8th European Alcohol Policy ConferenceI attended this biennial international conference in Edinburgh 20-21 Nov 2018. It had an overarching theme of viewing alcohol policy through the lens of the enlightenment. These are my notes of the proceedings. A formal synopsis of the event will be published by SHAAP in due course, including a range of videos that were commissioned for the event and one that was produced during the event through interviews with participants. Aberdeenshire features.The Twitter tag was #8EAPC and further insights can be obtained by skimming through the relevant tweets.

Fringe: New Alcohol ResearchThe evening before there was a fringe event celebrating the contribution of PhD and early career researchers:

Annie Taylor: women’s views on pregnancy and alcohol (she won ‘best poster’ for the full event and this is copied here)

Susan Calnan: Evaluation of methods to tackle hazardous consumption in Ireland’s college students. (Encourage establishment of a working group in academic institutions; alcohol free halls of residence…)

Ben Butterworth: The relationship between alcohol, trauma and memory. (Both hard to forget and hard to remember the details to achieve closure – alcohol both clouds memory and contributes to intrusive thoughts).

Claire Sharpe: Profiling nalmefene GP prescribing. (controversial; no better than much cheaper naltrexone; inappropriate medicalisation displacing psychosocial support; dodgy European medicines authorisation)

Max Griswold: Alcohol burden of disease and J-curves. 14u/w might be too high. Nathan Critchlow: Marketing and Consumption. Consumption varies with

marketing recall.

Day One

Nicola Sturgeon was supposed to open proceedings but unexpectedly had to go to London to discuss Brexit matters with the Prime Minister.

Dag Rekve, WHO

WHO: every 10 sec, a person dies from alcohol related causes.

There are huge inequalities in alcohol outcome due to socioeconomic status.

WHO launched the ‘SAFER’ campaign in New York in Sept 2018. http://www.who.int/substance_abuse/safer/launch/en/

We suffer from cognitive dissonance: we understand the harm but yet we continue to be reluctant to change.Vietnam gov are working up new alcohol laws to address health harms. They experienced intense lobbying from the European alcohol industry to ignore the evidence.Scotland is considered an important international hub for Alcohol Policy development. All countries need to discuss alcohol policy more vigorously, especially around education, price, availability and marketing.

Tiziana Codenotti, EuroCareWHO Europe goal is to reduce harmful alcohol consumption by 10%.Tackling alcohol related harm remains a top PH priority.We need to turn off the taps and not just mop up the floor.

Peter Rice, Chair SHAAPAlcohol is a risk factor across a wide range of conditions therefore SHAAP draws membership from a wide range of disciplines.

Eric Carlin, Director of SHAAPWe have an urgent moral imperative to work together to address harm. Change has often been in the face of opposition from alcohol industry. Such industries should operate on a more ethical basis.

The theme of the conference is ‘enlightened alcohol policy for the 21c’, drawing on the experience of the Scottish and wider European enlightenment on the 18c about evidence and reasoning.

Jurgen Rehm, Centre for Addiction and Mental Health: Alcohol in Europe

European WHO region drinks more than any other region. The % of disease attributable to alcohol in the world is highest in Europe.

There’s been no overall change in EU consumption since 2010. But Russian drinking has reduced by 26%.

Every 10th death in Europe would not occur was it not for alcohol.EU alcohol related YLL have done down differentially due to policies in different countries.

Russia has implemented significant changes including MUP.

Life expectancy of a Russian male has increased by 10y due to these policies.

In Europe, the relative impact of alcohol on burden of disease has been going up.

The proportion of deaths is greatest in young adults, more than any other risk factor.

Nobel Laureate Sir Angus Deaton calls these ‘deaths of despair’.The relative contribution of alcohol on burden of disease is increasing.

Barriers to change include:- The fear politicians have that alcohol policy may affect their re-election- Unfounded economic arguments about employment and economic viability

being linked to the alcohol industry (see: 1. splitting the bill: http://www.ias.org.uk/uploads/pdf/IAS%20reports/rp23022017.pdf; 2. Fraser of Allander Institute analysis of economic impact of changed UK alcohol consumption: https://www.sbs.strath.ac.uk/economics/fraser/20180411/The-economic-impact-of-changes-in-alcohol-consumption-in-the-UK.pdf)

Theme 1: Justice, chaired by Arianna Andreangeli (a competition expert)We apply neoliberal policies (ie focus on the drinker, not the drink; self-regulation; amoral) that assume a perfect market when in fact bounded rationality actually applies. We therefore very much need enlightened alcohol policy to moderate the down side of capitalism.A just alcohol policy works for all of society.Questions:

What makes a socially just alcohol policy? What role should the legal system have to protect health? How can we collaborate to achieve enlightened alcohol policy in the justice

setting?

