EUGLOREH project
THE STATUS OF HEALTH IN THE EUROPEAN UNION:
TOWARDS A HEALTHIER EUROPE

FULL REPORT

PART IV - PROTECTING AND PROMOTING  PUBLIC HEALTH AND TREATING  DISEASES: HEALTH SYSTEMS, SERVICES AND POLICIES

12. INSTITUTIONAL AND POLICY DEVELOPMENTS AT EU AND MEMBER STATE LEVEL

12.2. The European strategy for health

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12.2. The European strategy for health

 

This Report has highlighted a number of health determinants and their impacts on health. Over the last 7 years, EU public health activities, also aimed at controlling their impacts on health, have significantly expanded. In 2000, the Commission adopted a first communication on the health strategy of the European Community, followed by a second one in April 2005, developed on the basis of the competences listed in Article 152 of the Amsterdam Treaty and supported by the European Public Health Programme.

 

Following a consultation launched in December 2006 on “Health in Europe: A Strategic Approach-Discussion Document for a Health Strategy”, on 23 October 2007 the European Commission adopted a new Health Strategy, “Together for Health: A Strategic Approach for the EU 2008-2013”. Building on current work, this Strategy aims at providing, for the first time, an overarching strategic framework spanning over core issues in health as well as health in all policies (see also Chapter 11.5) and global health issues. The target of this Strategy is to set clear objectives to guide future work on health at European level, and to put in place an implementation mechanism to achieve these objectives, working in partnership with Member States.

 

The strategy focuses on four principles and three strategic themes for improving health in the EU. The principles include taking a value-driven approach, recognising the links between health and economic prosperity, integrating health in all policies and strengthening the EU’s voice in global health. The strategic themes include Fostering Good Health in an Ageing Europe, Protecting Citizens from Health Threats, and Dynamic Health Systems and New Technologies.

 

The European Commission will work to further strengthen the involvement of key stakeholders in contributing to the development and implementation of actions to protect and improve the health of European citizens. Building on the progress made through structures such as the EC Platform on diet, physical activity and health, the European Alcohol and Health Forum, the e-Health stakeholders' group and the Health Policy Forum, the European Commission will work closely with stakeholder groups, and with regional and local level bodies with a view to optimising their contribution to the implementation of the Strategy.

 

In implementing the Strategy, the Commission to work across sectors in accordance with the “Health in All Policiesprinciple (see Section 12.7.), and is likely to make use of a full range of instruments: legislation, communications, recommendations, guidelines and networks as well policy instruments such as strategies on tobacco, nutrition and physical activity, safety and health at work, emerging technologies, alcohol and mental health.

 

Regular overviews and reports on health issues in the EU and of the progress in tackling them will be undertaken to ensure the visibility of the Strategy and enable its progress to be followed. The White Paper sets out the first stage of the Strategy to 2013, when a review will take place to support the definition of further work towards the Strategy's objectives. A cooperation mechanism between the Member States and the Commission to ensure strategic cooperation for the implementation of the Strategy has been prepared, including a Council Working Group to identify priorities, define indicators, produce guidelines and recommendations, foster exchange of good practice and develop projects. The Commission will also ensure consistency with the work of its other existing bodies which deal with health-related issues, including streamlining and rationalising these bodies in terms of assessing what is needed and what is most effective to avoid any duplication of work.

 

This report provides deep consideration to policy and control tools devised so far particularly at EU, Intergovernmental and International level. To this end, each chapter dealing with a specific disease or health determinant includes a section describing the current status in the development of control tools and policies. For some examples, see Tables 12.4 and 12.5.

 

Table 12.4. Policies and control tools for selected diseases

Cardiovascular diseases (CVD)

 

Blood lipid and blood pressure control are the milestones of CVD prevention. An established concept in CVD prevention is that individual risk factors (such as hypertension and hypercholesterolemia) must be treated with increasing intensity as the CVD risk increases; treatment targets for LDL cholesterol and blood pressure in individuals with different risk profiles have been set in the most recent international guidelines. The preferential use of fats with favourable effects on the lipid profile (mono-and polyunsaturated, of vegetal or marine origin), a reduced intake of foods rich in preformed cholesterol, a moderate intake of salt and of salty foods, an increased intake of fruits, vegetables and fibre rich foods are the first step of the nutritional control of these risk factors; the hypolipidemic effect of such an healthy nutrition can be enhanced through a regular use of foods supplemented in phytosterols, soy protein, fibers. In high risk subjects, if these interventions fail to bring the patient’s blood lipids or blood pressure to the appropriate target, a life-long pharmacological treatment with drugs must be considered.

