problem drinking in those countries aresimilartothose
in Ireland. Thosestudies are: UK CabinetOfficereport
?( 2003) and the Scottish Executive’ s
2001).Those studies attempttocomprehensively assessthecosts tosociety in England
and Walesand in Scotland. Both studies estimate health costs,costs of alcohol related
crimeand accidents and costs of lostoutputduetoalcohol. TheScottish study also
estimates the human costsof problem alcoholuse to thosewhose lives areaffected by it
otherthan the drinker. Acomprehensivereporton the costs of problemalcohol usein
Northern Ireland was published in 2010. (Department of Health,Social Services and
Public Safety in NorthernIreland,2010). TheNorthern Ireland study uses a similar
methodology to the Scottishstudy.

1.2.3 Methodologyofcostestimates

If adequate datawere collected,itwould berelatively straightforward tomeasure the

directcosts of problemalcohol usetothehealthcareand criminal justicesystem and the
costsof alcohol related road accidents. Thosewhoengage inhazardous and harmful
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drinking oftendeny their problemalcoholuse,even tothemselves,so there is

considerable underreporting of theroleof alcohol in illness and accidents and even in
crime. Some costs of problemalcohol usein Ireland mustthereforebeestimated using
information gathered in studies in England and Wales (Cabinet Office2003),Scotland
(2001) and Northern Ireland (2010). This is theapproachtakenin Byrne(2010) and is
used inthis paper,which is largely an updating of theestimates in Byrne’ s paper.

1.2.4 Coststothehealthcaresystemofproblemalcoholuse

TheInternational Classification of Diseases lists nineconditions that are100%

attributabletoalcohol and a further thirty conditions thatarepartly attributabletoproblem
alcohol use. TheWHO’ s GlobalBurdenof Disease shows alcohol to bethethird most
significant risk factorfor ill healthand premature death after tobacco and high blood
pressure. Drinking alcohol is associated with a risk of developing such health problems
as alcohol dependence,livercirrhosis,cancerand injuries.

Alcohol misuse therefore places a heavy cost burden on public healthcare. TheIrish
studies showing theextentof this burden are summarised in Byrne (2010). Based onIrish
studies of the extentof alcohol related useof healthservices,Byrneestimatesthat 10% of
thecostof general hospitalservices,7% of thecost primary careand 10% of thecostof
mentalhealth services areattributable to alcoholmisuse.

For 2013,10% of thecost of acute hospitals was € 411 million,7% of thecostof primary
carewas € 214 million while 10% of thecost of mental healthservice was € 73 million.

As Hope’ s study of alcohol related harm to other’ s (Hope,2014) one intenadults

reported thatchildren for whom they haveparentalresponsibility experienced at least one
or more alcoholrelated arms as a resultof someoneelse’ sdrinking. Children who
experience such harms arevery likely torequire the services funded under the allocation
forchildren and families in the HSE’ s budget. Ten percent of thetotalallocated by the
HSEforspending on children and families for 2013 is € 54 million. It is likely that10% of
spending by the Department of Children and Youth Affairs alsorelatetoalcohol related
interventions. This figureis € 41 million for 2013.

Thetotal figureforhealth and socialcare expenditure related toalcohol misusein 2013 is

€ 793 million. Whilethis represents a decrease from Byrne’ sfigure for 2007 of € 1.3
billion this does notindicate areduction in alcohol related demands on thehealth service
but is mainly duetosignificantreductions in government spending on health since 2007.

CoststotheHealthcaresystemrelatedtoalcoholin2013
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Cost of generalacutehospital servicesrelatedtoproblem € 411mn

alcohol use(10%)

Cost toprimarycare(7%) € 214mn

Cost of mental health services(10%) € 73mn

Cost of servicesforchildrenandfamiliesinHSE(10%) € 54mn

Cost of servicetochildrenandfamiliesinDept. ofChildren € 41mn

andYouth Affairs(10%)

Totaldirecthealthcaresystemcostsrelatedtoalcohol € 793mn

Thetotal figureforhealth and socialcare expenditure related toproblem alcoholuse in

2013 is € 999 million. Whilethis represents a decreasefrom Byrne’ s figurefor2007 of
€ 1.3 billion this does notindicate areduction in alcohol related demands on thehealth
servicebutis mainly due to significantreductions in government spending on health since
2007. Thecosts estimates arebased on aproportion of the totalhealth carebudget spend
each year.

1.2.5 CoststotheCriminalJusticeSystemofAlcoholMisuse

Manycrimesresult from problemalcohol use. Themost commonly prosecuted are

drinking and driving related offences and public order offences. Alcohol is afactor in
manyassaults,including sexual assaults and in rape,domestic violence, murderand
manslaughter. Alcoholrelated crime therefore imposes considerablecostson the
criminal justicesystem. Thesecosts includethecosts of policing alcohol related crime,
thecostof processing alcoholrelated crimesin thecourts and thecost totheprison and
probation services of dealing with alcohol related crime.

In his 2010 paper, Byrneestimated on the basis of thestudy

(2001) that12% of the costof policing alcoholrelated crime,12% of the
costsof theprison system and 7% of thecosts of thecourts could beattributed to alcohol
related crime. For2013 thesefigures are:

Costsofalcoholrelatedcrime2013

Cost of GardaSiochanaresourcesdevotedtoalcohol € 166mn

relatedcrime
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Cost totheprisonserviceofalcohol relatedcrime € 7.3mn

Cost tothecourtsofalcohol relatedcrime € 7.3mn

Total direct costsofalcohol relatedcrime € 180.6mn

In additiontothedirect costs of detecting and punishing alcohol related crime, costs are
alsoincurred by the victimsof crime intheformof trauma,injury and even death. Other
costsincludethecost of property lost through burglary and criminal damageand the cost
of securitysystems incurred in anticipation of crime. Victims of crimemaybeabsent from
work and theiroutputis thereforereduced. In thestudy of the costs of alcoholmisusein
England and Wales, thesecosts are muchgreater than thecost to the criminal justice
system. Byrne (2010),taking thedirect costof alcohol related crime used ratios derived
from the UK study toestimatethesecostsfor Ireland. Theratios he used are:

Ratios

Criminal justicesystemcosts 1.0

Property/health andvictimservicescosts 1.40

Costsinanticipationofcrime 0.85

Crimecost oflost productiveoutput 0.55

Emotional impactcosts 2.70

Applyingtheseratiostothedirect cost ofalcohol relatedcrimegivesthefollowingfigures:

Criminal justicesystemcosts € 180.6mn

Property/health andvictimservicescosts € 252.8mn

Costsinanticipationofcrime € 153.5mn

Cost of crimerelatedlossofoutput € 99.3mn

Totalalcohol-relatedcrimecosts € 686.2mn

1.2.6 Costofalcoholrelatedroadaccidents
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Bedford etal (2006) found that alcohol was a factorin 30% of all road collisions and in
36.5% of fatal collisions. Alcohol related road accidents resultin loss of life, pain and
suffering,medicalcosts and lost output. Other relevantcosts include damagetoproperty,
insuranceadministration,policeand court costs. Thestandard method used toestimate
thecostof road accidentsis the“ willingness to pay” method which puts a statistical
value on a life by considering howmuch peoplearewilling topay for reduced risk of death.
Thewillingness to pay method covers loss of life,pain and suffering and medicalcosts as
well aslostoutput. Thewillingness topay method isused by the National Roads Authority
as the basis for calculating thecost of road accidents.

In 2012 therewere162 deaths on Irish roads and 7,942 injuries,of which 474 wereserious.
TheRSAcalculates thecost of all road accidents as € 773 million in 2012. This represents
a reduction of 44% between 2007 and 2012. If itis assumed thatalcohol was the crucial
factorin 30% of road accidents in 2012,thecost of such accidents was€ 258 million.

1.2.7 Costsofalcohol relatedabsenteeismfromwork

Asurvey by IBEC(2011) found that 4% of companies surveyed cited alcohol as amajor

factorin 4% of absences by men and 1% by women. Thesurvey found that 12% of
absences had somealcohol connection. For absencesnotduetoillness,5% had alcohol
as a main cause and 22% werealcohol related. IBECestimated thevalue of lostoutputdue
toabsenteeism as € 1.5 billionin 2010. The IBEC survey covered only privatesector
employers. Public sector employment is 20% of private sectoremployment which
suggests that thevalue of lost output should beaugmented by 20% which would give a
totalvalueof lostoutputof € 1.8 billionin 2010. Adjusting this figureto2013 values gives
a totalvalue for lost output of € 1.95 billion.

Toestimate the valueof lost output duetoalcohol requirestaking a figurebetweenthe4%

and 12% forabsences in which alcoholwas the main cause or a contributing factor while
foralcohol related absences not due to illness, requires taking afigure between 6% and
14%. Areasonablecompromisewould betoassumethat10% of the estimated total
value of lost output due to absenteeismis alcohol related. This gives a figureof € 195
million forthevalue of lost output due to alcoholrelated absenteeism.

