Alcohol misuse, public health, and public policy
http://www.100md.com
《英国医生杂志》
A comprehensive and evidence based approach is needed
Alcohol misuse continues to be associated with as many as 22 000 deaths each year in England, with cumulative economic, health, and social costs estimated at ￡20bn annually.1 While people in many other parts of Europe may have consumed a greater amount of alcohol in the past—although varying definitions of categories of consumption hamper accurate cross national comparisons2—the situation in England is one of increasing concern. According to recent figures, 38% of men and 23% of women in England exceed recommended maximum levels for the heaviest drinking day of the week,3 and alcohol related illness mortality is on the rise.4 Drinking patterns vary between England's regions in a predictable manner that reflects persistent health inequalities,5 notably with the highest rates of binge drinking found in the north-east. Formulating effective and palatable public policy to tackle this is difficult,6 not least because moderate regular intake of alcohol may benefit health.2 Improving the population's health and reducing health inequalities both require comprehensive and evidence based solutions.
Against this backdrop, the Licensing Act 2003 was introduced in England on 7 February 2005. The act is underpinned by four stated objectives: the protection of children from harm, the prevention of public nuisance, the prevention of crime and disorder, and public safety. Previously, concerns about crime and disorder were usually the sole grounds for objecting to the granting of an alcohol licence to premises such as pubs and bars. Under the new act, each of the four objectives must be given equal weight when an application is considered by the licensing authority (in most cases now the local authority). Importantly, however, the act does not allow objections to applications for licences on public health grounds.
In early 2004 the Alcohol Harm Reduction Strategy for England was published, identifying four key strands of activity: better education and communication, improving services for health care and treatment, combating alcohol related crime and disorder, and working with the alcohol industry.1 These activities have subsequently been developed within the government white paper Choosing Health.7 Although much is to be commended in these documents, they share two traits that affect how effective a public health response to alcohol misuse can be.
Firstly, detail remains limited on how the toll of alcohol misuse on population health and its contribution to health inequalities will be dealt with. As Professor Ian Gilmore, chair of the Royal College of Physicians' Alcohol Committee, cautioned in a recent interview, "the recommendations and policy measures promoted in these two documents concentrate too heavily on the aspects of drinking most closely related to law and order issues at the expense of health."8 The fact that references to public health were explicitly removed from the Licensing Act 2003 during its progress as a bill clearly reinforces such concerns.
Secondly, the emphasis given to action being led by the alcohol industry generates unease. The government has praised voluntary schemes such as the Portman Group's Code of Practice on the Naming, Packaging and Promotion of Alcoholic Drinks9; and it would be unhelpful to dismiss such schemes solely on a matter of principle, as they may generate legitimate opportunities to take cooperation further than regulation alone would achieve.There is strong evidence, for example, that intensive face to face training of those serving drinks (with strong management support) is effective in reducing levels of intoxication among customers.10 The systematic implementation of an evidence based intervention such as this requires balanced partnerships involving the alcohol industry from the outset. Genuine corporate social responsibility within the alcohol industry should be encouraged, and the recent announcement by the British Beer and Pub Association of new standards for drinks promotions and happy hours would seem to be a positive step.11 However, industry led initiatives should be approached with necessary caution and vigilance, as they can be ineffective and even counterproductive (as the tobacco industry's voluntary codes have repeatedly shown).12
The Licensing Act 2003 has generated welcome, if often intemperate, political and public discussion about the impact of alcohol misuse on the health and wellbeing of individuals and communities across England. Pragmatic and responsive public policies (whether national, regional, or local) must be comprehensive and grounded in the best available evidence if they are to be truly effective, as the consequences of getting it wrong are too great.
Soumen Sengupta, regional associate director
1 National Institute for Health and Clinical Excellence, North East Regional Office, Durham University Science Park, Durham DH1 3YG
(soumen.sengupta@nice.org.uk)
Lesley Hoyle, health inequalities lead
2 Langbaurgh Primary Care Trust, Guisborough TS14 7AA
Competing interests: None declared.
References
Cabinet Office. Alcohol harm reduction strategy for England. London: Cabinet Office, 2004. www.strategy.gov.uk/downloads/su/alcohol/index.htm (accessed 30 May 2005).
World Health Organization. Global status report on alcohol 2004. Geneva: WHO, 2004. www.who.int/substance_abuse/publications/en/global_status_report_2004_overview.pdf (accessed 30 May 2005).