 

Finland provides one of the best-documented examples of community intervention. In 1972, Finland had the world’s highest CVD mortality rate. Planners examined the policy and environmental factors contributing to CVD and sought appropriate changes, such as increased availability of low-fat dairy products, antismoking legislation and improved school meals. They used the media, schools, worksites, sports, education and agricultural to educate residents. After five years, significant improvements were documented in smoking, cholesterol and blood pressure. By 1992, CVD mortality rates for men aged 35-64 years had dropped by 57%. The program was so successful that it was expanded to include other lifestyle-related disease. Twenty years later, major reductions in CVD risk factor levels, morbidity and mortality were attributed to the Project.

 

In 2002, the Spanish Presidency issued a Presidency note on promoting cardiovascular health in the Health Council conclusions.

 

The European Union Council Conclusions, adopted under the Irish Presidency, called upon the European Commission as well as the Member States to ensure that appropriate action is taken  on promoting cardiovascular health, emphasize the importance of acting both at a population and an individual level, notably by identifying individuals at high-risk in a multi-sectoral cooperation and action.

 

The Luxembourg Declaration (Luxembourg Declaration29 June 2005), adopted under the Luxembourg Presidency, established an agreement among representatives of National Ministries of Health, European and National representatives of Cardiac Societies and Heart Foundations, present at the Luxembourg meeting, to pursue vigorously the initiation or strengthening of comprehensive CVD prevention plans and to ensure that effective measures, policies and interventions are in place in all European countries.

 

Several WHO resolutions and charters (EUR/RC56/R2; WHA53.17; EUR/RC52/R12; EUR/RC55/R1; EUR/RC54/R3; EUR/RC55/R6) have been adopted with a view to combat CVD and other major non-communicable diseases.

 

In 2006, a large conference organised by the European Society of Cardiology and the European Heart Network, with a special focus on “Women and CVD” was held in Brussels under the auspices of the Austrian Presidency.

 

The purpose to protect health and improve the quality of life in the European population by reducing the impact of CVD is registered fully in the EU Treaty (Article 152 of the EU Treaty) and in the objectives of the EU’s Lisbon Agenda and the prospects of the integration oh health in all policies expressed by the conclusions of the European Council of the 30 November 2006 under the Finnish Presidency. (276th Employment, Social Policy, Health and Consumer Affairs Council Meeting - Brussels30 November and 1 December 2006)

 

With the support of the European Commission, the World Health Organization (WHO-Europe), the European Heart Network and the European Society of Cardiology, the European Heart Health Charter was developed.

 

The European Heart Health Charter has been officially launched on 12 June 2007 at the European Parliament in Brussels. Experience in CVD control, spelt out in the European Heart Health Charter and its working programme, suggests that these strategic approaches are likely to include disease management programmes, population-based registers and screening programmes. These approaches will foster disease (including CVD) control and will help reduce inequalities in health and in accessing healthcare. The existence of a strategic framework will help to identify best practices in Europe and to ensure solidarity among EU Member States.

 

Cancer

 

A European Parliament Written Declaration adopted in October 2007 calls on the Council and Commission to formulate a comprehensive strategy addressing six basic cancer control factors: prevention, early detection, diagnosis, treatment and follow-up, and palliative care. The Parliament’s health committee has recently called on the Commission to set up an EU Cancer Task Force to provide leadership for improved prevention, screening and treatment of the disease in Europe.

 

For the primary prevention  of cancerfactors related to lifestyles (mainly smoking, diet and physical activity and alcohol) or the environment (carcinogenic chemicals). A new primary prevention approach has become recently available thanks to the development of a vaccine against the Human Papilloma Virus infection (HPV), which is a risk factor for cervical cancer.

For  the secondary prevention of cancer, the  organised population-based screening should be promoted for the following malignancies: mammography for female breast cancer, pap smear for cervical cancer and faecal occult blood for colorectal cancer. In 2003 the European Council published recommendations to European Member States for the implementation of organised screening programmes (European Council, 2003). Recommendations referred women between 20-30 for the screening of cervical pre-cancer lesions (with 3 or 5 years of interval); women aged 50 to 69 for breast cancer screening (with 2 or 3 years of interval) and men and women aged 50 to 74 for the screening of colorectal cancer (with 1 or 2 years of interval). The ultimate purpose of cancer screening is to reduce cancer mortality, and to reduce the incidence of disease that is too advanced for curative treatment, thus improving the quality of life. The basic approach is early detection of disease that is not clinically detectable yet

 

International differences and trends in cancer survival within Europe are larger than can reasonably be accepted. The geographical patterns and trends in survival are often broadly consistent with geographical differences or trends in the type of cancer, diagnostic investigations or overall investment in health care. There is increasing evidence that international survival differences are at least partly attributable to factors that are susceptible to intervention, such as differences in stage at diagnosis, access to optimal treatment and investment in health care. For this reason it is fundamental to support the spread of best practice among European countries and pressure to raise consistently poor standards.