1.2.8 Costofalcoholrelatedindustrialaccidents

Areport by theHealthand Safety Authority (2004) fortheDepartment of Jobs,Enterprise

and Innovation Economic estimated
conservatively that lost output duetowork related accidents was valued at € 1.8 billionin
2003. Thereportdid not estimatetheproportion of alcoholrelated accidents atwork, buta
UK study (AlcoholConcern,2000) found that 25% of accidents at work are alcoholrelated.
 12

As no study has been undertaken in Ireland toestimate the proportionof workplace

accidents thatarealcohol related it would be excessively pessimistic toassumethat 25%
of workplaceaccidentsarealcoholrelated in Ireland. Amoreconservativeapproach
would betoassumethatat least10% of workplace accidents arealcohol related. This
would givea value of € 180 millionfor lostoutputin 2003 prices which adjusted by the
GDPdeflator gives a valueof € 185 million.

1.2.9 Costofalcoholrelatedsuicide

Several studied showa positiveassociationbetween percapita alcohol consumption and

suicide. Brady (2006) finds thatthereis evidencethat problemalcohol usepredisposed to
suicidal behaviourthrough itsdepressive effects and promotionof adverselifeevents,
impairment of problemsolving skills and aggravation of impulsive personality traits.
Walsh (2010) finds that alcohol is a highly significant influence on suicide among men in
allagegroups between 15 and 54 years. Walsh(2010) alsofound thatalcohol
consumption influenced suicides among women under the ageof 35.

Whilethestudies of the social costof alcohol misusein theUK and Northern Ireland donot
include the costs of alcoholrelated suicide,the significant increasein thesuicide ratein
Ireland overthepast30 years in Ireland coincided with an equally significantincreasein
alcohol consumption.

Astudy by the Departments of Public Health in the former Health Boards (2001) based on
a survey of GPs and psychiatrists found that 21% of GP patients whoattempted or
committed suicidehad taken alcohol immediately preceding theeventand 21% of GP
patients and 27% of psychiatrists’ patients who had attempted orcommitted suicide
had a history of alcohol abuse.

In his paper, ,Kennelly (2007) estimated thecost of

suicide inIreland was € 835 million. Kennelly’ s estimates includethedirect costof
suicide such as medicaland emergency services costs but thesearesmallcompared to
his estimates of the indirect costs. The largeindirect cost is based on the “ willingness to
pay” approach to valuing human lifewhich is also used in estimating thecost of road
accidents. Assuming that 20% of suicides are alcoholrelated gives a costof € 167 million
forsuchsuicides in 2003 prices. Updating this figureby theGDP deflatorgives a figure of
€ 169 million.

1.2.10 Costofalcoholrelatedprematuremortality

Problemalcohol useleads to premature mortality formany people in thelabourforce and

thereforereduces output. Thenumber of working years lost for thosewhodie
 13

prematurely fromalcoholusecan be calculated and aneconomic value put on the output

they mighthaveproduced if they had stayed in the labour force until 65.

Thepsychological effectof premature death of apersonwhomisuses alcohol isborneby

his or her family and friends. Theeffects canbeestimated by the Willingness-to-Pay
(WTP) method whichvalues humanlifeaccording towhatindividuals would bewilling to
pay fora changethat reduces theprobability of illnessordeath. Estimates based on WTP
aremuch larger than thecost of material production lost using thehuman capitalmethod.

Martin et al(2011) estimate that 1.8% of deaths in Ireland areattributabletoalcohol.

Applying this percentagetothetotal number of deaths in Ireland in 2012,gives 382 deaths
attributabletoalcohol. Sufficientdatais not availablein Ireland tocalculatethecostof
prematuremortality using theWTP method. As the mortality costs for road accidents
and suicidegiven in this paper are based on theWTP method,itwould beinconsistentto
ignore the costof other types of alcoholrelated mortality. In theScottish study (2001)
which rigorously applied thewillingness to pay method, thecost of prematuremortality is
one third of the more tangiblecosts of lost output due to alcoholrelated absenteeismand
unemployment. Onethird of thecost of lost output due to alcoholrelated absenteeismas
calculated above is € 65 million.

1.2.11 EstimatedTotalSocialCostsofProblemalcoholuseinIrelandin2013

CategoryofCost € Million %of total

Cost tothehealthcare system 793 34

Cost of alcohol relatedcrime 686 29

Cost of alcohol relatedroadaccidents 258 11

Cost of lost output duetoalcohol relate 195 8

absenteeism

Cost of alcohol relatedaccidentsat work 185 7

Cost of alcohol relatedsuicides 169 6

Cost of alcohol relatedprematuremortality 65 3

TotalCosts 2351 100

1.2.12 Costsofproblemalcoholusein2007and2013
 14

TheestimatedtotalcosttoIrishsocietyofproblemalcoholuseis€ 2.35billionin2013. The

figures estimated in this papershowa significant decrease in theestimated cost to
society between 2007 and 2013. Byrne (2010) estimated the social costs for2007 at €
3.7 billion.

Thereduction in 2013 is due to anumber of factors:

thecostof alcohol related road accidents has fallen sharply,duetothefall in the

number of accidents
thecoststothehealth care systemand the criminaljusticesystem which are the
largest elements of the total cost are estimated asa proportion of total spending
on those services and spending hasbeen reduced significantly since 2007, when
governmentspending overall peaked beforetheonset of therecent recession.
Total spending on health fell by 23% between 2008 and 2013 and total spending on
thegardai,courts and prisons fell by 9% in the same period.

1.2.13 IrishandUKstudiesofthecostofproblemalcoholuse

Whilecomparisons between countries aredifficult,theproportion of GDP willbeused to

compareIreland withother neighbouring countries – NorthernIreland,Scotland,England
and Wales. Thetotalcost of problemalcohol usein Ireland estimated in this paper of €
2.35 billion represents 1.4% of GDP in 2013. In a study fortheHSE,Byrne(2010)
estimated thecostsof problem alcoholuse in Ireland for 2007. His estimateof thetotal
costof problem alcoholuse was € 3.7bn. Thisrepresented 1.9% of IrishGDP in2007. The
study forEngland and Walesestimated thecost of alcohol useas 1.7% of GDPwhilethe
study forScotland was 1.5%. The Northern Ireland study estimates thesocialcost of
alcohol misusein Northern Ireland in 2008 tobe1.8% of GDP. The costestimates for
Ireland aresomewhatsimilar to our neighbouring countries and higherthan theEU
average. Andersonand Baumberg (2006) calculated thetotaltangible costs of problems
alcohol usein the EU as 1.3% of GDPwitha range of 0.9% to2.4%.

Comparisonofestimatedsocial costsofproblemalcohol use

Country Yearforcosts Percent ofgrossdomesticproduct(GDP)

Ireland 2013 1.4%

 15

Ireland 2007 1.9%

NorthernIreland 2008 1.8%

EnglandandWales 2003 1.7%

Scotland 2001 1.5%

EUaverage 2006 1.3% with a rangefrom0.9%to2.4%

1.2.14 Limitationsofthecostestimates

As outlined aboveand discussed in more detail in Byrne(2010) estimating thecost of

problem alcoholuse presents many problems of methodology and availability of data.
For Ireland, improving thenational reporting systems in a numberof key areas would
enablemoreaccurate estimates of problemalcohol usein Ireland. Key information areas
are:

Recording of alcohol consumption by all patients in generalhospitals and notonly

thosewhosediagnosis directly relate to alcoholabuse
Recording of therole of alcohol ininpatient psychiatric admissions and psychiatric
outpatient services
Recording of therole of alcohol inall serious crimes such as murder,manslaughter,
grievous bodily harmand rape. At presentmostalcohol-related crimesrecorded
tend torelatetominor offences such as public orderoffenses.
Recording of alcohol related absences in all public and privatesector
organisations.
Recording of therole of alcohol infamily problemsby Family SupportAgencies.
Recording of alcohol’ s harmtoothers across a rangeof health and welfare
agencies.
Detained survey information on alcohol’ s harm toothers experienced in the
general populationand in high-risk sub-population groups.

1.3NewrelevantIrishresearch

Thisreportintroducestheconceptof‘ alcohol’ sharmtoothers’ inanIrishcontext.This

research studyconfirmsthatalcohol iscausingsignificant damageacrossthepopulation, in
workplacesandtochildreninfamiliesandcarriesa substantial economicburdentoall inIrish
society,at ahigherlevelthancomparablesocietiessuch asAustralia,Canada andAmerica.
 16

Overoneinfourpeople(28%)inthegeneral Irishpopulationreportedexperiencingatleast oneor

morenegativeconsequencesasa resultofsomeoneelse’ sdrinking- familyproblems,
passengerwitha drunkdriver, assault,propertyvandalisedandmoneyproblems. Inthe
workplace, oneintenIrishworkersexperiencedat least oneormorenegativeconsequencesdue
toco-workerswhowereheavydrinkers,suchastheabilitytodotheirworkwasnegativelyaffected,
theyhadtowork extra hoursandhadanaccident orclosecall at workduetoco-workersdrinking
habits. Overall, oneintenIrishparentsreportedthat childrenexperiencedat least oneormore
harmsinthepast 12monthsasaresultofsomeoneelse’ sdrinking– verbal abuse,left inunsafe
situations,witnesstoseriousviolenceinthehomeandphysical abuse
Theresultsindicatethat problemalcohol usecannolongerbeframedexclusivelyintherealmof
harmtothedrinker. Inoveraquarterofcases, harmtoothersisdocumentedandinthecaseof
eachoftwospecificsituations, oneavulnerablepopulation(children)andtheothereconomic
(theworkplace), oneintenreportharmtoothers.Whilemengenerallyexperiencemoreharmfrom
others,intwodomains– familyandfinance-womenexperiencemoreharm.

