« Previous | Contents | Next »
Listen
EFFECTIVE AND COST-EFFECTIVE MEASURES TO REDUCE ALCOHOL MISUSE IN SCOTLAND: AN UPDATE TO THE LITERATURE REVIEW
SECTION THREE: POLICY AND LEGISLATION
SUMMARY
This section reviews the effectiveness evidence relating to policy and legislative interventions. The main findings of the previous review were:
increasing the price of alcohol through taxation is effective in reducing consumption, although the size of the effect is uncertain;
reductions in permitted blood alcohol levels for drivers have been effective in reducing motor crashes and fatalities in the US;
evidence relating to licensing controls is unclear, particularly in the UK; and
no association has been found between advertising and alcohol consumption.
No cost-effectiveness studies were identified.
More recent studies indicate that:
the varying size of the price effect may be partly explained in terms of the impact of other regulatory interventions affecting the accessibility of alcohol;
taking account of the addictive properties of alcohol gives larger long-term price effects;
there is more evidence of price effects on heavy drinkers and young people;
evidence continues to support drink drive legislation and minimum age restrictions.
One study demonstrates the cost-effectiveness of lower blood alcohol limits for young or inexperienced drivers.
The results require to be interpreted with caution as they depend largely on studies conducted outwith the UK. More research on the impact of UK policy and legislation is required.
INTRODUCTION
3.1 This section concerns policy and legislative interventions that can impact on alcohol consumption and misuse. It covers:
fiscal policy (alcohol taxes);
drink driving controls;
licensing provisions; and
policy towards alcohol advertising.
These interventions have to be evaluated at a population level. The types of analysis include looking at trends over time, comparing outcomes before and after the introduction of some change, and comparisons of different populations with different policy or legislative frameworks. Whilst few new reviews of specific policies were identified for this report, an authoritative overview of the area (Babor et al 2003) and an evidence briefing from the Health Development Agency (Waller et al 2002) have been produced.
FISCAL POLICY
Types of intervention
3.2 Governments can influence the monetary price of alcohol through the level of general or specific taxation on alcohol products. However, it should be noted that the cost of obtaining alcohol includes other factors, such as time and effort, which can be affected by licensing controls and other policy instruments.
Evidence of effectiveness
3.3 The previous review identified evidence that increases in price reduce alcohol consumption but estimates of the size of the effect vary considerably. Estimates covered different time periods and different countries. There appeared to be some consistency in the finding that elasticities were higher for wine and spirits than for beer.
3.4 The effect of alcohol prices is included in the comprehensive policy review by Babor et al (2003). This review suggests that variations in estimates may be explained by prevailing social, cultural and economic circumstances. In particular, the relatively low elasticity for beer may result from studies in beer preferring countries, such as the UK and US. The existence of other policy measures to make alcohol less accessible may reduce the impact of price changes. A review of econometric studies (Chaloupka et al 2002) suggests that long-term effects of price may be higher, due to the addictive nature of alcohol consumption.
Population groups
3.5 There is conflicting evidence concerning the relative effects of price on heavy drinkers. Studies relating prices to alcohol consumption for heavy drinkers provide less convincing evidence than studies relating tax changes to changes in the incidence of alcohol related problems, such as mortality, morbidity, accidents and crime, which show reductions in problems resulting from price rises (Babor et al 2003). These studies provide indirect evidence that price increases are reducing the incidence of problem drinking. Chaloupka et al (2002) report similar findings. They emphasise the importance of considering the full price of alcohol, which includes acquisition costs, and not just the monetary price.
3.6 The previous review reported that the evidence relating to under-age and youth drinking was unclear. Babor et al (2003) report a small number of studies in this area which show both price and minimum legal drinking age affect beer consumption; frequent or heavy drinkers are more price sensitive; high taxes reduce consumption and probability of excessive drinking. Chaloupka et al (2002) report similar findings and also emphasise that the price faced by young people, and particularly students, may be much lower than average retail prices with alcohol being consumed at parties (zero price) and with discounts for college students.
DRINK DRIVE LEGISLATION
Types of intervention
3.7 In the US, legislation has been enacted to introduce lower permitted blood alcohol levels for younger drivers and for persons with previous convictions for drink driving. There have also been reductions in permitted blood alcohol concentration (BAC) levels for all drivers. A number of laws have been passed to bring into force additional sanctions for drink driving, such as mandatory licence suspension and ignition interlock devices.
Evidence of effectiveness
3.8 The previous review reported on the effectiveness of the introduction of zero levels of permitted alcohol consumption for drivers under 21 and reducing blood alcohol levels from 0.10 percent to 0.08 percent (the UK legal limit) for other drivers in the US. The evidence supporting these interventions is reviewed in Shults et al (2001) and this informs the recommendations of the Task Force on Community Preventive Services (Evans et al 2001). Similar evidence is reviewed by Morrison et al (2003), as part of a wider review of transport related interventions, and by Babor et al (2003).