 

The cancer burden of a given population is influenced by interventions of different kinds, from primary prevention of risk factors (also know as health determinants) mainly associated with unhealthy lifestyles, environmental exposures to carcinogenic chemicals or other determinants to early diagnosis, adequate treatment and end of life care. It is an extremely complex social undertaking to organize and deliver public health programmes that are designed both to reduce and monitor cancer incidence with preventive and epidemiological services, and to improve cancer outcomes with clinical services. It involves a wide range of professional expertise and input from organisations at all levels within the health system. Cancer control plans (NCPs) are very important tools through which competent Authorities in most European countries define, mainly at national level and in some countries also at regional level, priorities and main objectives of cancer control for a given timeframe as well as key tools (i.e. regulations and activity programmes) in terms of primary and secondary preventions and healthcare to achieve the adopted objectives. Obviously, such planning approach needs to be considered together with available financial and other resources available to implement the plan, thus putting the plan into a concrete feasibility dimension.

 

Cancer research in Europe is of a high standard, but fragmentation and lack of sustainability remain the largest barriers in implementing innovation into cancer care. In January 2006, the European Commission launched a specific support action, Eurocan+Plus, to identify barriers to collaboration in research and recommend methods of overcoming these hurdles to improve cancer research in Europe. Achieving this goal will bring about real progress in cancer control and allow Europe to move beyond what is currently possible within our current knowledge situation. It will also have positive effects on the efficient use of resources, quality of cancer research, quality of patient care, the attractiveness of Europe for the biomedical industry and the organization of education for doctors and researchers.

 

About one hundred cancer registries operate in Europe today, playing a key role in public health. Yet in several EU Member States, severe constraints on registry operation have been imposed by statute law or professional regulations. These constraints were intended to improve patient confidentiality, but in some cases they failed to take account of the public health impact. Such constraints caused the closure of several cancer registries in several countries  and very nearly did so in other. Constraints have also prevented some registries from linking death certificates with cancer records.  The specific problem in some countries is the budget and the support of cancer registration

 

Diabetes

 

Long term complications, observed in both forms of the disease, can  be reduced or even prevented if the appropriate near normo-glycaemia is obtained through intensive treatment from diagnosis onwards. For type 2 diabetes primary intervention (prevention of obesity and overweight) as well as secondary intervention (early intensive treatment) can modify the progression. Early diagnosis and/or active detection of previously not diagnosed T2DM may contribute considerably to complication reduction. This becomes even more important  as some countries report percentages as high as 50 % of non-diagnosed patients (prior to complications) with the diagnosis made when the first complications are already present.

 

The case for screening for undiagnosed diabetes has probably become somewhat stronger than it was in the past, because of the greater options for reduction of CVD and because of the rising prevalence of obesity and hence type 2 diabetes   investigated patients with acute myocardial infarction (AMI) and confirmed  the high frequency of previously undiagnosed DM and IGT in patients with AMI. The importance of OGTT in the diagnostic work up of this vulnerable high-risk group cannot be over-emphasised. The rationale of screening is to detect a disease or a high risk state in an early stage, in order to reduce morbidity and mortality by timely initiation of adequate treatment. The WHO 2003 report defines screening as the process of identifying those individuals who are at sufficiently high risk of a specific disorder to warrant further investigation or direct action.

 

Main relevant factors for primary prevention are those overweight and obesity and those high blood pressure and high cholesterol.  Because of the increase of obesity (the so called pandemic), the dither prevalence of type 2 diabetes is rising and  has become a public health issue. We  can curtail the “diabesity” (diabetes & obesity) epidemic only when we take overweight and obesity seriously.

 

In 2005, only 12 of the 25 (IDF Europe/FEND Diabetes Policy Puzzle, 2005) EU Member States had established national diabetes plans and/or guidelines. There is currently no benchmark for assessing the level of implementation of national plans/guidelines in Member States. Existing national plans and guidelines differ significantly among Member States, particularly in implementation. This causes inequalities in life expectancy, health status and access to high-quality health services for people living with diabetes across Europe. In the process of learning to live with diabetes, the person with diabetes should be assisted to learn to live with diabetes. Behaviour is based upon knowledge, attitude and skills.