Alcohol wasinvolvedin38%ofall self-harmcases.Whileoverallalcohol involvement decreased

slightlyfrom2011,alcohol wassignificantlymoreofteninvolvedinmaleepisodesofself-harm
thanfemales(42%versus36%, respectively).

Alcohol-RelatedSelf-HarmandSeasonality
Withregardtoseasonalityandself-harm, overall significantlydifferent patternswerefoundfor
menandwomenwhenwe analysedself-harmdataofpatientswhohadnot takenalcohol atthe
timeoftheself-harmact. Aratiohigherthan1indicatesthat thereweremoreself-harmactsthan
expected.However,whenanalysingthedatabasedonthosewhohadusedalcohol,therewasa
remarkablesimilaritybetweentheseasonalityoffemaleandmaleself-harminthat bothgenders
showedsimilarpeaksinself-harminMarch,JulyandAugust.Furthermore, formenanadditional
self-harmpeak emergedinMaywhenalcohol wasinvolved.
http://www.headstrong.ie/sites/default/files/My%20World%20Survey%202012%20Online.pdf

TheHeadstrongMyWorldSurveywasalargescalestudyofyouth mental healthinIreland, which

surveyedover14,000peopleaged12-25.Thesurveyreportedsiximportantthemes:
1. One‘ GoodAdult’ inayoungperson’ slifeisakeyindicatorofyoungpeople’ smental
health
2. 58%of thoseaged16andolderreportedexcessivedrinking
3. Nottalkingabout problemswaslinkedtosuicidal behaviour
4. Sharingproblemswaslinkedwith bettermental health
5. Manyyoungpeopleindistressarenot seekinghelp
6. Moneyisa significant stressor.

(FortheDepartmentofHealth)
 17

This report was commissioned from CPJ Consultants by the Department of Health. It sets out the
issues relating to hazardous and harmful consumption of alcohol in Ireland. It looks at the
international experience and policy response and makes recommendations about how the
problems caused by hazardous alcohol consumption can and should be tackled in Ireland, with a
specific focus on pricing policies.

doi:10.1093/alcalc/agu015

Abstract

Aim: International researchindicatesthat therolewhich alcohol playsinaccidentstendstobe

understatedinmediareports. Evidencesuggeststhatpublicsupport foralcoholharmreduction
policieswouldincreaseifpeoplewerebetterinformedabout theroleofalcohol inseriousinjuries.
Wehypothesizedthat theroleofalcohol inIrish accidental deathsisunder-reportedintheIrish
printmedia.Method: Weidentifiedall traumaticandpoisoningdeaths(excludingsuicides)in
Irelandduringthe years2008and2009wherealcohol wasmentionedonthedeath certificate.We
conductedanInternet-basedsearchfornewspaperreportsofthesedeaths. Thecontent ofeach
report wasexaminedandratedformentionofalcohol’ spossibleroleinthe individual death.
Results: Thisstudydemonstratestheunder-reportinginIrishnewspapersoftheroleofalcohol in
traumaticandpoisoningdeaths.Wheredeathswerereported,theroleplayedbyalcohol was
generallyignored.Conclusion: Thisrepresentsa missedopportunitytoinformthepublicabout
theroleofalcohol inthesedeaths.Moreaccurateinformationwouldpermit thepublictomake
moreinformeddecisionsregardingtheirownbehaviourandregardingtheirsupport foralcohol
harm-reducingstrategies.

FromIrishhealth.com
Excessalcoholconsumptioncanleadtomanygastrointestinalsymptoms, rangingfromreflux
anddiarrhoeatolife-threatingconditionssuchascancerandlivercirrhosis.Accordingto
specialist registraringastroenterology, DrAudreyDillon, andconsultant gastroenterologist,Dr
GlenDoherty, ofSt Vincent’ sUniversityHospital inDublin,alcohol-relatedgastrointestinal
problemscancausesdiseases‘ that carrysignificantmorbidityandmortality’ . Theypointed
out thathospital admissionsasa result ofalcohol consumptionhave‘ risendramatically’ in
Ireland.Between1995and2002alone, theyincreasedbya massive92%.Between1995and2007,
alcohol-relatedliverdiseaserosebyastaggering190%, ‘ witha worryingtrendamongyounger
agegroups– a 247%increaseamong15-34yearolds’ .“ Approximately10%ofall general
inpatient hospital costs, 7%ofGPcostsandupto30%ofemergencydepartmentcostsaredirectly
attributabletoalcohol,” thedoctorssaid.Alcohol consumptioncanaffecttheoesophagus,
stomach, bowel,pancreasandliver. Furthermore, alcohol hasbeen‘ directlylinkedtocancerof
theoral cavity, pharynx,oesophagus,stomachandupperairways’ . Thedoctorsalsopointedout
thatalcohol liverdiseaseleadstocirrhosis,‘ which carriesa significantlivercancerrisk’ and
alcohol hasalsobeenimplicatedintherisk ofbreast cancer.“ Asalcohol consumptioncontinues
toincreaseinIreland, thetreatmentofthegastrointestinal-relatedcomplicationswill prove
challenging,” DrDillonandDrDohertywarned.
 18

Theymadetheircommentsin ,theJournal of the IrishCollegeofGeneral

Practitioners.

The Health Research Board report

reportedmore than40,000casesweretreatedfor
problemalcohol usebetween2008and2012.Thetotal numberof casestreatedincreasedfrom
7,940in2008to8,604in2011andthendecreasedto8,336in2012.Butthenumberofpreviously
treatedcasesgrewfrom3,606inthefirst yearofthestudyto4,212in2012.Thenumberofnew
casestreatedwasupbyalmost 18percentfrom3,833to4,520in2011. That droppedto4,028the
followingyear.Twoout ofthreeofthosepresentingfortreatment weremaleandthemedianage
was40. The overall incidenceoftreatedproblemalcohol use among15-64yearoldsinIreland
rosefrom119.7per100,000ofpopulationto141.2in2001beforedecliningto125.1in2012.
Waterford, Donegal,Sligo, LeitrimandWexfordsawthehighest incidenceof newcasesinthe
five-yearperiod. All ofthesecountieshadmorethan224casesper100,000of the 15-64yearold
population,thestudysaid.IncidencewaslowestinClare,Roscommon,Wicklow, MayoandMeath,
whereeach hadfewerthan83casesper100,000. Incompletereporting,however, meant that
somecounties’ figuresunderstatedthenumberofcasespresentingfortreatment.

Intheeight-yearperiod2004– 2011atotal of4,606deathsbydrugpoisoninganddeathsamong

drugusersmetthecriteriaforinclusionintheNDRDI database. Ofthesedeaths,2,745weredueto
poisoningand1,861weredeathsamongdrugusers(non-poisoning). Theannual numberof
deathsin2011increasedto607, comparedto597in2010.The2011figureislikelytoberevised
whennewdatabecomeavailable. The annual numberofpoisoningdeathsincreasedfrom338in
2010to365in2011.Malesaccountedforthemajorityofdeathsineach yearsince2004;72%ofall
poisoningdeathsin2011weremale.Themedianageofthosewhodiedin2011was39years,
similartopreviousyears. Overhalf(59%)ofall poisoningdeathsinvolvedmorethanone
substance (polysubstance use). Thisrepresentsa 28%increasefrom2010when168
polysubstance poisoningswererecordedcomparedto215in2011.Alcohol wasinvolvedin37%
ofpoisoningdeathsin2011, morethananyothersubstance.Alcohol alonewasresponsiblefor
17%of all deaths.

Abstract
Alcohol consumptioniscausallyrelatedtocanceroftheupperaero-digestivetract,liver,colon,
rectum,femalebreast andpancreas. Thedoseresponserelationshipvariesforeachsite.We
calculatedIreland’ scancerincidence andmortalityattributabletoalcohol overa10-yearperiod.
Between2001and2010,4,585(4.7%)male and4,593(4.2%)femaleinvasivecancerdiagnoses
 19

wereattributabletoalcohol. Thegreatestriskwasfortheupperaero-digestivetract where

2,961(52.9%)ofthesecancersinmalesand866(35.2%)infemaleswereattributable toalcohol.
Between2001and2010,2,823(6.7%)ofmalecancerdeathsand1,700(4.6%)offemalecancer
deathswereattributabletoalcohol.Everyyearapproximately900newcancersand500cancer
deathsareattributabletoalcohol.Alcohol isa majorcauseofcanceraftersmoking, obesityand
physical inactivity.Publicawarenessofriskmust improve.Overhalfofalcohol relatedcancersare
preventablebyadheringtoDepartment ofHealth alcohol consumptionguidelines.