South East Public Health Observatory. Indications of Public Health - Lifestyle and its impact on health. London: Association of Public Health Observatories, 2005. www.apho.org.uk/apho/viewResource.aspx?uri=http://www.phenet.org.uk/?id=1678 (accessed 30 May 2005).
Office for National Statistics. Alcohol-related death rates in England and Wales, 2001 to 2003. London: ONS, 2005. www.statistics.gov.uk/statbase/Product.asp?vlnk=13614&More=n (accessed 30 May 2005).
Wanless D. Securing good health for the whole population: final report. London: HM Treasury, 2004. www.hm-treasury.gov.uk/consultations_and_legislation/wanless/consult_wanless04_final.cfm (accessed 30 May 2005).
Doll R. One for the heart. BMJ 1997;315: 1664-8.
Department of Health. Choosing Health: making healthy choices easier. London: Department of Health, 2004. http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAnd Guidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4094550&chk=aN5Cor (accessed 30 May 2005).
ePolitix.com. Interview with Professor Ian Gilmore, Royal College of Physicians. 26 January 2005. http://www.epolitix.com/EN/ForumInterviews/200501/ 86b2c0b1-0cee-4528-92c7-383a64c6d182.htm (accessed 30 May 2005).
Department for Culture, Media and Sport, Home Office, Office of the Deputy Prime Minister. Drinking responsibly: the government's proposals. London: Department for Culture, Media and Sport, Office of the Deputy Prime Minister and the Home Office, 2005. www.homeoffice.gov.uk/docs4/consult_alcohol.html (accessed 30 May 2005).
Mulvihill C, Taylor L, Waller S. Prevention and reduction of alcohol misuse. 2nd ed. London: Health Development Agency, 2005. www.hda.nhs.uk/Documents/alcoholEB2ndedition.pdf (accessed 30 May 2005).
BBC News Online. Pubs to scrap happy hour drinks. 23 May 2005. http://news.bbc.co.uk/1/hi/uk/4571989.stm (accessed 30 May 2005).
Saloojee Y, Dagli E. Tobacco industry tactics for resisting public policy on health. Bull WHO 2000;78: 902-10.
Alcohol misuse continues to be associated with as many as 22 000 deaths each year in England, with cumulative economic, health, and social costs estimated at ￡20bn annually.1 While people in many other parts of Europe may have consumed a greater amount of alcohol in the past—although varying definitions of categories of consumption hamper accurate cross national comparisons2—the situation in England is one of increasing concern. According to recent figures, 38% of men and 23% of women in England exceed recommended maximum levels for the heaviest drinking day of the week,3 and alcohol related illness mortality is on the rise.4 Drinking patterns vary between England's regions in a predictable manner that reflects persistent health inequalities,5 notably with the highest rates of binge drinking found in the north-east. Formulating effective and palatable public policy to tackle this is difficult,6 not least because moderate regular intake of alcohol may benefit health.2 Improving the population's health and reducing health inequalities both require comprehensive and evidence based solutions.
Against this backdrop, the Licensing Act 2003 was introduced in England on 7 February 2005. The act is underpinned by four stated objectives: the protection of children from harm, the prevention of public nuisance, the prevention of crime and disorder, and public safety. Previously, concerns about crime and disorder were usually the sole grounds for objecting to the granting of an alcohol licence to premises such as pubs and bars. Under the new act, each of the four objectives must be given equal weight when an application is considered by the licensing authority (in most cases now the local authority). Importantly, however, the act does not allow objections to applications for licences on public health grounds.
In early 2004 the Alcohol Harm Reduction Strategy for England was published, identifying four key strands of activity: better education and communication, improving services for health care and treatment, combating alcohol related crime and disorder, and working with the alcohol industry.1 These activities have subsequently been developed within the government white paper Choosing Health.7 Although much is to be commended in these documents, they share two traits that affect how effective a public health response to alcohol misuse can be.
Firstly, detail remains limited on how the toll of alcohol misuse on population health and its contribution to health inequalities will be dealt with. As Professor Ian Gilmore, chair of the Royal College of Physicians' Alcohol Committee, cautioned in a recent interview, "the recommendations and policy measures promoted in these two documents concentrate too heavily on the aspects of drinking most closely related to law and order issues at the expense of health."8 The fact that references to public health were explicitly removed from the Licensing Act 2003 during its progress as a bill clearly reinforces such concerns.