 

The establishment of a strategy on diabetes at EU-level would:

- Create a framework for exchange and cooperation between Member States;

- Help to increase the coherence of actions in different policy sectors;

- Open up a platform for involving stakeholders including patient and civil society organisations finding solutions.

 

Recently there have been a number of documents that have underlined a resurgence of interest in the disease across the European Union and at an international level:

- the EU Health Council in 2004, under the Irish Presidency, stressed the importance of developing a coordinated  European strategy for diabetes;

- the Otocec Declaration (2004) European Diabetes week, Nov 2004 was signed by more than 80 representatives of 35 EU and national diabetes associations;

- Austria made Type 2 diabetes a key healt h priority during its Presidency in 2006;

- the European Parliament in April 2006 urged the European Commission and the European Council to make care and prevention of diabetes a priority and to develop a European wide strategy to tackle the disease;

- the recommendations of the  EU Conference on Prevention of Type 2 Diabetes, organized in Vienna in February 2006,  were   adopted by the formal Health Council  in June 2006 in the form of Diabetes EU policy;

- the International Diabetes FederationEuropean Region (IDF Europe) and the Federation of European Nurses in Diabetes (FEND) presented the paperDiabetes: EU Policy Recommendations” as on input to the future work of the European Commission on one of Europe’s most critical public health issues, diabetes

- the United Nations signed the Resolution on Diabetes, recognised its global threat to health worldwide in December 2006. (UN resolution A/Res/ 61/225).

 

November 14th , the current IDF World Diabetes Day, was declared a United Nations Day to be observed every year starting in 2007.  

 

 

 

 

Table 12.5. Policies and control tools as applied to selected health determinants

 

1. Tobacco

 

1.1. Individual interventions

 

An individual approach to smoking cessation includes pharmacotherapy and behavioral therapy. Only 3% of smokers manage to quit smoking using will power alone. Success depends to a great extent on motivation, but a combination of pharmacotherapy and behavioral therapy probably yields best results. Nicotine replacement therapy (NRT) in form of patches, chewing gum, lozenges, inhalers and nasal sprays helps relieve the withdrawal symptoms that prevent many smokers from quitting. It contains nicotine, but does not contain thousands of other harmful substances found in cigarettes and snuff.

 

The non-nicotine pharmacotherapy includes several drugs from different categories. Two of the most promising are bupropion and varenicline. They are both prescription drugs approved by national authorities of some countries to help patients stop smoking. Bupropion is an antidepressant drug that reduces withdrawal symptoms and lessens the urge to smoke. Varenicline, recently approved both in Europe and USA, is a partial nicotine agonist that prevents the nicotine-withdrawal symptoms, and eliminates the reward from smoking.

 

Certain moods, times of the day, or activities may present strong triggers for craving a cigarette. Pharmacotherapy is not a cure for these smoking triggers. Furthermore, the motivation to quit smoking determines the success rate of smoking cessation to a large extent. Some studies found that the integration of behavioral therapy can increase the quitting rate by another 50-100%. Psychosocial interventions are helpful at all phases of tobacco addiction treatment, not only as a first-line intervention. There is a wide range of psychosocial treatment options, including counseling via internet and telephone, as well as individual and group counseling.

 

1.2. Collective interventionstobacco control in the EU

 

Collective interventions geared towards the reduction of tobacco related harm can be categorized as follows:

·                      measures to reduce the demand for tobacco products (price, taxation);

·                      measures to reduce exposure to environmental tobacco smoke (smoking bans in public places);

·                      measures to limit tobacco industry advertising, promotion and sponsorship; and

·                      measures to raise awareness about the addictive nature and health hazards of tobacco use

Curbing tobacco use is a longstanding EU health priority. The EU has been actively contributing to the reduction of tobacco consumption for more than twenty years. This contribution has evolved from prevention, training and research within the scope of the fight against cancer, to a broad strategic tobacco control approach. The current EU-wide efforts are based on four mutually reinforcing pillars:

·                      legislative measures, based on the Community Treaties as well as more specific, secondary legislation;

·                      support for Europe-wide and cross-national smoking prevention and cessation activities, financed via action programmes and the Community Tobacco Fund;

·                      mainstreaming of tobacco control into a range of other Community policies; and

·                      ensuring the Community’s achievements also have an impact outside the EU region, by fostering international co-operation and taking on a major role in tobacco control at a global level.

 

EU action focuses on supporting prevention, collaboration between Member States, and research. The quest for a smoke free EU also forms part of the Environment and Health Action Plan, through which passive smoking is now more actively tackled.