2.UpdateofInternationalEvidence

2.1Alcoholconsumption

According totherecent World HealthOrganisation report,

, worldwidealcohol consumptionin 2010 was equal to 6.2 litres of pure
alcohol perperson aged 15 years or older. TheWHOEuropeanRegioncontinuestohavethe
highestalcoholconsumptionintheworldat10.9litres of purealcohol percapita (15+ years).
Althoughalcohol consumption declined by 10% sincethe2003-2005 period,the
European Region consumes4.7 litres higher than theworld average (6.2 litres). TheWHO
Regionconsumes morethan a quarterof the totalalcohol consumed worldwide.

Alcohol related harm is determined,apart from the environmental factors, by threerelated

dimensions of drinking,thevolume of alcohol consumed,thepattern of drinking and on
rare occasions thequality of thealcohol consumed. Alcoholconsumption has been
identified as acomponent cause for morethan200 diseases,injuries and other health
conditions,with ICD-10 codes. For mostdiseases and injuries causally impacted by
alcohol,thereis a dose-response relationship – in other words,thehigher the
consumption of alcohol,thelarger therisk fortheseconditions.

Factors affecting alcohol consumptionand alcohol-related harminclude,age,gender,

family risk factors,socioeconomic status,economic development,cultureand alcohol
controland regulation policies (Babor et al 2010). Children,adolescents and elderly
peoplearetypically more vulnerable to alcohol-related harmfroma given volume of
alcohol than otheragegroups. Early initiationof alcohol use(before 14 yearsof age) isa
predictor of impaired health status, becauseit is associated withincreased risk for
alcohol dependenceand abuseat laterages,adverse impactson braindevelopment,car
crashesand other unintentional injuries.

As peoplegrowolder,their bodies aretypically less able to handlethesamelevels and

pattern of alcohol consumption asin previous years, leading toa higherburden from
unintentionalinjuries such as alcohol-related falls. Thealcohol-related burden of disease
 20

among older age groups is an increased public health concern forWHO becauseof the
rapidly ageing population in many countries worldwide(WHO 2014).

Men areless often abstainers,drinking more frequency and in largerquantities,resulting

in higher levels of injuries. However,for women the same level of consumption leads to
morepronounced health outcomes such as cancers,gastrointestinaldiseasesor
cardiovascular diseases (Rehmet al 2010).

Thepattern of drinking is alsoimportant. Theamount of alcohol on a singleoccasion is

importantformany acuteconsequences such as alcohol poisoning,injury and violence.
Heavyepisodicdrinking (HED), defined by WHO as the consumption of 60 ormore grams of
purealcohol (6+standard drinks inmost countries and in Ireland) on at leastonesingle
occasionat least monthly, isassociatedwithdetrimentalconsequences,eveniftheaverage
levelofalcohol consumptionofthepersonconcernedisrelativelylow. The prevalenceof heavy
episodic drinking (HED) worldwide was 7.5%,however,in theWHO EuropeanRegion HED
was 16.5% (Table1). The overall prevalenceof heavyepisodic drinking in Ireland was
39%,which was higher formales (53%) than females (25.5%),based on the information
provided in the recentWHO report (WHO 2014). When Ireland was compared with the
EU28 countries, theprevalenceofHEDamongmalesinIrelandrankedthirdhighestinEurope
after Austria and Czech Republic (Appendix1). For females,theprevalenceofHEDinIreland
rankedsecondhighest after Austria (Appendix 2).

2.2Alcohol-relatedharms

Thereis increasing awareness of thesignificant impact of harmfuluseof alcohol1 notonly

on individuals,but also on global public health. Theharmfuluse of alcohol ranksamongthe
topfiveriskfactorsfor disease,disabilityanddeath throughouttheworld. Itis a causal factor
in more than 200 diseases and injury conditions. Drinking alcohol is associated witha risk
of developing suchhealth problems as alcoholdependence,livercirrhosis,cancerand
injuries and morerecently linked toinfectiousdiseases(tuberculosis,HIV/AIDS).

Overallworldwide,about3.3 milliondeaths in2012 wereestimated tohavebeencaused

by alcohol consumption,after taking intoaccountthebeneficialeffects of low-risk
patterns of alcohol consumption on somediseases. This corresponds to5.9% of all
deaths( oneineverytwentydeaths)intheworldeachyear (7.6% for men,4% for women). The
highestnumbers of deaths werefromcardiovasculardiseases,followed by injuries
(especially unintentionalinjuries), gastrointestinal diseases (mainly liver cirrhosis) and
cancers. TheWHO European Region has thehighestproportion of alcohol-attributable

1 The WHO global strategy to reduce the harmful useof alcohol, defines “ harmful use” inthe context of
public-healtheffectsof alcohol consumption(WHO 2010).
 21

deathsrelative to all deaths in theworld. This is notsurprising,as alcohol consumption in

theEuropean region is also the highest in theworld.

In 2012,5.1% of the globalburden of disease and injury,as measured by DALYs1,was

attributabletoalcohol. About a quarter of allalcohol-attributableDALYs were dueto
neuropsychiatric disorderscompared with 4% for all alcohol-attributabledeaths. This is
mainly due to Alcohol usedisorders (AUDs) which cause moredisability than mortality
compared toothers chronic diseases. Alcoholconsumption causes more deaths and
greaterburden of disease in theWHO European region than in any otherregion of theworld.
In theEuropean Region and particularly inhigh-incomecountries within Europe,thereis a
much higheralcohol-attributablediseaseburden compared to alcohol-attributable
deathsbecauseof the disabling impact of AUDs.

Table3: Summaryoftotal consumption,harmful drinkingpattern(HED) andburdenofdiseasefor

theWHOEuropeanRegionandtheWorld.
World WHOEuroRegion

Total alcohol percapita consumption(15+

years) litresofpurealcohol
6.2litres 10.9litres

PrevalenceofHeavyepisodicdrinking 7.5% 16.5%

(HED)(percentage)

Alcohol-relatedDeaths 5.9% 13.3%

Alcohol-attributablefactions(AAFs)for (3.3milliondeathsper
all-causedeaths-%ofall deaths year)

BurdenofDisease

Alcohol-attributablefractions(AAFs)for 5.1% 12.8%

all-causeDALYs-%ofall global DALYs
(139,000DALYs)

It isimportant to notethat harmfuluseofalcoholkillsordisablespeopleatarelativelyyoung

age, resulting in theloss of many years of lifetodeath and disability. Among allgroups
 22

starting from 15 years old,alcohol-attributabledeaths arehighestin theEuropean region.

Within theWHO EuropeanRegion,those aged 20-39 years have the highest proportion of
alcohol deaths (onein four) and forthe15-19 agegroup isonein five. While worldwide
alcohol-attributabledeaths are highest within the populationaged 40-49 years.

Alcohol’ sharmtoothers

Harmful useof alcoholresults insignificanthealth,socialand economic burden on

society atlarge. Alcoholconsumption canhaveboth health and social consequences for
others around thedrinker, such as family member, friends,co-workers and strangers. The
types of harmtoindividuals around the drinker includeinjury,neglectorabuse,default on
socialrole,property damage,toxic effects and loss of amenity or piece of mind. TheWHO
has identified alcohol’ s harmtoothers as a priority research area toenablefurther
burden of diseases studies includethis significantarea of alcohol-related harm, whichis
currently not included.

Alcohol related harm imposes significant socialand economic cost in society in three
main categories– direct costs mainly bornebygovernment such as costtothehealth
care,criminal justiceand thewelfare systems. Indirectcosts such as lost productivity due
toabsenteeism,unemployment,decreased output,reduced earningspotentialand lost
working years due to premature pension or death,mainly bornebysociety at large. The
third categoryis intangiblecosts,generallypoorly measured,such as thepain and
suffering and more generally diminished quality of life. The intangiblecostsaremainly
borneby drinkers as well astheir families and potentially by others linked tothedrinker.
Alcohol-attributable costs havebeen estimated at about € 125billionperyear in the
European Union (EU) in 2003 (Anderson etal 2006). In addition, the estimated intangible
costswere 270 billion in theEuropean Union.