Secondly, the emphasis given to action being led by the alcohol industry generates unease. The government has praised voluntary schemes such as the Portman Group's Code of Practice on the Naming, Packaging and Promotion of Alcoholic Drinks9; and it would be unhelpful to dismiss such schemes solely on a matter of principle, as they may generate legitimate opportunities to take cooperation further than regulation alone would achieve.There is strong evidence, for example, that intensive face to face training of those serving drinks (with strong management support) is effective in reducing levels of intoxication among customers.10 The systematic implementation of an evidence based intervention such as this requires balanced partnerships involving the alcohol industry from the outset. Genuine corporate social responsibility within the alcohol industry should be encouraged, and the recent announcement by the British Beer and Pub Association of new standards for drinks promotions and happy hours would seem to be a positive step.11 However, industry led initiatives should be approached with necessary caution and vigilance, as they can be ineffective and even counterproductive (as the tobacco industry's voluntary codes have repeatedly shown).12
The Licensing Act 2003 has generated welcome, if often intemperate, political and public discussion about the impact of alcohol misuse on the health and wellbeing of individuals and communities across England. Pragmatic and responsive public policies (whether national, regional, or local) must be comprehensive and grounded in the best available evidence if they are to be truly effective, as the consequences of getting it wrong are too great.
Soumen Sengupta, regional associate director
1 National Institute for Health and Clinical Excellence, North East Regional Office, Durham University Science Park, Durham DH1 3YG
(soumen.sengupta@nice.org.uk)
Lesley Hoyle, health inequalities lead
2 Langbaurgh Primary Care Trust, Guisborough TS14 7AA
Competing interests: None declared.
References
Cabinet Office. Alcohol harm reduction strategy for England. London: Cabinet Office, 2004. www.strategy.gov.uk/downloads/su/alcohol/index.htm (accessed 30 May 2005).
World Health Organization. Global status report on alcohol 2004. Geneva: WHO, 2004. www.who.int/substance_abuse/publications/en/global_status_report_2004_overview.pdf (accessed 30 May 2005).
South East Public Health Observatory. Indications of Public Health - Lifestyle and its impact on health. London: Association of Public Health Observatories, 2005. www.apho.org.uk/apho/viewResource.aspx?uri=http://www.phenet.org.uk/?id=1678 (accessed 30 May 2005).
Office for National Statistics. Alcohol-related death rates in England and Wales, 2001 to 2003. London: ONS, 2005. www.statistics.gov.uk/statbase/Product.asp?vlnk=13614&More=n (accessed 30 May 2005).
Wanless D. Securing good health for the whole population: final report. London: HM Treasury, 2004. www.hm-treasury.gov.uk/consultations_and_legislation/wanless/consult_wanless04_final.cfm (accessed 30 May 2005).
Doll R. One for the heart. BMJ 1997;315: 1664-8.
Department of Health. Choosing Health: making healthy choices easier. London: Department of Health, 2004. http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAnd Guidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4094550&chk=aN5Cor (accessed 30 May 2005).
ePolitix.com. Interview with Professor Ian Gilmore, Royal College of Physicians. 26 January 2005. http://www.epolitix.com/EN/ForumInterviews/200501/ 86b2c0b1-0cee-4528-92c7-383a64c6d182.htm (accessed 30 May 2005).
Department for Culture, Media and Sport, Home Office, Office of the Deputy Prime Minister. Drinking responsibly: the government's proposals. London: Department for Culture, Media and Sport, Office of the Deputy Prime Minister and the Home Office, 2005. www.homeoffice.gov.uk/docs4/consult_alcohol.html (accessed 30 May 2005).
Mulvihill C, Taylor L, Waller S. Prevention and reduction of alcohol misuse. 2nd ed. London: Health Development Agency, 2005. www.hda.nhs.uk/Documents/alcoholEB2ndedition.pdf (accessed 30 May 2005).
BBC News Online. Pubs to scrap happy hour drinks. 23 May 2005. http://news.bbc.co.uk/1/hi/uk/4571989.stm (accessed 30 May 2005).
Saloojee Y, Dagli E. Tobacco industry tactics for resisting public policy on health. Bull WHO 2000;78: 902-10.