Christine Goodall, Medics against ViolenceSocial Justice: the right to health and avoidance of premature death whomever you are. Violence and alcohol affect those most socially deprived the most. Alcohol is a significant health inequality.

Learn from our young people. They are drinking and getting involved in violence less than older people. Our understanding of ACEs emphasise the need to become trauma informed. We should lock up the people we are scared of not the people we are mad at. We are locking up people with health issues.

Johanna Gripenberg, Stockholm Centre for Psychiatric ResearchWe need to consider prevention at 3 levels across a range of settings:Various settings: Primary

careNight time

Responsible beverage

Schools, etc etc

economy

servers

Universal (all) Reduce overselling

Selective (key groups at risk) Reduce intoxicated sales

Individual (those in need)A needs assessment should aim to understand community needs, community norms and values, ripeness for change, interventions likely to mobilise people, which settings. Loads of emphasis on community mobilisation and engagement for effective action. There needs to be a long term commitment. It takes time to plan and develop; implement interventions; see the effects come through.We can reduce alcohol problems but the legal and policy systems are essential in doing that.

Lesley Graham, ISDCurrenly in 2017 there is a 6x difference beween alcohol mortality in the richest and poorest in scotland.

Social Justice is a social contract between an individual and society based on reciprocity (give and take) between the needs and rights of the individual and society.It is the right and responsibiltiy of the state to regulate alcohol.

We need to address upstream determinants (ie structural determinants such as marketing, alcohol free childhood and socially just public spaces cf drink driving, etc) and downstream factors such as non-discriminatory access to treatment and support for recovery.There is a role for the legal system in protecting health.

2/3 coming into prison have an alcohol problem and 1/3 of those are dependent. Action: This is the place to find people and divert them into treatment!

Wim van Dalen, Dutch Institute for Alcohol Policy3 elements of policy:-regulation-enforcement (dutch authorities reluctant to do)-public supportBlurring – new alcohol outlets in unconventional locatione eg barbers, supermarkets, garden centres

Diane Black, European FASD Alliance

That people can and do recover from alcohol problems is an important principle BUT there is an exception to it: FASD. Maybe up to 5% of babies born with some effects due to prenatal alcohol exposure. Alcohol damages the pre-frontal cortex, affecting executive function eg poor planning and judgement. Also leads to earlier and heavier drinking in life.

Support, not stigma and blame, needed for women drinking during pregnancy. Action: do we talk about FASD in sex education in Schools?

Joe Fitzpatrick MSP, Minister for Public Health and Sport.Scotland continues to experience inequalities in the harm caused by alcohol. Joe argues we are almost 80% higher consumption levels compared to the rest of the world. He recognises the link with social deprivation.SG commitment today to tackling alcohol harm is welcomed and necessary. Joe launched the new alcohol framework 2018. (https://www.gov.scot/publications/alcohol-framework-2018-preventing-harm-next-steps-changing-relationship-alcohol/).

New alcohol strategy reinforces commitment to 3As: affordability, availability and attractiveness, based on the best international evidence:-MUP level will be reviewed in May 2020-Press for advertising control powers to be devolved if Westminster doesn’t act. (Self regulation doesn’t work). Scots gov give Alcohol producers a warning - want to see health info on labels by next Sept or will look at mandatory approach. we need to protect children from alcohol marketing. Kids too aware of alcohol brands and images. - praises the commitment of @ScotWFootball in not accepting alcohol brand sponsorship-Adopt WHO SAFER framework- a robust and principled stance on industry - they should have no role in public health policy, in provision of health information or in education.

Reaction from English colleagues to the framework: “Not perfect but so much better than anything coming out of Westminster. North of England suffers many of same alcohol harms as Scotland”.

Justice Secretary Humza Yousaf announced at same time that he rules out plans to reintroduce alcohol within football stadiums.

Theme two: Health, chaired by Aisha Holloway, Edinburgh UniIt’s a priveledge to work in this area to witness the depths of dependency and the joy of recovery. The voices of lived experience teach us every day.Questions:

What is a healthy relationship with alcohol? Which interventions can reduce alcohol-related health harms? How can we collaborate to achieve enlightened alcohol policy in relation to

public health?

Carina Fereira-Borges, WHOThere is no safe drinking threshold. All levels bring some added risk of cancer (7 types).