2.3Evidenceofeffectiveness

Theextentandnatureofthealcohol-attributablediseaseburdenandsocial harmsprovidesa
solidrationaleforimplementingeffectivealcoholpoliciesbygovernments. The WHO Global
strategy toreduceharmfuluse of alcohol identifies guiding principles for the
developmentand implementation of alcohol polices at alllevels. Oneof thekey guiding
principles is thatalcohol policies should bebased on the bestavailable evidenceand that
public healthshould be given ‘ proper deference’ in relationtocompeting interests. A
substantial body of knowledgehas accumulated during recent years on thefeasibility,
effectiveness and costeffectiveness of different policy options shown toreduce
alcohol-related harm. The WHO report affirms that
 23

Thereis alsostrong evidence of effectiveness for certain measures againstdrink-driving

such as setting low BAClimits and enforcing them by randombreathtesting (Babor et al
2010). Screening and brief interventions forhazardous and harmfuldrinking have a good
cost-effectiveness profile,although their implementation requires more resources than
areneeded forpopulation-based measures (Chisholm et al2004; Anderson et al 2012).
Thereis someevidenceof effectiveness of multicomponent community interventions
(Holder et al2000; Wagenaaretal 2000;Ramstedtetal 2013). Therecent research
evidenceon the effectiveness of minimum unitpricing in reducing consumption and harm
has received much attention(Zhao et al2012; Zhaoet al 2013; Holmes etal 2014).

2.4Globalmonitoringframework

As a followon fromtheUNPolitical Declaration onNon-Communicable Diseases (NCD) in

2011 whereharmful useof alcoholwas identified ata key risk factor,along with tobacco
use, anunhealthy dietand lack of physicalactivity,onealcohol-related voluntary global
target wasrecommended

In addition,the following threealcohol-related indicators for monitoring were identified

Total alcohol percapita (aged15+years)consumptionperyear
Age-standardizedprevalence ofheavyepisodic drinkingamongadolescentsandadults
Alcohol-relatedmorbidityandmortalityamongadolescentsandadults.

For achieving thevoluntary target on alcohol,theGlobal Action Pan forthepreventionand

controlof NCDs proposed that Member Statesreduce the harmful useof alcoholthrough
thedevelopmentand implementation,as appropriate,of comprehensiveand
multisectoralnational policies and programmes,as outlined in theGlobal strategy to
reducetheharmfuluse of alcohol.
 24

3.Regulationofalcoholmarketing

3.1Rationale

Alcohol useis theleading causeof deathand disability foryoung peoplebetween theages

of 15-24 years(Goreetal 2011). Alcohol canalter the young developing brain,potentially
affecting bothbrain structure and function. This may causecognitiveorlearning
problems and/or make the brainmorepronetoalcohol dependence. This is especially a
risk whenpeoplestartdrinking at ayoung ageand drink heavily (US Surgeon General
Report 2007). Exposuretoalcohol marketing decreases theage that adolescentsstartto
drink and increases the amountthatadolescents whoalready drink consume. TheIrish
Government has given international commitments toprotect young peoplefromthe
pressure to drinking and to reduceexposuretoalcohol marketing (WHO
1995-2011).Therefore, protecting children from exposure to alcoholmarking is an
importantpublic health goal forIreland.

3.2ResearchEvidenceoneffectsofalcohol marketing

Thereis compelling evidence that alcoholmarketing is having an effectonyoung

people’ s drinking. This evidence basehas grownand the quality of the research design
has expanded. Numerouslongitudinalstudieshavefound that youngpeoplewhoare
exposedtoalcoholmarketingaremorelikelytostartdrinking,or ifalreadydrinking,todrinkmore
(Andersonetal 2009). These findings havebeen endorsed by theScientific Group of the
European Alcoholand Health Forum. Asummary of some of thekey findings from the
systematic reviewareprovided in Appendix3. Sincethatsystematic review,morestudies
continue to confirm and expand the findings,in particular related toalcohol branded
sports sponsorship and newdigital media.

Alongitudinal study in Scotland reported that involvement with alcohol marketing at

baseline (12-14 yrs) was predictive of both uptakeof drinking and increased frequency of
drinking atfollow-up (14-16 yrs). Awareness of marketing atbaselinewas also
associated with an increased frequency of drinking atfollow-up (Gordon et al2010). This
dose-responserelationship is alsoconsistent with that found with awareness of tobacco
marketing and tobacco consumption among young people(Davis et al2008). Grenard et
al (2013) showed that exposure to alcoholadvertising and liking of those ads inearly
adolescence had a significant influence on theseverity of alcohol related problems later
in adolescence,which was mediated by growth in alcoholuse in theintervening years.

Adolescenceis a timewheresocial engagement,communication,independenceand self-

expression are key developmental issues through such areas as sport, music and dance.
 25

These same lifestyle areas are increasingly used by thealcohol industry topromote pro
alcohol lifestyles (Hope2013). Although alcohol marketing may not beaimed at
underagedrinkers,they are nevertheless exposed to and affected by it. Adolescentsare
highly susceptibletoimageappeals becauseof their preoccupation with personal image
and identity (McCluretoal 2013).

Alcohol ismarketedthroughanintegratedmixofmarketingstrategies including broadcast (TV,

radio), outdoors (billboards, posters),print(newspapers/magazines),sponsorship,
merchandise,special price offers, product placement,package/productdesign and new
digital media (SNS,SME texting). AScottish study, using cross-sectional data,examined
thecumulativeimpact of alcohol marketing on youth (12-14 years) on drinking behaviour
(Gordon etal 2011). Fifteendifferent types of alcohol marketing wereexamined including
TV,print,outdoors,sponsorship,pricepromotionsand new digitalmedia. Two-thirds or
moreof the youth (12-14 year olds) were awareof advertson TV,clothing with alcohol
brands and sponsorship of sports by alcoholbrands. Adolescentswhohad had an
alcoholic drink wereaware of significantly more alcohol marketing channelsthan
adolescents who never drank. Therewas a significantrelationship between awarenessof
and involvementwithalcohol marketing and drinking behaviour (Gordon et al2011).

Asignificant associationwere found between ownership of alcohol– branded

merchandise and bingedrinking which occurred through (mediated) both drinkeridentify
and brand allegiance,identified by theresearchers as marketing-specific cognitions,
cognitions that marketersaim to cultivate intheconsumer (McClureetal 2013). While
exposuretoallforms of marketing areassociated with drinking by young people,more
active engagement,such as owning merchandise and downloading screensavers were
shown tobe stronger predictors of drinking. Early alcohol brand allegiancewas related to
not only drinking and futureintention to drink, but also consuming larger quantities (Lin et
al 2012). Exposuretoalcohol consumptionin movies was associated withyouthbinge
drinking and was little influenced by cultural differencebetween six countiesin Europe
(Hanewinkel et al 2012).

Examining thedifferent marketing areasin isolation whileuseful,underestimates the

power of modern marketing. Alcoholis marketed using multiple channels of
communications (integrated marketing), therefore the impactofthecumulativeexposureto
alcohol marketingismorepowerfulthanjustindividualchannels.

Alcohol brandedSportssponsorship

Alcohol marketing is notconfined to formalcommercialadvertisements. Thearea of

alcohol branded sports sponsorship illustrates the saturationexposureofalcoholproduct
 26

placementduringsportingevents. Astudyon the extentof marketing strategiesduring a

televised sports series concluded that, sport isincreasingly used as a vehiclefor the
promotionof ‘ risky consumption’ products (Lindsay et al2013). Theresearchers
examined themarketing for alcoholic beverages,gambling products and unhealthy foods
during thetelevised coverageof AustralianNational Rugby Leagueseries. Out of a total of
360 minutes,200 minutesof incidental alcohol marketing took place during the three
games,which was much higherthan for gambling (26 mins) orunhealthy foods(8 mins)
marketing. This equates to11.3 episodesper minute. Overone-third (37%) was ‘ on
field’ alcoholmarketing such as banners,display boards,paddings surrounding thegoal
posts,painted logos on the field,players uniform. The off-field alcohol marketing included
brand signagein coaching area, towels,chairs,drink coolers and in the teamdressing
rooms. Forabout twothirds of thetelevision broadcast,themarketing for atleastone
‘ risky’ product, mostnotablyalcoholwas visible. The commercial break
advertisements accounted for less than 1% of episodes,representing justover7% of the
marketing timeforallthree products. This illustrates thatembedded marketing strategies
can beextensive insports programmes and is similartoproductplacement in television
programmes, movies, videogames and onlineproduct placement.