Population groups
3.9 The only specific groups considered are under-age drinkers and persons with previous convictions, covered above.
Evidence of cost-effectiveness
3.10 Shults et al report one study that models the economic effects of lower BAC for young or inexperienced drivers (Miller et al 1998). Assuming a 20% reduction in crashes, the benefit to cost ratio is estimated at $11:1. Costs included legal system costs and compliance costs for those receiving a six-month licence suspension.
LICENSING
Types of intervention
3.11 Licensing controls can affect a range of issues, such as hours of operation for outlets selling alcohol, types of outlet permitted to sell alcohol, the density of outlets within an area and the age at which alcohol can be legally purchased or consumed. In some countries, such as the US, sales of alcohol may be controlled through public monopoly. These controls may increase or reduce the ease of access to alcohol, which is part of the cost. Promoting lower alcohol content in beverages and the promotion of alcohol free events and alternative activities may have potential to reduce consumption and related harms but there is little evidence of effectiveness (Babor et al 2003).
Evidence of effectiveness
Licensing hours
3.12 The evidence relating to the impact of licensing hours remains unclear.
Outlet density
3.13 Outlet density is one factor in the cost of access to alcohol and, in general, an increase in the number and type of outlets will increase consumption. Accidents and violence are more likely in areas with high density of outlets but there is no evidence that changing density over time changes the total of problem outcomes (Babor et al 2003). There may be other factors associated with high-density areas that contribute to accidents and violence.
Outlet type
3.14 Babor et al (2003) suggest that off-premise monopoly systems limit consumption and alcohol related problems and are less likely to sell to minors. Such systems result in fewer stores with limited opening hours. Newburn and Shiner (2001) suggest that factors in the drinking environment, such as availability of seating and noise levels, can affect both levels of consumption and alcohol related problems but this is not based on a systematic review.
Age limits
3.15 Shults et al (2001) review evidence of the effect of changing minimum drinking age on motor vehicle accidents and fatalities. Overall the impact is in the region of 10% to 16%, with crashes decreasing with an increase in the minimum drinking age and vice versa. A subset of studies that restricted analysis to the age group directly affected by changes in the legislation reported a median change in crashes of 19%. Maintaining the age limit at 21 in the US is supported by the Task Force on Community Preventive Services (Evans et al 2001).
3.16 Wagenaar and Toomey (2002) provide a systematic review of minimum drinking age laws (MDAL) on alcohol consumption, drink driving and traffic crashes and other health and social outcomes, and also review the literature around underage access. They conclude that the balance of evidence supports the effectiveness of MDAL in reducing alcohol consumption, drink driving and adverse traffic related outcomes. There is some evidence of other effects but the pattern is less clear. There appears to be little enforcement of MDAL with purchase attempt studies showing 44-97% of outlets selling to minors without requesting proof of age. Studies of enforcement initiatives show reductions in sales to minors of at least a half. Babor et al (2003) support the effect of minimum drinking age and stress the importance of enforcement.
ADVERTISING CONTROLS
Types of intervention
3.17 Governments can potentially restrict the level of advertising and the content of advertising, either by legislative action or through voluntary agreements with the alcohol industry. There may also be controls on other promotional activities.
Evidence of effectiveness
3.18 The evidence relating to advertising bans remains mixed, with the most recent study showing bans decreasing consumption (Saffer and Dave 2002; cited in Babor et al 2003).
Population groups
3.19 Babor et al (2003) review research that considers the cumulative effect of exposure to advertising by children and young people, and advertising content, in shaping attitudes towards alcohol. A small amount of research has also been done on sponsorship and Internet marketing, which may be particularly targeted at the young.
QUALITY AND RELEVANCE OF EVIDENCE
3.20 Evidence relating to policy interventions can be difficult to obtain and to interpret as it mainly comes from natural experiments resulting from policy changes. Chaloupka et al (2002) identify an importance source of potential bias in cross sectional studies of US States, where a more anti drinking social attitude may be associated with higher taxation and vice versa. Studies that have attempted to control for such effects have mixed results, with studies reporting either small or large reductions in estimated elasticities. The same potential bias may exist in other cross sectional studies, together with other limitations identified previously; weak study designs, publication bias, short follow up and multiple interventions implemented at the same time. There are relatively few studies of licensing interventions and the results need to be treated with some caution.
3.21 The lack of evidence associating advertising and alcohol consumption may be the result of little variation in spending levels and opportunities to substitute other forms of promotion. The effect of advertising bans in cross-country comparisons could be due to reverse causality; i.e. countries with low consumption being more likely to have alcohol advertising bans. This problem also affects US studies relating to a number of policy issues, where attitudes towards alcohol vary across states and states that implement the most restrictive legislation may be predisposed to reduce alcohol consumption or problem drinking.
3.22 Results from the US must be considered in the context of falling total consumption. Cross-national studies may be affected by cultural differences that make results difficult to interpret. Caution should be exercised in translating results from one country to another.
FURTHER RESEARCH
3.23 The main research priority remains the lack of UK evidence and any new initiatives should be carefully evaluated. Longer-term follow up of the impact of legislative action is also required.
« Previous | Contents | Next »