Alcohol is a type 1 carcoinogen, like tobacco.The view that moderate drinking brings health benefits needs to be re-evaluated.Reduce your risk. Moderate your consumption.There is no excuse to ignore the evidence now.

Evidence is a threat to alcohol marketing and research findings challenge claims by the alcohol industry of trivial association between alcohol and poor health.Warns industry that the longer delay in implementing alcohol policies the more severe the interventions we will need to deal with the problem.

Unbelievable example of alcohol marketing (for relax wine) “Screw Cancer”

Lauri Beekmann, Nordic Alcohol and Drug Policy NetworkLauri’s son asked him, “is vaping safer than smoking?”. He replied, “is shooting yourself in the stomach healthier than shooting yourself in the head?”Re alcohol, are we looking for ways to shoot ourself in the hand or the foot?For politicians to keep alcohol policy on the agenda, they need the suppoprt of the people. Eg people objecting to tobbaco smell leg to legislative change.

Andrew Fraser, NHS Health ScotlandOur relationship with alcohol will not change without changing the culture. Culturally, we seem to be unable to enjoy ourselves without alcohol. It’s not that way in other countries.

There is a close relationship between consumption and affordability.

Enforcement: the risk of being caught drink driving is more motivating than the level deemed to be intoxication.

https://twitter.com/NHS_HS/status/1064894291762429957

Frank Murray, Alcohol Health Alliance IrelandAs a liver doctor I see people dying. A call to arms. They are victims of the alcohol industry.

We need to see alcohol as a product in society, not a product in an economy. Focus on individual responsibility is a failed experiment! We need alcohol policies which tackle alcohol harm at a population level. Terminology: “Victims of the Alcohol Industry” vs “Alcoholics”.John Snow, one of the fathers of modern epidemiology, traced the source of a cholera outbreak in Soho to a contaminated water tap and closed it, thus ending the outbreak. He didn’t say drinking the water was “a matter of individual choice”!‘Everyone is entitled to their opinion but no-one is entitled to deny the facts: alcohol causes cancer’.When medics in Ireland got involved with the media, people listened. They positioned themselves “support the government to make difficult choices”.

But yet, youngsters ask, “if they allow alcohol advertising, how dangerous alcohol can really be?” Marketing challenges the credibility of experts.Alcohol - it is hard for many people to accept that alcohol is harmful to health. The messages about the 'benefits' of alcohol & glamorisation of alcohol adds to this

unacceptance. We need to examine the source of these messages and what their motives are.100 years ago the arguments were about what drunk men were doing to women and children. The temperance movement went hand in glove with the votes for women movement.Case for civil claims against alcohol industry:

- We know that alcohol causes cancer but there is no warning or labels. VS- Civil law requires proof that ‘that’ particular drink caused ‘that’ particular

disease.?? (Not sure about that… )

Theme Three: Gender, Chair: Catherine Severi, IASAlcohol industry enhances gender inequalities:

- hyper-sexualisation of women- Promotes macho/ dominant men- Harsher penalties for intoxicated women (doubly deviant)

Questions:- How do different genders differ in their relationship with alcohol?- How does the industry target different genders?- How can we collaborate to achieve enlightened alcohol policy in relation to

gender?

Carol Emslie, GCUMen and women use alcohol differently.Men drink more, their deaths are double and hospital admissions triple that of women.But yet, alcohol companies are targeting women with all their marketing ingenuity under the guise of empowerment, not unlike big tobacco did. In the digital age, brands increasingly aim to convert social actions into word of mouth advertising for gin and vodka.

But you wouldn’t know that given the media, cue obligatory bench girl…

Women are judged more harshly than men – harsher sentences when intoxicated.Ignoring gender leads to inaccurate and incomplete conclusions.Industry focuses on men on sports, brotherhood, and lads together.

Industry increasingly focuses on women as an underdeveloped market:- Sexualising and objectifying women- Fun, sophistication, female companionship, glamourous, stylish- Appropriating empowerment, feminism and women’s independence

Each time we buy ‘prosecco o’clock’ cards, we are contributing to alcohol industry marketing."Time's up for the alcohol industry appropriating female empowerment" Call this out: #DontPinkMyDrink

Natasa Blazko, Ministry of Health SloveniaMany alcohol policies cannot simply be solved at a national level, given cross-border issues with alcohol sales, so more countries must champion the WHO Safer initiative.The alcohol gender consumption gap is closing. Increase in consumption highest in higher educated women.

Increasing trends of 15 y/o girls drinking whilst reducing in boys. Boy’s beer, girls drink spirits.

Helena Cortez-Pinto, European Association for the Study of the LiverWomen are more sensitive to alcohol and develop liver disease at a lower dose and in less time than men.