An analysisof sixtelevised English Professional Footballrecorded visualalcohol

references ata frequency of nearly two perminute during the broadcast of thegames,
while verbalreferences and formal commercial advertisements accounted for less than
1% of broadcast time. Thevisual alcoholreferences included billboards alongsidethe
field of play,on the field of play,on-screen around replays,substitutions and score
updates. Theresearchers concluded thatthefrequently repeated nature of such
momentary glimpses,may combine to have agreater effect thansingle instances of
formal commercials (Graham& Adams 2013). An examination of embedded alcohol
visuals during theEURO2012 international soccermatches,showed that morethan one
perminute visual alcoholreferences wereidentified (Adams et al2014). Alongitudinal
study investigating theassociation between alcoholbranded sports sponsorship and
youth drinking among 14 year oldsin fourEuropeancountries (N=6,650) found that
adolescents who wereexposed to alcoholbranded sports weremorelikely to consume
alcohol more frequently. Exposurealsoindirectly influenced alcoholexpectancies,in
otherwords increased their expectation that alcoholwillmakethem feel morepositive
because of exposuretoalcohol branded sports sponsorship and thereforemorelikely to
drink (de Bruijn 2012a).
 27

Digital media

Theadvanceof alcohol marketing intosocial networking sites(SNS), atechnology widely

used by young people intheir daily lives,further extends therisk of exposuretoproalcohol
environmentsand youth drinking. AEuropean study, involving over 9,000 children from
fourcountries,reported thatthehighertheexposureof 14 yearolds toonlinealcohol
marketing,the higher therisk of binge drinking,indicating a doseresponseeffect (de
Bruijn,2012b).

SNSischangingthedynamicsofalcoholculturesinsignificantwaysandisshapingyoung
people’ salcoholuse. Thereareseveral studies which havereported onexposureof
childrenand adolescents toalcohol marketing on social media sites. In theUK, Facebook
was identified as thesocial media sitewith the highest reach,closely followed by
YouTube. The study demonstrated thepotentialfor high exposureof children and young
peopletoalcohol marketing through socialmedia websites. Marketer-generated brand
presenceon thefivealcohol brands studied wereidentified on Facebook,YouTubeand
Twitter with varying levels of userengagement (Winpenny et al2014). WhileFacebook
has an agerestriction inplace,the study reported 39% of boys and 48% of girls aged 6-14
accessed Facebook during thestudy period,suggesting that childrenprovidefalseages
toaccess Facebook. Whilein mostcases with YouTube and Twitter access was possible
by all ages. Young people in Ireland are nodifferent,with significant numbers (82%) of
13-16 year oldswitha profileon socialnetwork sites,which is higherthan the European
average. ( . Jernigan& Rushman (2013) reported thatuseractivity
on Facebook for the 15 alcohol brands most popular among US youth has grown
dramatically in the last number of years. However, protection againstyouth exposureto
alcohol marketing onsocial media sites is considered weak. Theresearchers found no
alcohol brandedsitesusinganykindofageverificationfromathirdparty,they allrely on the
individualusertoreportaccurateinformation.

Thealcohol industry’ s drivetouseSNS,blurs theline between user-generated and

industry marketing materials. An illustrationof this blurring,as reported byBradshaw
(2011),is theDiageo’ s advertising dealwithFacebook,described by Vice President of
Global Marketing at Diageo,

KathyParker,SeniorVP ofGlobal MarketingDiageo(Bradshaw2011).

 28

Diageo’ s engagement with Facebook resulted in a 20% increasein sales of fiveof their
key brands intheUS. IntheUK,Nicholls (2012) identified anumberof distinct marketing
methods used by alcoholbrands when using social media suchas real-world tie-ins,
interactivegames,competitions and timespecific suggestions todrink. He highlighted
thefactthat social mediagoesfurther thananypreviouscommunicationplatforminblurringthe
boundariesbetweenunidirectionaladvertisingmessages,consumerinteractionandbroader
socialactivities.

According toMcCreannoretal (2013) high levels of alcohol related materialon SNS

posted by users and frequent,on-going engagement with such materials bylarge
audiences intensifiesthenormsofintoxicationandentrenches‘ intoxigenic’ environments.
An exampleis therecent ‘ NEKnomination’ games,evidentin Ireland and elsewhere,
whereSNS environments wereused todare others to engagein reckless and dangerous
drinking games, with tragic consequences,demonstrating theserious risksposed for
adolescents and young people.

Arecent study inIreland,commissioned byAlcohol Action Ireland,examined alcohol

marketing exposureamong Irish adolescents (13-17 years) using a proportionalstratified
samplein threeregions (N=686) (AAI personalcommunication). Thefindingsshowed
highestexposuretoalcohol marketing was inoff-line(traditional) alcoholmarketing
(91%), followed by online(77%) and ownership of alcohol branded merchandise (61%),
based onprevious week exposure. The top fouroff-lineexposuremedia wereTV,outdoor,
newspapers and public transport. Onlineengagement with alcohol marketing was
reported by adolescents for-pop-up alcohol ads, invite to ‘ like’ an alcohol brand or
event sponsored by an alcohol brand and received an onlinequiz’ s aboutalcohol or
drinking. Childrenwhoowned alcohol branded merchandiseweremorelikely toengage in
drinking,bingedrinking and drunkenness,which weresimilar tofindings elsewhere
(McClureetal 2013 and Lin et al 2012). Intention to drinkin thenext year was also
predicted by exposuretoonlinemarketing.

Thereis a strongbodyofresearchevidencewhichshowsthatexposuretoalcoholmarketing,
whetheritisonTV,online,inmovies,inpublicplacesor alcoholbrandedsportssponsorship,
predictsfutureyouthdrinking. Theeffects of alcohol marketing on young people’ s
drinking aresimilartothatshownfor tobacco(Lovatoet al 2004) and food marketing
(Hastings et al2005).

Collective responsibility is necessary if theburden from alcoholis tobe reduced,sothat

current and future adolescentscan livehealthy and productive lives. The public health
experience whichradically changed tobacco policy showswhat can be achieved.
 29

3.3RegulationandEnforcement

Given theevidencethat exposuretoalcohol marketing hasa significant impact on the

decisions of young peopletodrink,stringent statutory regulations arerequired to protect
childrenfromthese significantrisks and negativeconsequences some of which resultin
serious disability. Alcohol is marketed through multiplechannels and themarketing
campaigns createpro drinking stimuli. Childrenaremostat high risk of indiscriminate
exposuretoalcohol marketing in three key areas:-

thepublic domain (outdoors),such as billboards,public transport and sporting

events,
on TV,beitfromdirect commercials or product placement across a rangeof
programmes, with sports programmes carrying a high risk of saturation exposure,
thenew digital media,in particularsocialnetwork sites,which arethefocus of
socialengagement for mostadolescents. It is nowtheplatformwherealcohol
commercialcompanies engagewith socialmediausers, providing a lethal
cocktailfor embedded alcohol marketing and wherethemedia userhas in effect
become a ‘ marketer’ forthealcohol industry.

Thecumulativeeffectofyoungpeople’ sexposureinthesemajor areasofalcoholmarketing

createsaproalcoholcultureamongyoungpeople,whoaresusceptibletoriskandharm.

BestPractice

Aproposed Framework forAlcoholRegulation and Enforcementcould includethe

following elements:

1) Clear publichealthobjectives – to protectpublic health and provide greater

protection forchildrenand young people, by reducing theexposureof children and
young people to alcoholmarketing.

2) Precautionaryapproach – recognising that society has asocial responsibility to

preventand protectchildren fromexposuretorisk to their health and well-being,
even whenfull scientific certainly has not been agreed by all.

3) Transparency -identify what alcohol marketing practisesarepermitted,for volume,

placeand content,sothat the measures are clear and transparent for the public to
understand (equivalenttotherules of the road).
 30

4) Sustainability – lowcost enforcement mechanisms are essential,as itrequires

long term commitmenttoprotect presentand future generations of children from
risk of early onset of drinking

5) Enforcement – ensurethat national young organisations/citizens groups can

validatecompliance issues and areproactive.

6) Accountability – requireindustry todisclose information as requested by

Government (Minister of Health) toensure exposure to alcoholmarketing by
young people is adequately reduced, in linewith legaltargets.

7) Infringements – where validated,fines actas a good deterrent as does offender

coveragein media (nameand shame).

These principles areconsistent with the approachestakenfor better regulation ina wide
rangeof sectors,including environmentalprotection and tobaccocontrol.

Not inlinewith best practice is theuse of audienceprofiling which is promoted by the

alcohol industry todeciderisk exposure. Itis fundamentally flawed,as itfails toprotect
largenumbers of children from exposure to alcoholmarketing. This was effectively
illustrated in recentstudiesexamining the frequency of embedded alcoholmarketing in
sports matches (Lindsay et al 2013; Graham& Adams2013). In the Australianrugby
series, the estimated viewed audienceaged 5-17 years was 290,711 young people(10.5%
of total audience) in gameone, 269,499 young people(10.7% of audience) in gametwo
and 321,466 young people (11.9% of totalaudience) in gamethree. Whilethe
consumption of alcohol products and gambling products arerestricted to thoseover 18
years of age, yet approximately 10-12% of theaudiencewatching theNationalSports
series were under 18 years (Lindsayetal 2013). In theUKEnglish Professional Football
matches,theaudience under18 years ranged from 19,000 youth (6.5% of audience) in one
gameto450,000 youth (9% of audience) in anothergame, in matches analysed (Graham
& Adams 2013). Using theaudienceprofiling method,allof theseprogrammes complied
with therules,yetsubstantialactual numbers of young people(under 18) were exposed to
high volumes of embedded alcohol marketing throughouteach of thegames. Therefore,
audienceprofiling is noteffectiveand should be avoided.

