Proposals to deal with alcohol misuse

What has the Government noted about alcohol consumption?
1. The Government has noted the excessive patterns of alcohol consumption and resultant social, economic and health harms as set out in the Report of the Steering Group on a National Substance Misuse Strategy. It has also accepted the broad thrust and evidence base of the Report of the Steering Group on a National Substance Misuse Strategy in particular that a broad range of complementary measures is required to successfully reduce consumption of, and harms associated with, alcohol misuse.

What measures has the Government approved today on alcohol misuse?
2. The Government has approved the drafting of legislation – in the form of a Public Health (Alcohol) Bill – to provide for:

• minimum unit pricing for retailing of alcohol products;
• regulation of marketing and advertising of alcohol, specifically to
• limit advertising of alcohol on television and radio from 2016 to evening hours;
• limit advertising of alcohol in cinemas to films classified as over 18s;
• restrict advertising of alcohol in outdoor media from 2018, with a statutory code of practice to govern such advertising in the interim;
• the enforcement by Environmental Health Officers of regulations relating to the sale, supply and consumption of alcohol products under section 16 of the Intoxicating Liquor Act 2008 so as to restrict advertising, promoting, selling or supplying alcohol at reduced prices or free of charge,
• regulate advertising of alcohol in print media by way of a statutory code;
• prescribe the manner in which alcohol may be portrayed in advertisements;
• regulation of sports sponsorship, specifically to place an existing voluntary code that governs sports sponsorship on a statutory footing;
• structural separation of alcohol from other products: – provide enforcement powers for Environmental Health Officers in respect of existing legislation that has yet to be commenced on structural separation;
• · health labelling of alcohol products specifically –
• the placing of health (to include pregnancy) advice and warnings on all alcoholic drink containers (bottles, cans etc.) and on promotional materials;
• the display of the amount of pure alcohol as measured in grams and the calorie count contained in each container/measure on the label/container.

The Steering Group recommended that drinks industry sponsorship of sport should be phased out. What will happen next?
3. At its meeting on 22 October, the Government recognised the public health concerns associated with alcohol sponsorship of sport, while acknowledging also the potential impact of any regulatory measures on funding for sports organisations. It agreed to establish a working group to consider the value, evidence, feasibility and implications (including the public health consequences for children and young people and the financial impact on sporting organisations) of regulating sponsorship by alcohol companies of major sporting events, and that the group will also consider alternative sources of funding for sporting organisations to replace potential lost revenue arising from any such regulation. The group will comprise of a number of departments and shall be chaired by the Dept of An Taoiseach. It is to report within 12 months.

4. In the meantime, the Government wants the existing voluntary code that governs sports sponsorship to be placed on a statutory footing. If the proposed statutory code contains any differences to the existing voluntary code of practice, these will be brought back to the Cabinet Committee on Social Policy for approval.

What advertisements on billboards and other ‘outside’ media will be banned?
5. This refers to outdoor media advertising. The Dept of Health, in conjunction with relevant government departments, will put in place a process which will identify the forms, frequency and prevalence of outdoor media advertising to be either encompassed or exempted from any restrictions. The clear policy rationale for dealing with restricting the outdoor advertising of alcohol products is that children need to be protected from branded alcohol advertisements. Research shows that, among young people, alcohol advertising and promotion predicts both the onset of drinking among non-drinkers and increases levels of consumption among existing drinkers.

What is Minimum Unit Pricing (MUP)?
6. MUP sets a minimum price per gram of alcohol. The minimum price of an alcohol product would therefore be based on the number of grams of alcohol in the product. The sale price of the alcohol product could not be below this minimum unit price.

Does this mean that everyone pays more for their drink?
7. No! The aim of MUP is to increase the price of alcohol which is cheap relative to its strength. MUP will be the instrument to be used to tackle the very low cost at which alcohol is sold in the off-trade sector (particularly in supermarkets). By using MUP, we hope to target harmful and hazardous drinkers and reduce their consumption as there is evidence that this cohort of drinkers tend to purchase disproportionate amounts of such alcohol, no matter what is the income level of the drinker.

How will MUP work?
8. Once legislation on MUP has been passed the Government will set a minimum price per gram of alcohol. This minimum price will be based on research currently underway with Northern Ireland, which is also interested in a policy on MUP. The minimum price per alcoholic drink would then be the minimum price per gram of alcohol multiplied by the number of grams in the alcoholic drink.