We should expect increasing alcohol related disease in women:- Higher vulnerability- Targeted market- Converging consumption

Alcohol ads are usually specifically targeted to either men or women & link their products with a sense of attractiveness towards the opposite gender, exploiting sexism in society.

Dorothy Newbury-Birch, Teeside Uni and INEBRIAStop talking about “those people” who drink too much and talk about “us” instead.If I were to screen this audience, 1/3 would screen as drinking too much.The results of 7 years study into ABI in youth was that it didn’t make any difference. Youngsters said:

- Parents give us drinks- We don’t want our parents knowing how much we drink

- Boys and girls drinkt he same. Vodka, easy to hide from mum. Yongsters don’t count drinks in units or glasses but in bottles.

- Girls drinking will often talk about sexual assault. Both boys and girls drink due to poor relationships at home and because it is fun.

- Youngsters drinking less than previous generations.

If you’re a young girl growing up and feeling very insecure about your body, you’re seeing alcohol adverts that tell you that you can be attractive if you drink.The FASD message, “no drinking no risk” is great if you know you are pregnant but many will not know and there is a risk of creating guilt, fear and stigma for those who drink and then discover they are pregnant.Need to avoid stigma and shame of women especialy since men still drink more by providing information directly from the woman’s healthcare provider or midwife).Women have different subseptibilities to men:

- Can be pregnant- More sensitive to alcohol

Public health is about rebalancing power imbalances in society:- Gender- Class- Poverty, etc

Day 2Theme four: Economics. Chair, Alison Douglas, AFSThe enlightenment was a melting pot of ideas but we are still suffering from the free market ideas of Adam Smith. Our challenge is to make the economic case for health.At least we can agree on one thing: that alcohol companies put the interests of their shareholders above public interest - and are required to do so. That’s exactly why WHO and scotgov are clear industry can’t be part of health policy.Questions:

- How can policy balance economic benefits and health and social harm?- Which state interventions can reduce harm?- How can we collaborate to achieve enlightened alcohol policy in relation to

economics?

Yevgeniy Goryakin, OECD Health Division

It is important not to overstate the economic arguments for alcohol. The OECD have developed a microsimulation model that might take non-healthcare stakeholders on board.Eg impact of MUP on diseases and deaths avoided and medical and other expenditures such as productivity.Even liberal economists can agree for the need for policy interventions of some sort in alcohol policy due to externalities of consumption.Minimum price modelling from OECD (to be published soon) suggests increasing the prices of the cheapest alcohol by 10% is projected to reduce mortality, as well as medical and other expenditures across the European continent

Emanuele Scafato, Istituto Superiore di SanitaWe are all dreamers seeking to overturn the power of the alcohol industry.We should empower people – a social network- to socially market health. Take the same approach as the alcohol industry. Use social marketing to bring to fore the added value of Health and its long term economic benefits.The way forward for alcohol policy - experience from Italy is that empowerment is key to alcohol policy; people is the key resource to create change

https://www.drugsandalcohol.ie/29991/1/WHO_fs-alcohol.pdf

https://twitter.com/scafato/status/1065331337400381440“Don’t know you but “No half measure” is a clever & fair final claim that should find “rebels” across Europe. Waiting but also working for a renewed “club” of brave members committed to build up higher levels of alcohol prevention for people and societies.”

Myriam Savy, ANPAAMyriam providing insight into the French context. In France, wine is treated as a different commodity and is often exempt from discussions on alcohol harm. Alcohol industry have entered the political sphere and this is unacceptableIn France, the wine lobby is very close to President Macron. The French Agricultural minister was previously exec director of a French wine lobby. French interests don’t like being reminded that wine is alcohol.

Aveek Bhattacharya, IASA big stumbling block is the fear that Alcohol Policy could be harmful to the economy. There is not a trade off between health and wealth. There is not a balance to be struck.16% all working life years lost in England due to alcohol. Reducing harmful drinking will inc size and productivity of labour force.

We can do both reduce alcohol harm and boost economy. Alcohol industry may lose but rest of the industries will benefit when there is increase on price of alcohol, limits on availability and marketing. Evidence based approach. 2/3 of sales revenue in England comes from heavy drinkers. Addressing excess consumption is bad news for the alcohol industry but not bad for the economy."If people didn't spend £13bn on alcohol they would buy other stuff,"

Fraser of Allander Institute modelled that a 10% increase in alcohol tax resulted in increases in GDP and employment. Reductions in drinking results in higher economic growth.The key agenda is affordability. For a 1% increase in price, consumption falls by 0.5%. We don’t need to be afraid of economics, indeed, we have it on our side.