BestPracticeExamplesinEurope

The FrenchLaw ‘ LoiEvin’ isa good exampleof astrong transparent framework with the
key approach of providing guidance on whatis allowed,ratherthan stating whatis
forbidden in order toavoid ambiguity(Box1). In the French system,complianceis
monitored by non-governmentalorganisations.
 31

BoxI: Alcohol advertisingrestrictioninFrance

Franceimplementedimportantrestrictionsonadvertisingandsponsorshipinfavourof
alcoholicbeveragesinaccordancewiththe of1991.Atotal banexistsonTV
andonsponsorshipofanykind.Inbroadcasting, advertisingisforbiddenbetween17:00hours
and00:00hours, andonWednesdays(whenschoolsareclosed)from07:00hoursto00:00
hours.Advertisingisforbiddenintheprintmedia andoninternet websitesdedicatedtoyoung
people.
Advertisingisstill allowedon:
-billboardsandconveniencestorebrandpremises;
-small postersoranyiteminsideaspecializedpoint ofsale;
-cataloguesorbrochuressentbyproducers, importers, merchants, etc.;
-vehiclesusuallydedicatedtothedeliveryofalcoholicbeverages;
-promotional material fortraditional feastsandfairsdedicatedtolocal alcoholicbeverages;
-promotional material fortraditional museums, universitiesandcoursesonoenology;
-itemsspecificallydedicatedtotheconsumptionofalcoholicbeverages, marketedduringthe
directsaleofalcoholicbeveragesbytheproducerorduringtourist visitstotheproductionsite.

Thecontentofadvertisementsisrestrictedto: thedegreeofalcohol, originoftheproduct (soil,

characteristics),denomination,composition, detailsoftheproducerorsellers, development
process,termsofsale, waystoconsumetheproductandanyobjectivereferencetothe
characteristicsoftheproduct.Theaimistolimit advertisingtoobjectiveinformationabout the
product. Ahealthwarningmessagemust beplacedoneveryadvertisement allowed.
Respect fortheregulatoryframework isassuredbytheadvertisingregulationauthorityandby
surveillanceofadvertisementsbynongovernmental organizations.Violationsoftherulescan
bemetwith afineofupto€ 75000. Themaximumfinecanbeincreasedtoupto50%ofthe
budget fortheillegal activity.
DrPierre-YvesBello, Bureaudespratiquesaddictives(MC2), Directiongénéraledela
santé, Ministèredu travail,del’ emploi etdelasanté,Paris, France.
Source: .WHO Regional Office forEurope.

The FinnishAlcoholLaw includesa newsection todeal with new forms of onlineand social
media marketing. Thenewlaw restricts onlinealcohol advertising toprotectyoung
people. Thelaw clearly specifies whatis included and what isexcluded (see Box 2). In
Finland,a National Supervisory Authority forWelfareand Health supervises compliance
with Alcohol marketing regulation,together with the Regional StateAdministrative
Agencies.

Box2: Finland’ snewAlcohol MarketingRegulations2

Background: InFinlandtoday,all majoradvertisersarepromotingtheirproductsacrosstotallynew
platforms: social networks, viral videos, mobilephonesandvirtual communities. Gamesand
contestsareusedtoengageconsumersinmarketingactivities: “ Likeusandwin… !” . Young
peopleareespeciallyenthusiastic participantsinallonlinesocial networks.

2 Special thanksto Mr Ismo Tuominenfor assisting withthis summary, Ministerial Councellor – legal
affairs, Department forPromotionof Welfareand Health, Finland.
 32

ThegovernmentofFinlandtook noteofthistrendandtheevidencethat alcohol advertisingand

promotion"
” .

InDecember2013, theParliament ofFinlandapproveda Bill restrictingnewformsofonlineand

social mediaalcohol advertising. Thenewlawwill comeintoeffectin2015.
AccordingtotheFinnishAlcohol Act
- Alladvertisingofstrongalcoholicbeverages(>21%)isprohibited,butadvertisingofmildalcoholic
beveragesispermittedwith certainrestrictions:
-Not targetedtominors, noreferencetosocial orsexual successetc.
-TVwatershed 7.00-22.00
-Outdoorban -inpublicplacesi.e.streets, billboards,roadsides,buses,trams, deliveryvehicles, …
(exceptpublic events)
-Indoorbaninpublicplacesi.e.publicshoppingmall areas,hallways,TV-radioshopsetc.(except
restaurants, alcohol retail shops)
- Onlineandsocialmediamarketingban
"All advertisingandsalespromotionactivitiesareprohibitedif
-theyinvolvetakingpart inagame,lotteryorcontest orif
-theyinvolveanytextual orvisual contentproducedbyconsumersoranysuch content orcontent
producedbysuch actor*,which isintendedtobesharedbyconsumers"
*Thisappliesonlytoinformationnetworkingserviceactivitiesofa commercial actor.
Itdoesnot applytoprivatecitizens.

Thismeansthat alcohol advertisingwith anydigital gamesorgamingappsinconsoles, tablets

andmobilephonesaswell asproductplacement invideogameswill bebanned.All kindsof
alcohol salespromotionquizzes, competitionsandprizesinsocial media(aswell asinreal life)
will bebanned.Allowingpeoplesharingtheirstories,photosorvideosinthesocial media platform
ofanalcohol brandandmakingavailableviral videosintendedtobesharedbyconsumerswill be
banned.
Internet-marketingofalcohol will not bebannedassuch as,“ conventional” textual and
audiovisual content isstill allowedwith previousrestrictions.

Norway has a statutory lawthat regulates alcohol marketing and is administered by the
Minister of Health and CareServices. Nomarketing practices of alcoholareallowed
including a banof alcohol industry sports sponsorship. Complaints about violations of the
laws can befiled by any citizen to the DirectorateforHealth and SocialAffairs which is
responsibleformonitoring and imposes sanctions when thelaws havebeen violated.

TherearealsoseveralotherEuropean countries wherecertain aspects of alcohol

marketing arebanned. AlcoholindustrySportssponsorship is banned in seven WHO
European Region countries -France,Malta,Norway,Turkey,Former YugoslavRepublic of
Macedonia,Uzbekistanand Turkmenistan. A ban on alcohol advertising outdoors
(Billboards) is in placein Belarus, Sweden,Iceland,Norway,Uzbekistanand Turkmenistan.
Healthwarninglabels are required on alcoholadvertisements in fourteen countries –
 33

Belgium,Estonia, France,Israel, Latvia,Lithuania,Poland,Republic of Moldova,Romania,

Russia,Slovenia and Sweden,Ukraine,Uzbekistan.
 34

4.Healthlabelling

Health labelling serves two interconnecting purposes:

1. Health warning labels: Provides informationabout the risks associated with

alcohol use,both specific,drinking during pregnancy,drinking before driving,and
general health risks.
2. Low-risk drinking guidelines: Relevant information on alcoholcontainerscan help
drinkers track their alcohol intake,such as number of standard drinks in the bottle
(1sd=10 grams in Ireland),calories (obesity) and ingredients (sugarcontent).

4.1HealthWarningLabels

Baboretal (2010) examined theresearch evidenceonwhat effect health warning labels

on alcohol containers has on consumers and concluded,
“

Information from surveys indicate that a significantproportion of the populationhas seen

thesehealth warning labels. Thereis some evidencethathealth warning labels increase
knowledge regarding therisk of drink-driving and drinking during pregnancy among some
groups (lightdrinkers). Among college students,a health warning ‘ alcohol isa drug’
resulted in greaterperceived risk than the standard US warning labelson alcohol
containers (Creyer etal 2002). A reviewby MacKinnonand Nohre(2006) concluded that
thereis noconvincing evidenceof aneffect of general alcohol warning labels on
behaviour. Itmay bepossible to enhance awareness of health warning labels by
combining itwith others strategies such ascommunity-based campaigns tochange
alcohol policies or enforcealcohol-related regulation,but sofar evidenceis lacking. In the
Eurobarometer surveyof 2009,79% of EU citizens supported health warning messages
(pregnancyand driving) on bottles and an even high proportion (82%) supported warnings
on advertisements (Special Eurobarometer 331). Kerr & Stockwell (2012) have indicated
thataccurate information on thealcohol content of specific beverages isessentialto
promote drinker’ s tracking of alcohol intakeand that the number of defined standard
drinks in each alcohol container is aneffective way of enabling it.