What else did the Government agree to today on alcohol?
9. The Government agreed that public health messaging relating to alcohol will be based on grams of alcohol and that weekly low-risk drinking guidelines should be 168 grams (17 standard drinks) and 112 grams (11 standard drinks) for men and women respectively – with 1 standard drink equating to 10 grams of pure alcohol. It agreed that Ireland should set as a target for 2020 the OECD average consumption figure of 9.1 litres of pure alcohol consumed per person over 15 in the population per annum (current 11.6 in 2011). Finally, it agreed that the Department of Health should report on progress on the implementation of these measures and other recommendations in the Steering Group report by way of an annual report to be laid before the Houses of the Oireachtas.

When was the report from the National Substance Misuse Strategy Steering Group published?
10. February 2012

What happens next?
11. Legislation in the form of a Public Health (Alcohol) Bill will be drafted; this is the first time that legislation on alcohol and public health will be developed. In addition, implementation of the approved range of measures on availability/supply, prevention, treatment and rehabilitation and monitoring pillars in the Substance Misuse report will commence. An annual report will also be written that will report on progress with implementing these measures; this report will be laid before the Houses of the Oireachtas.

What were the Terms of Reference of the National Substance Misuse Strategy Steering Group?
12. They included:

· Having reviewed existing policies and reports, including at EU and international level, set out an evidence-based framework which identifies effective policies and actions to tackle the harm caused to individuals and society by alcohol use* and misuse (* alcohol use” in this context refers to the use of alcohol across the entire population. It does not imply that all alcohol use is harmful);
· decide on appropriate structures and frameworks for an effective and efficient implementation plan for the National Substance Misuse Strategy;
· align, as far as possible, these policies and actions with the existing 5 pillars of the National Drugs Strategy – supply, prevention, treatment, rehabilitation and research;
· make proposals for an overall National Substance Misuse Strategy to incorporate the National Drugs Strategy 2009-2016.

Who sat on the Steering Group?
13. The Steering Group, chaired by the Department of Health, was established in December 2009 to advise Ministers on a new Strategy. When establishing the Group, a cross-departmental and cross-sectoral representation was required in order to effectively reflect a whole-population approach. The Steering Group comprised representatives from relevant Departments and agencies, medical professional bodies, the community and voluntary sectors and the alcohol industry, including:

· Department of Justice & Equality;
· Department of Education & Skills;
· Health Service Executive;
· The College of Psychiatry of Ireland;
· Royal College of Physicians in Ireland;
· Irish College of General Practitioners; and
· Alcohol Action Ireland.

Why is policy on alcohol and illicit drugs being combined in one Strategy?
14. The Programme for Government commits to having a “National Addiction Strategy” dealing with both drugs and alcohol. The Government decided in 2009 to include alcohol in a National Substance Misuse Strategy. Arising from this decision, a Steering Group chaired by the Department of Health (originally the Steering Group was jointly chaired by the Department of Health & Children and the Department of Community, Rural & Gaeltacht Affair) was established to advise Ministers on a new Strategy.

15. The reasons for combining the approach to alcohol and drugs include the following:

· they are all psychoactive substance that can impair motor skills and judgement;
· they are drugs of dependence;
· alcohol can act as a gateway to the use of illicit drugs for some people;
· polydrug use is now commonplace and those who drink alcohol and use other drugs place themselves at greater risk and make treatment responses more complicated; and
· broadly the approaches to prevention and treatment are similar in the cases of both alcohol and drugs.

What were the key findings of the Steering Group?
16. On the harmful effects of alcohol, the Steering Group noted – among other things – that alcohol:

· Was responsible for at least 88 deaths every month in 2008 (source the National Drug-Related Deaths Index); 1 in 4 deaths in young men were estimated to be due to alcohol, which compares to 1 in 12 deaths due to cancer or 1 in 25 due to cardiovascular disease;
· is a contributory factor in half of all suicides and in deliberate self-harm; it also increases the risk of more than 60 medical conditions – such as cancers;
· is associated with 2,000 beds being occupied every night in Irish acute hospitals; a quarter of injuries presenting to emergency departments and 7,866 admissions in 2010 to specialised addiction treatment centres;
· is associated with harms to the baby because of mothers drinking during pregnancy and is a factor in unplanned pregnancies;
· increases the risk of children needing special care, with the an estimation that adult alcohol problems are associated with 16% of child abuse cases;
· was a trigger in a third of domestic abuse cases in 2005;
· related illness cost the healthcare system €1.2 billion and alcohol-related crime cost an estimated €1.19 billion, both in 2007; the cost of lost economic output due to alcohol was estimated to be €527m in 2007 and finally, alcohol related road accidents cost an estimated €530m in 2007.

17. On Irish alcohol consumption patterns:

· Per capita consumption is considered a good indicator of alcohol-related harm in a country. International evidence indicates that the higher the average consumption of alcohol at the individual level and in a population, the higher the incidence of alcohol-related problems for both.
· In 2010 the per capita consumption in Ireland equated to 11.9 litres of pure alcohol per adult, corresponding to 482 pints of lager, 125 bottles of wine or 45 bottles of vodka. Given that 19 per cent of the adult population are abstainers, the actual amount of alcohol consumed per drinker is considerably more.
· Per capita consumption would be reduced to 9.2 litres of pure alcohol if every adult drank at the low risk ceiling quantity of alcohol.
18. The Steering Group specified a series of harm patterns for alcohol that seem to represent an insurmountable ‘wall of harm’ hazardous to Irish people, 1.5million Irish drinkers drink in a harmful pattern.

19. On the economic benefits of the alcohol industry, the Steering Group acknowledged the economic benefits of the alcohol industry to the Irish economy. The alcohol industry provided an estimated 50,000 jobs and €2 billion in VAT and excise revenues to the State in 2008. There was a turnover of €2.95bn by the alcohol manufacturing industry in the same year. Also pubs in Ireland are deemed to be an important component of the Irish tourism industry, though there has been an estimated decline in jobs in the on-trade sector (pubs and other hospitality venues) of 26% between 2000 and 2008.

20. On the supply and availability of alcohol, the Steering Group noted that alcohol availability is a key factor and measures to reduce supply are essential if the population targets to reduce consumption are to be met. The supply chapter is predicated on regulating and controlling the supply and price of alcohol so that the potential for alcohol-related harm is minimised. The recommendations from the Steering Group are derived from five practical ways to achieve this principal objective:

· Reduce the supply of cheap alcohol;
· control the availability of alcohol;
· prevent the sale of alcohol to minors;
· restrict alcohol marketing and sponsorship;
· prevent drink-driving.

21. The report declares that, despite having one of the highest excise duty regimes for alcohol in the EU, alcohol still remains cheap in Ireland. The majority of the Steering Group were in favour of fiscal measures to increase the price of alcohol. Recommendations of the Group included:

· Increase the price of alcohol to make it less affordable;
· introduce legislation to provide for a minimum price per gram of alcohol; and
· prohibit savings from multiple purchases.

22. The introduction of a social responsibility levy was also among the recommendations.

23. In dealing with supply, the Report addressed:

· the licensing process and regulatory environment governing the on-trade and off-trade (the off-trade comprises specialist off-licenses and mixed trading outlets);
· the sale and display of alcohol in the off-trade;
· the sale of alcohol to various cohorts of consumers (under 18s, intoxicated persons); and
· server training programmes.

24. The Steering Group recommended that a statutory code of practice be enacted on the sale of alcohol in the off-licence sector; and that existing statutory provisions for the structural separation of alcohol from other products in mixed trading outlets such as supermarkets, be commenced.

25. The report also dealt with the Marketing & Promotion of alcohol. The Supply chapter gives a brief overview of existing statutory and non-statutory codes of practice on advertising and promotion of products in so far as they apply to alcohol products. It addresses the issue of sponsorship by the alcohol industry in sports and other large public events, and brand-stretching (alcohol advertising on clothes, etc). It recommended statutory control of all alcohol advertising in all Irish media, along with the feasibility of investigating the control of advertising alcohol in digital media given the global nature of such advertising. The Group recommended that drinks industry sponsorship of public events should be phased out as part of this statutory framework.

26. On the role of Prevention Strategies in reducing alcohol and drug related harms, the Steering Group noted that the population based approach for preventing the misuse of alcohol is predicated on raising awareness generally and deploying measures to delay children starting to drink. At the outset, the Steering Group recommended that the low-risk weekly consumption guidelines of pure alcohol should be 168 grams and 112 grams for men and women respectively (the Irish standard drink is calculated at 10 grams); and that alcohol products should be labelled with calorific content, weight of alcohol content, and health warning on drinking during pregnancy.

27. The prevention chapter aims to fortify the message on the harms of alcohol to the same degree of diffusion and saturation in all media that matches the promotion of consuming alcohol by the alcohol industry. The Group recommended co-ordination of prevention activities across all statutory and voluntary organisations at both national and local levels for the purposes of using information technology and marketing of alcohol harms to target underage drinking, anti-social behaviour, general excessive drinking, and drinking in pregnancy.

28. On the Treatment and Rehabilitation of those experiencing problems associated with alcohol and drugs, the Steering Group recognises that the focus needs to be broadened beyond individuals with moderate to severe alcohol dependence to the large cohort of drinkers whose problems are less severe. Screening and brief interventions are effective for many and should be carried out in general community settings and delivered by non-specialised trained personnel. The aim is to develop a national treatment and rehabilitative service that promotes early intervention and that is based on integrated care. Particular emphasis is put on family support services (especially children affected by parental drinking), aftercare and detoxification.

29. The aim is to encourage early intervention to treat alcohol use and misuse. With this aim in mind, the Group recommended the establishment of a Clinical Directorate in the Health Service Executive that would be responsible for improving treatment. The overall aim of the approach to intervention is to encourage reduction in consumption. Protocols for screening and intervention should be implemented across all relevant sectors of the health and social care system – including maternity services.

30. Some of the other recommendations of the Steering Group include developing regulatory standards for all residential services with regard to substance misuse; addressing gaps in child and adolescent service provision and developing multi-disciplinary child and adolescent teams; assigning liaison nurses to all general hospitals for the purposes of screening and brief interventions for alcohol related illnesses; integrating care planning between mental health and drug/alcohol services, and developing links with mental health teams (community and specialist); developing an approach to addressing the needs of children and families experiencing alcohol dependency problems.

Research
31. The objective with respect to research and information is to ensure the availability of data on alcohol use and to inform policy development and services delivery. And in this regard, the Steering Group recommended the collection of data on alcohol to be used to identify the prevalence and patterns of alcohol use and misuse; demand for alcohol treatment; alcohol-related deaths; public expenditure; and harm reduction.

Harms to children from alcohol
32. The Steering Group referred to the pattern of alcohol consumption of children based on available evidence. It reported that the average age of first alcohol use in children decreased from 15 years of age for children born in 1980 to 14 years of age for children born in 1990; and alcohol marketing leads to young people starting drinking at a younger age – and drinking more.

33. The Steering Group declared that:

· Exposure to alcohol advertising and promotion predicts both the onset of drinking among young non-drinkers and increases the level of drinking among existing young drinkers;
· Irish 16-21 year olds list alcohol advertisements as five of their top ten favourite advertisements.

34. The harms for children identified by the Group are clearly set out in the report. Most of the harms are generic but specific harms applicable to children include the following:

· A range of disorders known as fetal alcohol spectrum disorders are caused by mothers drinking alcohol in pregnancy;
· alcohol misuse by adults increases the risk of children requiring special care: alcohol was identified as a risk factor in three-quarters of Irish teenagers for whom social workers applied for admission to special care; and it is estimated that adult alcohol problems are associated with 16% of child abuse cases;
· Irish adolescents with serious drug and alcohol problems had commenced alcohol use at a much earlier age than their counterparts without significant drug or alcohol problems.

35. As stated, the Steering Group was wholly cognisant of children when framing their recommendations; and therefore, these recommendations are again generic – applying to all cohorts of the population including children. Some more specific recommendations for children include the following:

· With a particular focus on impacting on the age of the onset of alcohol consumption, and the consumption levels of under 18 year olds, introduce a statutory framework with respect to the volume, content, and placement of all alcohol advertising in all media in Ireland (including the advertising of pubs or clubs). This will involve the utilisation of existing legislation (such as the Broadcasting Act 2009) as well as the development of new legislation. Measures envisaged by the Steering Group are (a) a 9.00 p.m. watershed for alcohol advertising on television and radio; (b) alcohol advertising in cinemas to only be associated with films classified as being suitable for over 18s; (c) prohibiting all outdoor advertising of alcohol; and (d) all alcohol advertising in the print media to be subject to stringent codes, enshrined in legislation and independently monitored;
· drinks industry sponsorship of sport and other large public events in Ireland should be phased out through legislation by 2016;
· utilise Information and Communications Technology and consider a social marketing approach, to target – among others – underage drinking;
· develop a system to monitor the enforcement and effectiveness of the provisions in licensing law concerning the sale, supply or delivery of alcohol to minors;
· introduce mandatory age authentication controls on the advertising of alcohol on web sites hosted in Ireland; investigate feasible approaches to, and subsequently implement controls on, the volume, content and placement of all alcohol marketing in digital media; and engage with EU colleagues to explore the feasibility of introducing common restrictions on advertising on a European level;
· encourage the provision of alcohol free venues for young people, with an emphasis on those most at risk, (such as Youth Cafés, alcohol free music and dance venues and sports venues);
· further develop a co-ordinated approach to prevention and education interventions in relation to alcohol and drugs as a co-operative effort between all stakeholders in a number of environments that include youth organisations and services;
· further develop prevention measures aimed at families in relation to alcohol misuse (including prevention measures in relation to parental alcohol problems and the effect of this on children);
· continue the development and monitoring of SPHE in schools and Youthreach centres for education.

36. The Steering Group also covered issues pertinent to children and families within its elaboration on the treatment and rehabilitation of people due to the misuse of alcohol. These include addressing gaps in child and adolescent service provision and developing multi-disciplinary child and adolescent teams; along with developing an approach to addressing the needs of children and families experiencing alcohol dependency problems.