Legally, these efforts are firmly grounded in the Community Treaties and supported further by a range of specific regulations. The legal competencies of the EU enable it to make some unique contributions to tobacco control in Europe, and indeed globally. The WHO Framework Convention on Tobacco Control (FCTC), which all Member States and the Community have signed, has been a significant factor in the further advancement of tobacco control at EU and Member State level. Within the Treaties of the Community, articles 152 and 95 EC provide the legal base for EU policy and action in the area of tobacco control. These articles are concerned respectively with public health and internal market issues. Through the application of these two articles, a range of more specific measures and agreements have been developed to support the EU’s efforts in the area of tobacco control.

The provisions in the Treaty have been given force through a range of secondary legal measures to support tobacco control. Together, they underpin and complement the Community’s action, including a range of smoking prevention and cessation activities. Binding legal measures include Directives on:

·                      the advertising and sponsorship of tobacco products;

·                      the structure and rates of excise duty applied on manufactured tobacco;

·                      the manufacture, presentation and sale of tobacco products;

·                      television broadcasting, banning the advertising of tobacco products; and

·                      minimum safety and health requirements for the workplace.

Non-binding legal measures include:

1) a Council Recommendation on the prevention of smoking and on initiatives to improve tobacco control. This recommendation pays particular attention to measures restricting youth access to tobacco; and

2) a Resolution on banning smoking in public places. Since the adoption of the resolution in 1989, Member Statesgovernments have developed their own specific action to implement this resolution, and have done so at their own pace.

 

 International organisations

 

The WHO Framework Convention on Tobacco Control (FCTC) is the first-ever global health treaty providing a comprehensive tobacco control framework (WHO, 2005). The FCTC objective is 'to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke.' The EU Council approved the FCTC in June 2004, and subsequently ratified it on 30 June 2005.

 

Significant measures to reduce the demand for tobacco, that are supported by the FCTC include:

price and tax measures;

protection from exposure to tobacco smoke, particularly in workplaces, public transport and indoor public places;

regulation of the contents of tobacco products;

regulation of tobacco product disclosures;

packaging and labeling of tobacco products, requiring large health warning labels and prohibiting the use of deceptive labels such as "light", "low tar", and "mild";

education, communication, training and public awareness;

tobacco advertising, promotion and sponsorship. Countries are to undertake a comprehensive ban on tobacco advertising, promotion and sponsorship within five years of ratifying the treaty if their constitutions allow this. If there are constitutional constraints, countries are required to put restrictions in place; and

demand reduction measures concerning tobacco dependence and cessation.

The FCTC also supports measures to reduce the supply of tobacco. These include:

1. illicit trade in tobacco products (smuggling);

2. sales to and by minors, and

3. provision of support for economically viable alternative activities.

By signing the Treaty, countries also commit themselves to take supportive measures at national level. Key examples of these measures are:

the establishment of a national coordinating mechanism or focal point for tobacco control;

the inclusion of tobacco cessation services in national health programmes, and

promoting the participation of NGOs in the development of national tobacco control programmes.

 

Under the UN Charter, identifying solutions to international social and health problems falls within the remit of the Economic and Social Council (ECOSOC). Their Resolution 2004/62 on Tobacco Control supports the WHO Framework Convention on Tobacco Control. It urges UN Member States to strengthen tobacco control measures and programmes.

On 7 February 2008 WHO released a new Report on “Global Tobacco Epidemicshowing that while progress has been made, not a single country fully implements all key tobacco control measures, and outlined an approach that governments can adopt to prevent tens of millions of premature deaths by the middle of this century. In this new report which presents the first comprehensive analysis of global tobacco use and control efforts, WHO finds that only 5% of the world’s population live in countries that fully protect their population with any one of the key measures that reduce smoking rates. The report also reveals that governments around the world collect 500 times more money in tobacco taxes each year than they spend on anti-tobacco efforts. It finds that tobacco taxes, the single most effective strategy, could be significantly increased in nearly all countries, providing a source of sustainable funding to implement and enforce the recommended approach, a package of six policies called MPOWER. The six MPOWER strategies are:

Monitor tobacco use and prevention policies

Protect people from tobacco smoke

Offer help to quit tobacco use

Warn about the dangers of tobacco

Enforce bans on tobacco advertising, promotion and sponsorship

Raise taxes on tobacco.

