26 October 2021
LCP’s Dr Andrew Thompson outlines the links between alcohol consumption and poor health outcomes and explores some of the options available to policy makers ahead of the widely anticipated spending review.
Rising alcohol deaths and the ‘alcohol harm paradox’
In 2020, deaths directly caused by alcohol rose to their highest levels in England and Wales for 20 years, and Scotland recorded a 12 year high. There is, however, a disparity across society between the level of alcohol consumed and the harm experienced. Individuals from more deprived areas suffer greater alcohol harms, despite drinking at comparable or lower levels to those from less deprived areas. For example, alcohol-specific deaths in Scotland during 2020 were 4.3 times higher among those from the most deprived areas compared with the least deprived. This is the ‘alcohol harm paradox’, and the drivers behind it are numerous, often intertwined, and worryingly entrenched, with little support for ‘levelling-up’.
Alcohol and cancer risk
Alcohol is a major risk factor for cancer, and evidence is emerging that the alcohol harm paradox plays a role in alcohol-related cancer outcomes. The importance of alcohol in the development and progression of cancer is often underestimated despite a causal link having been established between alcohol consumption and cancers of the oral cavity, pharynx, oesophagus, liver, colon, rectum, and female breast. Data from the World Health Organization (WHO) suggest that, in 2016, alcohol caused an estimated 376,200 cancer deaths, 10.0 million cancer-related years of life lost (YLLs), 236,600 cancer-related years lived with disability (YLDs), and 10.3 million cancer-related disability-adjusted years of life (DALYs), representing 4.2%, 4.2%, 4.6%, and 4.2% of all deaths, YLLs, YLDs, and DALYs lost due to cancer globally.
Consumption of alcohol is rising in many countries due to increasing numbers of alcohol drinkers and rising levels of alcohol intake, and this is especially stark among women and in regions of rapid economic growth.
What are the options for policy makers?
Despite its importance in cancer risk, there is a general lack of awareness that alcohol can cause cancer. A public health campaign to educate the general population of the carcinogenic properties of alcohol would be a simple, cost-effective first step. However, unlike smoking and lung cancer, there is no single cancer on which to anchor such a campaign and overcoming the ‘everything causes cancer’ trope requires careful consideration to maximise impact. Established approaches such as labelling are likely to have some effect, although collaborating with well-known cancer charities is likely to be a more fruitful venture in terms of reach and message acceptance.
Taxation is another potential option. A study published in September 2021 by WHO reported that doubling excise duties on alcoholic beverages could prevent an estimated 10,700 new cancer cases and 4,850 alcohol-related cancer deaths across 50 countries in the European Region every year. The modelling demonstrated that the UK could benefit the most by avoiding 1,800 new cancer cases and 680 deaths, 10.9% of the annual totals.
Decreasing the affordability of alcohol is known to reduce per capita consumption but is generally unpopular with the public and therefore governments are often reluctant to act. Tax from alcohol is also an important source of income for the UK Government, with duties estimated to raise over £12 billion per year for the Exchequer. In May 2018, Scotland introduced minimum unit price, whereby alcoholic beverages cannot be sold for less than 50p per unit of alcohol. Data suggest an immediate impact on purchasing habits, with the largest reduction in sales observed in households that previously purchased the most alcohol, and a fall in alcohol-specific deaths in Scotland during 2019 was associated with minimum unit price. However, a report by the Institute for Fiscal Studies highlighted that MUP results in reduced tax revenue and a windfall for the alcohol industry. Restructuring the duties system to one that taxes all alcohol in proportion to its alcohol content, with a special levy on strong spirits, was proposed by the IFS as alternative approach to MUP. Modelling demonstrated a similar impact on consumption but an increase in tax revenue of more than £70 million, and now there is a growing expectation that the Chancellor will make amendments to alcohol taxation in the upcoming spending review.
Alcohol-related illness places an enormous burden on the NHS and services are now dealing with significant backlogs alongside late-presenting patients with more severe illness in an area of healthcare that is generally under-resourced and lacking treatment options. Even when treatment is available, there is evidence of inequalities in access to treatment at the individual level (e.g. screening and brief alcohol interventions) and the effectiveness of treatment. Cancer is just one example of more than 60 diseases associated with alcohol consumption. However, it holds a special place in societal conscience and therefore is suitable as a nexus for driving behaviour change. Crucially, any interventions must consider how to reduce the gap between most and least deprived in terms of alcohol harms, which in turn will likely narrow the societal gradient associated with multimorbidity and the need for complex care.