4.2Low-riskdrinkingguidelines

Therearechallenging issues in setting low-risk drinking guidelines. As pointed outby

Stockwelland Room(2012),there are twomain approaches – ‘ relativerisk’ as used in
developing the new Canadian guidelines and ‘ absolute risk’ as used in Australia. A
relativerisk approach considers theproportionate changein risk foran individual orsocial
 35

category fora given consumption of alcohol,while the absoluterisk approach is

concerned with thecategory’ sabsoluteincrement in risk from the alcoholconsumption,
regardless of thelevelof risk from others factors. The main difference inresults between
thetwo approachesis thatwith ‘ relative risk’ the upper limitper occasion formen is set
higherthatforwomen (Stockwell & Room 2012). Froma health promotion perspective,
theissueis how widely arelow-riskdrinking guidelines recognised and towhat extentdo
they affect normsand behaviour. A‘ standard drink’ measuretendstobeused in
population surveys and in clinical settings to evaluateoverall consumption and
hazardous and harmful drinking patterns. However,theresearch evidenceshowsthat
‘ standard drink’ or units arewidely misunderstood by thegeneral public (Kerr&
Stockwell,2012). Firstly, the ‘ standard drink’ definition varies across countries and
typically contains less alcohol than actual drinks. Secondly, drinkershavedifficulty
defining and pouring standard drinks, with over-pouring being the norm, sothat theintake
volume is typically underestimated. The lack of knowledgeof low-risk drinking
guidelines was also confirmed in a sampleof young people(16-25 yrs) in England (de
Visser &Birch 2012). In a largegeneral population in Australia, knowledgeof the official
guidelines was also low,with younger respondents and heavier drinkers providing higher
estimates of low-risk drinking thresholds (Livingston 2012). Evidenceon theeffectsof
guidelines on actual drinking behaviour remains scant. However,Stockwelland Room
(2012) reported ontwoAustralian studies where changes intheguidelines, from
abstinenceduring pregnancy to aguidelineof less than 7 standard drinking per week and
nomorethan 2 drinks a day,produced apositive(reduction in theproportion of pregnant
women drinking moderately or more heavily) and an negativeeffect (drop in abstainers
among mothers of babies born beforeand after the changes).

Kerr and Stockwell (2012) indicatethat ‘ standarddrink’ labellingisaneffective,butlittle

usedstrategy,forenablingdrinkerstotracktheiralcohol intakeandpotentiallyconformto
low-riskdrinkingguidelines. Anadded benefit of health labelling, over and above the benefit
of communicating the risks associated with alcohol use,is thelabelling of the number of
standard drinks on thealcohol container which can provide opportunities forgreater
awareness of low-risk drinking guidelines.

Thelow riskdrinking guidelines (weekly) in Ireland had traditionally followed theUK guide,
using theUK unitof 8 grams. However,a study published in 2009 established that the
standard drink in Ireland is 10 grams and recommended theupper weekly low riskdrinking
guidelines be revised tothe11/17 standard drinks toreflect that fact (Hope,2009). In
Ireland,a survey conducted in 2012 by Ipsos MRBI on behalf of theHealth Research Board,
showed thatvery few peopleunderstand what astandard drink is. Only one inten(9%)
 36

peopleknew thelow risk drinking guidelineweekly upperlimit (old limits) of 14 standard

drinks for women and 21 formen. Themajority supported labelling alcohol containers to
include calories,alcoholic strength,ingredients and health warnings (82%-98%).
Therefore,theinformation and opportunityis now available to ensurethatthestandard
drink is explicitly stated on thelabel of alcohol containers sold in Ireland,which hasa high
level of public support. The proposed Frameworkfor Alcohol regulation and
Enforcementcould equally apply tohealth labelling. Thecontent of thehealth labeland
theenforcementmechanisms should betheresponsibility of theDepartmentof Health
with delegated responsibility totheHealth ServiceExecutive.

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40
 41

Appendix1

Prevalence of Heavy episodic drinking (% in 2010)

EU28 - males
Austria 53.0
Czech Republic 53.5
Ireland 53.0
Finland 51.8
Lithuania 50.6
Belgium 47.7
Greece 47.6
Hungary 44.5
France 42.2
Cyprus 42.0
Slovakia 41.3
Estonia 40.1
Malta 38.0
Denmark 37.8
Luxembourg 36.9
UK 35.5
Sweden 33.2
Latvia 30.3
Portugal 30.1
Bulgaria 27.0
Croatia 20.5
Spain 19.7
Germany 19.4
Romania 13.8
Slovenia 13.1
Netherlands 10.5
Poland 10.1
Italy 8.0
 42

Appendix2

Prevalence of Heavy episodic drinking^ (% in 2010)

EU28 - females
ustria 28.9
eland 25.5
huania 25.0
h Republic 24.9
reece 22.8
nland 22.0
elgium 21.7
UK 20.9
nmark 19.5
rance 17.7
ovakia 16.8
Malta 15.7
weden 14.5
Latvia 13.2
ulgaria 12.7
ortugal 11.5
embourg 11.4
ungary 10.3
yprus 9.4
stonia 9.3
Spain 7.3
ermany 5.9
roatia 2.0
omania 1.7
ovenia 1.6
herlands 1.3
oland 0.9
Italy 0.7
 43

Appendix3

Effectsofexposuretoalcoholadvertisingondrinkingbehaviour
SummaryofKeyfindings

Asummaryof keyfindingsontheeffectsofexposuretoalcohol advertisingondrinkingbehaviour

(deBruijn2012c), are:
12yearoldswhoarehighlyexposed to overallalcoholadvertising aremore likelytostart
drinkingwithinayear, comparedto12yearoldswhoareonlyslightlyexposedtoalcohol
advertising(Collinset al 2007).
Youngsterswhowatchmore alcoholadvertisementsontelevision thanaverageare44%
morelikelytohaveeverusedbeer, 34%more likelytohaveeverusedwine/hardliquorand
26%morelikelytohaveeverdrunk threeormoredrinksononeoccasion(Stacyet al 2004).
Innon-drinking13-year-olds, exposureto in-storebeerdisplays predictstheage ofonsetof
drinking(Ellicksonet al2005).
Teenageboyswhoownan alcohol-brandedpromotionalitemare1.78timesmorelikelyto
start usingalcohol thanboyswhodidnot ownsuch items. Forgirlsthefigurewas1.74
(Fisheret al 2007).
Possessionofa promotionalitemfromanalcohol producerandanattitudinal susceptibility
towardalcohol brandspredictedtheageofonset ofdrinkingaswellasbingedrinking
among10-14yearolds(McClureet al 2006;McClureet al 2009).
Teenagerswhoarehighlyexposedto alcoholadvertising will drink morealcohol whenthey
areintheirtwenties.Inyoungsterswhohavebeenslightlyexposedtoalcohol advertising,
alcoholconsumptionstabilizesintheearlytwenties(Snyderet al 2006).
10-12yearoldsexposedto outdooralcoholadvertisementswasassociatedwith
subsequentintentionstodrink (Pasch 2007).

Someadditional studiesnot insystematicreview

Studiesontheimpact of exposureto alcoholportrayalinfilms concludedthat thestart of
alcoholusewaspositivelyrelatedtobaselineexposuretoalcohol advertising(Sargent et
al 2006; Hanewinkel et al 2009;Morgensternetal 2011).
Experimentalstudiesontheimmediateeffect ofalcoholadvertisingsuggest adirect
effectofexposureto alcoholmarketingcuesinfilmsand/ortelevisioncommercials.(Engelset
al 2009; Koordemanet al 2011).
Hazardousdrinkingwasmorecommoninadult sportspeoplewhoreceivedsomeformof
sportsponsorship thanthosewhoreportednosponsorship(O’ Brienet al 2011).

In2009theScientificGroupoftheEuropeanAlcoholandHealthForumconcludedthat“
44
 45

Alcohol consumption per adult in Ireland, 1984-2013

16.0
14.0
litres of pure alcohol

12.0
10.0
8.0
6.0
4.0
2.0
0.0
198 198 198 198 198 198 199 199 199 199 199 199 199 199 199 199 200 200 200 200 200 200 200 200 200 200 201 201 201 201
4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3
Beer 6.6 6.7 6.9 6.7 6.6 7.3 7.6 7.5 7.7 7.4 7.5 7.6 7.9 8.0 8.2 8.3 8.1 7.9 7.7 7.4 7.2 7.0 6.8 6.6 6.1 5.6 5.6 5.5 5.4 5.1
Spirits 2.1 2.5 2.4 2.2 2.3 2.3 2.4 2.3 2.2 2.2 2.2 2.1 2.3 2.4 2.4 2.8 3.0 3.1 3.2 2.5 2.5 2.5 2.6 2.7 2.4 2.0 2.2 2.2 2.3 2.0
Wine 0.6 0.6 0.6 0.6 0.7 0.7 0.8 0.8 0.8 0.9 1.0 1.1 1.3 1.3 1.5 1.7 1.9 2.1 2.3 2.4 2.7 2.8 2.9 3.0 2.8 2.6 3.0 3.1 3.1 2.8
Cider 0.2 0.2 0.2 0.2 0.2 0.2 0.3 0.3 0.4 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2 1.1 1.1 1.1 1.1 1.1 1.1 0.9 0.9 0.8 0.8 0.8 0.8
Total 9 5 10 10 9 8 10 10 11 10 11 11 11 11 12 12 13 13 14 14 14 13 13 13 13 13 12 11 11 11 11 10