The report also documents the epidemic's shift to the developing world, where 80% of the more than eight million annual tobacco-related deaths projected by 2030 are expected to occur. The global analysis, compiled by WHO with information provided by 179 Member States, gives governments and other groups a baseline from which to monitor efforts to stop the epidemic in the years ahead. The MPOWER package provides countries with a roadmap to help them meet their commitments to the widely embraced global tobacco treaty known as the WHO Framework Convention on Tobacco Control, which came into force in 2005. Other key findings in the report include:

 

Only 5% of the global population is protected by comprehensive national smoke-free legislation and 40% of countries still allow smoking in hospitals and schools;

Only 5% of the world’s population lives in countries with comprehensive national bans on tobacco advertising and promotion;

Just 15 countries, representing 6% of the global population, mandate pictorial warnings on tobacco packaging;

Services to treat tobacco dependence are fully available in only nine countries, covering 5% of the world’s people;

Tobacco tax revenues are more than 4000 times greater than spending on tobacco control in middle-income countries and more than 9000 times greater in lower-income countries. High-income countries collect about 340 times more money in tobacco taxes than they spend on tobacco control.

 

2. Alcohol

 

Risk reduction strategies include a set of measures in a jurisdiction or society aimed at minimizing the health and social harms that result from alcohol consumption. They are implemented by alcohol policies, which include authoritative decisions that are made by governments through laws, rules and regulations, coming from the legitimate purview of legislators and other public interest group officials, and not from private industry or related advocacy groups. In the context of public health the central purpose of alcohol policies is to serve the interests of public health and social well-being through their impact on health and social determinants, such as drinking patterns, the drinking environment, and the health services available to treat problem drinkers.

 

Alcohol is a major economic commodity that is associated with substantial governmental tax receipt and Europe can be considered the centre of the global alcohol industry, acting as both the largest market and the major producer of alcoholic drinks. Therefore, it may be appropriate to recall that the trade in alcohol in the whole European Union accounts for 1.3% of all exports and 0.3% of all imports, thereby contributing8.9 bn to the goods account balance, with such trade not necessarily affected by European and domestic policy to reduce the harm done by alcohol

 

Maintaining the relative price of alcohol

 

When other factors are held constant, the more affordable alcohol is, the more it is consumed; and the less affordable it is, the less it is consumed. The way drinkers respond to and compensate for price changes is complex, because of the possibilities for substitution. Drinkers tend to shift to more expensive beverages if relative prices decrease, either within the same beverage category or across beverage categories.  If prices are raised, they both reduce overall consumption but also shift to cheaper beveragesHeavy drinkers tend to buy the cheaper products within their preferred beverage category. The impact of an increase in alcohol price is stronger in the longer term than it is in its immediate effects.  From a public policy perspective, it is the long term effects, taking into account alcohol’s dependence producing properties that are more importantYoung people are particularly sensitive to price. Policies that increase alcohol prices have been shown to reduce the proportion of young people who are heavy drinkers, to reduce underage drinking, and to reduce per occasion binge drinking. Higher prices also delay intentions among younger teenagers to start drinking and slow progression towards drinking larger amounts. Heavy drinkers are also sensitive to price, with higher alcohol taxes or prices leading to reductions in deaths from liver cirrhosis, fatality rates from traffic crashes, and reduced rates of crime, including assault, violence related injury, homicide, family violence, and child abuse and other violence towards children.

 

While it may be predicted that the revenues from tax on alcohol depends on the total amount of alcohol drunk in a country, the evidence suggests that this is not the case. There is no apparent correlation between the revenue from alcohol-specific taxes (as a % of government revenue or % of GDP) and per capita consumption.  The best predictors of the importance of alcohol-specific taxes are unsurprisingly the average alcohol tax rates, which relate very closely to the income from alcohol taxes.

 

Managing the sale of alcohol

 

The smaller the number of outlets for alcoholic beverages, the greater the difficulty in obtaining alcohol, a situation that is likely to deter alcohol use and problems. A number of studies have indicated that although changing either hours or days of alcohol sale can redistribute the times at which many alcohol related crashes and violent events related to alcohol take place, it does so at the cost of an overall increase in problems. Around-the-clock opening in Reykjavik, for instance, produced net increases in police work, in emergency room admissions and in drink-driving cases

 

There is also evidence that restricting days and hours of sale reduces problems. In the 1980s Sweden re-instituted Saturday closing for spirits and wine off-premise sales after studies showed that Saturday sales were associated with increased rates of domestic violence and public drunkenness . Some 20 years later, when Saturday opening of government alcohol stores was re-instituted, there was a 3.6% increase in alcohol sales.

 

Almost all countries legally restrict alcohol sales to minors. There is very strong evidence that changes in minimum drinking age laws can substantially effect youth drinking and alcohol-related harm, particularly road traffic accidents; however, the full benefits of a higher drinking age are only realized if the law is enforced.

 

Advertising controls

 

Eight US-based well designed longitudinal studies and one Belgian well designed longitudinal study show that the volume of advertisements and media exposure increase the likelihood of young people starting to drink, the amount they drink, and the amount they drink on any one occasion. There have been no published longitudinal studies that do not find such an effect. These findings are similar to the impact of advertising on smoking and eating behaviour. It is difficult to study the relationship between expenditure on commercial communications, or whether or not there are bans on alcohol advertisements in a jurisdiction and drinking by young people. Where this has been done, some studies have found that increased expenditure on advertising is associated with increased alcohol-related harm amongst young people, and that total bans have reduced alcohol-related harm, whereas others have not.  In general, later studies seem to have found more of an effect of commercial communications. The evidence would thus show that there is a need to specify the extent to which alcohol advertising in certain categories of media and publications is allowed, and it would suggest that, as is the case with tobacco, consideration should be given to the prohibition of advertising of alcohol products on television and radio and in specified certain print media.  There are good examples of regulations on alcohol marketing in some countries. France’s Loi Evin is one such model which bans most advertising and sponsorship and restricts permitted advertising to description of the product without any of the messages which make advertising particularly attractive to younger people. When the Loi Evin was challenged in the European Court of Justice, it was upheld, noting that it is in fact undeniable that advertising acts as an encouragement to consumption; the French rules on TV advertising are appropriate to ensure their aim of protecting public health; and they do not go beyond what is necessary to achieve such an objective .

 

Setting and controlling blood alcohol levels.

 

Establishing a maximum blood-alcohol level (BAL) for driving is a well-established and widely diffused drinking-driving countermeasure.  Over the years, the level specified as maximum has been lowered in a number of countries, and is as low as zero or 0.2g/l in a number of countries, and 0.5g/l or lower in most countries in Europe.  Both establishing a BAL and lowering it are effective in reducing drinking-driving casualties (Anderson and Baumberg 2006). There is also convincing evidence that both intensive random breath testing, where police regularly stop drivers on a random basis to check their BAL, and sobriety checkpoints, where all cars are stopped and drivers suspected of drinking driving are breath-tested, reduce alcohol-related injuries and fatalities.

 

Setting lower BALs (including a zero level) for young or novice drivers; administrative driver's license suspension for a driver caught with a positive BAL particularly in legal systems in which a criminal drinking-driver case may be delayed or successfully fought by a defence lawyer; and the use of an ignition interlock, a mechanical device which does not allow a car to be driven by a driver with a BAL above a low level, for reducing repeat infractions by convicted drinking drivers are all effective in reducing drink driving casualties

 

Finally, there are a number of measures that have shown to be not effective in reducing drinking and driving (Anderson and Baumberg 2006). These include designated drivers and ride services, such as the BOB campaign. No study has evaluated whether the use of designated drivers actually decreases alcohol-related motor vehicle-related injuries (Ditter et al, 2005). However, although the BALs of designated drivers are generally lower than those of their passengers they are still often higher than the legal limit for drinking and driving. Further, an increase in passenger alcohol consumption is often found when a designated driver is available.

 

Educational programmes and information campaigns

 

Whilst the provision of information and persuasion to reduce alcohol related harm might seem appealing, particularly in relation to younger people, it is unlikely to achieve sustained behavioural change in an environment in which many competing messages are received in the form of marketing and social norms supporting drinking, and in which alcohol is readily available. Many careful systematic reviews have evaluated school based education which aimed to reduce alcohol related harm, and found that classroom based education is not an effective intervention to reduce alcohol related harm; although there is evidence of positive effects on increased knowledge about alcohol and in improved attitudes, there is no evidence for a sustained effect on behaviour

 

In general, public information campaigns are also an ineffective antidote to the high quality, pro-drinking messages that appear far more frequently in the media. Further, counter advertising (a variant of public information campaigns which provides information about a product, its effects and the industry that promotes it in order to decrease its appeal and use) has inconclusive effects. Whilst drinking guidelines have been used in a number of countries, there have been no evaluations that find an impact of these guidelines on alcohol related harm . The United Kingdom’s ‘sensible drinking guidelines’ when relied upon as a key prevention strategy in a liberalizing policy environment failed to deter increases in alcohol consumption. The exception to this evidence of inefficacy is the evidence for the impact of mass media campaigns to reduce drinking and driving, particularly in jurisdictions with strong policies in place concerning drinking and driving.  

 

Drinking context

 

Licensed drinking environments are associated with drunkenness, drink-driving and problem behaviours such as aggression and violence, with some licensed premises being associated with a disproportionate amount of harm. Nearly all evaluations in training bar staff in responsible beverage service when backed up with enforcement have demonstrated improved knowledge and attitudes among participants, although this wears off over time. These studies have also shown some effects on serving practices, but not always. Whilst servers are usually willing to intervene with customers who are visibly intoxicated, they generally will not intervene with individuals solely on the basis of the customer’s estimated blood alcohol concentration (BAC) or number of drinks consumed. In terms of the effects on customer intoxication, several studies have found that server training results in lower BAC levels of customers generally and fewer customers with high BAC levels. Studies of the impact of adhering to bar policies for avoiding intoxication have also found modest effects in reducing heavy consumption and high risk drinking, but were not as successful as originally expected. The impact of responsible beverage service is greatly enhanced when there is active, but ongoing enforcement of laws prohibiting sale of alcohol to intoxicated customers.   

 

Community based prevention programmes can be effective in reducing drinking and driving, alcohol related traffic fatalities and assault injuries. Community mobilization has been used to raise awareness of problems associated with on-premise drinking, develop specific solutions to problems, and pressure bar owners to recognize that they have a responsibility to the community in terms of such bar-related issues as noise level and customer behaviour. Evaluation results from community mobilization approaches as well as documentation from grassroots projects suggest that community mobilization can be successful at reducing aggression and other problems related to drinking in licensed premises.

 

Advice and treatment

 

Healthcare-based interventions for hazardous and harmful alcohol consumption reduce alcohol consumption, as well as demonstrating reductions in alcohol related problems and alcohol-related mortality. The community based Malmö study, undertaken during the 1970s, demonstrated that under the right conditions, the effects can be dramatic. An intervention for heavy drinkers resulted in half the deaths that occurred in the control group without the intervention at six year follow-up. There is extensive evidence that shows the effectiveness and cost-effectiveness of opportunistic screening and brief interventions for persons with hazardous and harmful alcohol use in the absence of severe dependence.  If these programs were widely adopted in health care systems, the population impact on excessive drinking could be significant.   For people with more severe alcohol dependence and related problems, a wide variety of specialized treatment approaches have been evaluated, including behavioural, psychosocial, and pharmacological interventions of varying intensities in both community and residential settings (Miller and Wilbourne 2002). The evidence shows that individuals exposed to these treatments, especially when delivered in a timely manner, achieve better outcomes than those not receiving treatment. Further, for the average person, the effectiveness of these treatments tends to be comparable regardless of intensity, modality or setting

 

Relevant alcohol policy  documents

 

·                      Television Without Frontiers Directive

http://europa.eu.int/eur-lex/en/consleg/pdf/1989/en_1989L0552_do_001.pdf

·                      Commission Recommendation on maximum permitted blood alcohol content, 2001

http://europa.eu.int/eur-lex/lex/LexUriServ/LexUriServ.do?uri=CELEX:32001H0115:EN:HTML

·                      Council Recommendation on the drinking of alcohol by young people, in particular children and adolescents, 2001

http://europa.eu/scadplus/leg/en/cha/c11564.htm

·                      European Commission Road Safety Action Programme 2003-2010

http://europa.eu/scadplus/leg/en/lvb/l24257.htm

·                      European Commission Communication on EU alcohol strategy, 2006

http://ec.europa.eu/health/ph_determinants/life_style/alcohol/documents/alcohol_com_625_en.pdf

·                      European alcohol and health forum, 2007

http://ec.europa.eu/health/ph_determinants/life_style/alcohol/alcohol_charter_en.htm

 

Projects funded under the Public Health Programme 2003-2008

·                      PHEPA: Primary Health Care European Project

http://www.phepa.net

·                      EUROCAREAlcohol Policy Network in the Context of a Larger Europe: Bridging the Gap

http://ec.europa.eu/health/ph_projects/2003/action3/action3_2003_02_en.htm

·                      ELSAEnforcement of national Laws and Self-regulation on advertising and marketing of Alcohol

http://ec.europa.eu/health/ph_projects/2004/action3/action3_2004_16_en.htm

 

Research projects on alcohol

·                      Genomics, mechanism and treatment of addiction

http://cordis.europa.eu/

·                      European Prospective Investigation into Cancer, Chronic Diseases, Nutrition and Lifestyle

http://cordis.europa.eu/fetch/

·                      DRUID: Driving under influence of drugs, alcohol and medicine

http://cordis.europa.eu/eoi/dsp_details.cfm?ID=2638

·                      DG SANCO pages on Alcohol

http://ec.europa.eu/health/ph_determinants/life_style/alcohol_en.htm

 

 

For more information see:

http://ec.europa.eu/health/ph_overview/strategy/health_strategy_en.htm