Theme five: Youth, Chaired by Eric Carlin, SHAAPQuestions to be answered:

- What do we know about young people and alcohol?- How can we learn from Young People’s experiences?- How can we collaborate to achieve enlightened alcohol policy in relation to

youth?

Marijs Geirnaert, Association for Alcohol and Other Drug Problems (VAD - Flanders)In the Flemish part of Belgium, 34% of 12-15 year olds surveyed had had a drink in the last year, which is a significant improvement compared to the figures from ten years ago. Used photo voice to good effect to capture issues. Will continute this technique until no more new issues come up.

Aleksandra Laczmarek, EuroCare FYFA projectPresenting the FYFA Project, which explores the relationship between sports & sponsorship from the alcohol industry and the link between alcohol, sports and young people.

Lukas Galkus, Alcohol Policy Youth NetworkAs long as drinking is affordable and is a social norm, young people will continue to start drinking alcohol.Countries wanting to protect young people from alcohol harm should not be afraid of implementing a complete ban on advertising, including social media, like the one in Lithuania. In Lithuania there are bans on advertising alcohol on all forms of media, including social media. ‘Other countries shouldn’t be afraid to tackle it, because it’s possible to do’.

Tracy Shildrick, Newcastle UniversityLet’s not talk about young peoples alcohol use in abstract. Think about the wider complexity of their lives. Young people are generally rejecting the normalisation of alcohol.

"listen to young people, look at the whole picture" , not just the youth drinking problem

Peter McManus, European Youth ParliamentAlcohol is the top risk factor for death and disability amongst young people but don’t say to young people, “alcohol is bad”, ask them “How would you improve matters”.Peter calls for young people to be involved in alcohol policy making and to ask always for their input.

Mariann Skar, EuroCare

It is a consumer right to have health information on alcohol labels. It is the right of the consumer to make informed choices and information needs to be displayed on alcohol labelsIreland leading the way on this iniative in Europe.Mariann outlined the long campaign for improved EU requirements on alcohol labelling in collaboration with consumer groups & brewer, praises leadership of Commissioner @V_Andriukaitis & says there is light at end of the tunnel! The European Commission stated in 2017 that there are no objective reasons to not have adequate labelling on alcohol bottles. It is purely political,

Theme six: Recovery, Chaired by Manuel Cardoso, Intervention on Addictive Behaviours and Dependencies General GirectorateThis theme was introduced by a movie featuring Michaela from SRC and her recovery journey.We need to learn from people in recovery in order to address alcohol problems in our communities and support individuals.Questions:

- What does recovery mean?- Who is responsible for recovery?- How can we collaborate to achieve enlightened alcohol policy in relation to

recovery?

Maria Louisa Marin Puig, Associacio Rauxa, Barcelona

One thing is clear. It can take multiple attempts at recovery. It saddens me so many public services dont recognise recovery as a process. When people relapse they need to know you will still be there. Care about supporting the individual not controlling the addiction

David McCartney, LEAPDavid provided a very personal assessment of his experience of dependent drinking and how he overcame his difficulties and what helped him achieve sustained recovery.He characterised his difficulties in the same way as Robin Williams on cocaine relapse: “I was violating my standards faster than I could lower them”."It's a good news story. I am not very proud of my behaviour when I was drinking, but I'm immensely proud of my recovery".David emphasised the importance of peer support and belonging to his recovery. Knowing we are not alone is crucial in overcoming shame and in regaining our lives and identity.From his experience he thinks strengthening the bridge between treatment and meeting those already in recovery is paramount. "I feel recovery from alcohol dependence has left me in a better place than if I hadn't had it in the first place,"

Georg Schomerus, Griefswald University, Germany

Georg argued that alcohol use disorders are more stigmatising than any other MH disorder. Self stigma to do with guilt and change. As soon as you are addicted you are not one of us, you are an outcast.Stigma is a huge barrier to recovery. The threshold for seeking help is very high due to stigma.Georg said that individual choice becomes more restricted and social environment more important as people become more unwell.

A continuum model between health and illness. It is not black and white. Recovery as a process not an accomplishment.

Justina Murray, SFAADJustina spoke about using local assets to include families and prevent them feeling isolated or stigmatised in their community. Justina also spoke about the success of CRAFT and on what family recovery looks like. 'Family recovery can happen even if the person using substances is not in recovery'

This is how family recovery looks like & feels

We need greater kindness and compassion

Each of the videos shown before each theme will be made publically available shortly for teaching, training and wider sharing.

Posters: