Health impacts of increasing alcohol prices in the European Union: a dynamic projection

Alcohol-associated liver disease and public health policies

Alcohol-associated liver disease (ALD) rates have increased substantially in the United States and elsewhere around the globe. These increases are largely the result of increases in alcohol use. While there are many levels at which alcohol use interventions can be implemented in order to reduce alcohol use and its negative health consequences, public policy initiatives have emerged as a powerful way to intervene across a population. In this narrative review, we will review major US national as well as worldwide alcohol-associated public health policies with a particular focus on describing how such policies have influenced rates of ALD and its complications and outcomes. We will describe global alcohol public health policy frameworks, review key alcohol policy models, describe existing notable policies and their impacts, and highlight gaps in ALD policy literature where further research and policy interventions could reduce rates of mortality from ALD.

Effects of public policies in the prevention of cardiovascular diseases: a systematic review of global literature

OBJECTIVES

Given the growing interest worldwide in applying public policies to improve human health, we undertook a systematic review of studies investigating whether public policies targeting unhealthy products could reduce cardiovascular diseases.

STUDY DESIGN

This study was a systematic review of the literature.

METHODS

We searched research studies published in 2000-2020 from major databases, including MEDLINE and Embase. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and narratively synthesized the studies based on vote counting and direction of the intervention effect.

RESULTS

Ninety-eight studies, mostly from high-income countries, met the inclusion criteria. Most studies were on public policies targeting sugar-sweetened beverages and tobacco, followed by alcohol, sugar, salt, and junk foods. Overall, many reported that several fiscal, regulatory, and educational policies generated beneficial effects of reducing the diseases. Those studies that reported no or limited effects highlighted several sociodemographic and health risk characteristics and design and implementation aspects of the policy interventions as factors limiting the policy effects; most of these are modifiable with appropriate policy interventions. For instance, low magnitude of tax, substitution with other unhealthy products, firms' competitive response strategies, pre-existence of smoking bans, incremental enactment of smoking regulations, degree of enforcement, and various sociocultural factors minimized the effects of the policies.

CONCLUSION

The literature supports a growing consensus on the beneficial effects of public policy for improving human health. The design and implementation of public policies must address various impeding factors and incorporate appropriate remedial measures. Further research is needed from low- and middle-income countries and on whether and how multiple policy instruments work in tandem.

Reducing the Burden of Disease Through Tobacco Taxes in Mongolia: A Health Impact Analysis Using a Dynamic Public Health Model

BACKGROUND/OBJECTIVES

Smoking is the leading risk factor for many chronic diseases. The quantitative analysis of potential health gains from reduced smoking is important for establishing priorities in Mongolia's health policy. This study quantifies the effect of tobacco-tax increases on future smoking prevalence and the associated smoking-related burden of disease in Mongolia.

METHODS

The dynamic model for health impact assessment (DYNAMO-HIA) tool was used. The most recent data were used as input for evaluating tobacco-taxation scenarios. Demographic data were taken from the Mongolian Statistical Information Services. Smoking data came from a representative population-based STEPS survey, and smoking-related disease data were obtained from the health-information database of Mongolia's National Health Center. Simulation was used to evaluate various levels of one-time price increases on tobacco products (25% and 75%) in Mongolia. Conservative interpretation suggests that the population will eventually adjust to the higher tobacco price and return to baseline smoking behaviors.

RESULTS

Over a three-year period, smoking prevalence would be reduced by 1.2% points, corresponding to almost 40 thousand smokers at the population level for a price increase of 75%, compared to the baseline scenario. Projected health benefits of this scenario suggest that more than 137 thousand quality adjusted of life years would be gained by avoiding smoking-related diseases within a population of three million over a 30-year period.

DISCUSSION

Prevention through effective tobacco-control policy could yield considerable gains in population health in Mongolia. Compared to current policy, tax increases must be higher to have a significant effect on population health.

IMPLICATIONS

Tobacco taxation is an effective policy for reducing the harm of tobacco smoking, while benefiting population health in countries where the tobacco epidemic is still in an early stage. Smoking prevalence and smoking behaviors in these countries differ from those in Western countries. Reducing the uptake of smoking among young people could be a particularly worthwhile benefit of tobacco-tax increases.

Revisiting the Swedish alcohol stasis after changes in travelers' allowances in 2004: petrol prices provide a piece of the puzzle

BACKGROUND AND AIMS

In 2004, Sweden had to allow virtually unlimited private alcohol imports from other EU countries. Purchases from abroad in addition to the sales from Systembolaget stores (Sweden's alcohol retail monopoly) are a significant source of alcohol consumption in southern Sweden. However, survey studies designed to measure the expected increase in overall alcohol consumption in southern Sweden failed to detect a meaningful change. Since this was considered 'puzzling', this study aims to (at least partially) provide an explanation for this finding by testing an economic proposition, i.e., a coincidental and sudden increase in petrol prices reduced the affordability of private alcohol imports.

METHODS

Using monthly sales at the provincial level covering Jan 1997-Dec 2005 for beer and spirits, we employed a fixed-effect panel design. Two models were examined: (i) a model investigating the relationship between distance, petrol prices and alcohol sales before the liberalization, and (ii) a model investigating this relationship after the liberalization.

RESULTS

The model before the liberalization showed, as expected, that domestic alcohol sales decrease when petrol prices decrease. However, the model after the liberalization model revealed that the effect of petrol prices on beer sales depends on the (traveling) distance from the borders and, after full liberalization, the coefficients for petrol prices become positive. For spirits, the results were inconclusive.

CONCLUSION

In the aftermath of import liberalization of the Swedish alcohol market, increased petrol prices temporarily made private alcohol imports economically unattractive for consumers living close to the border. This may partly explain why, after that event, surveys did not detect the widely expected increase in self-reported alcohol consumption.

Health impact assessment to predict the impact of tobacco price increases on COPD burden in Italy, England and Sweden

Raising tobacco prices effectively reduces smoking, the main risk factor for chronic obstructive pulmonary disease (COPD). Using the Health Impact Assessment tool "DYNAMO-HIA", this study quantified the reduction in COPD burden that would occur in Italy, England and Sweden over 40 years if tobacco prices were increased by 5%, 10% and 20% over current local prices, with larger increases considered in secondary analyses. A dynamic Markov-based multi-state simulation modelling approach estimated the effect of changes in smoking prevalence states and probabilities of transitioning between smoking states on future smoking prevalence, COPD burden and life expectancy in each country. Data inputs included demographics, smoking prevalences and behaviour and COPD burden from national data resources, large observational cohorts and datasets within DYNAMO-HIA. In the 20% price increase scenario, the cumulative number of COPD incident cases saved over 40 years was 479,059 and 479,302 in Italy and England (populous countries with higher smoking prevalences) and 83,694 in Sweden (smaller country with lower smoking prevalence). Gains in overall life expectancy ranged from 0.25 to 0.45 years for a 20 year-old. Increasing tobacco prices would reduce COPD burden and increase life expectancy through smoking behavior changes, with modest but important public health benefits observed in all three countries.

Taxation of the fat content of foods for reducing their consumption and preventing obesity or other adverse health outcomes

BACKGROUND

Overweight and obesity are increasing worldwide and are considered to be a major public health issue of the 21st century. Introducing taxation of the fat content in foods is considered a potentially powerful policy tool to reduce consumption of foods high in fat or saturated fat, or both.

OBJECTIVES

To assess the effects of taxation of the fat content in food on consumption of total fat and saturated fat, energy intake, overweight, obesity, and other adverse health outcomes in the general population.

SEARCH METHODS

We searched CENTRAL, Cochrane Database of Systematic Reviews, MEDLINE, Embase, and 15 other databases and trial registers on 12 September 2019. We handsearched the reference lists of all records of included studies, searched websites of international organizations and institutions (14 October 2019), and contacted review advisory group members to identify planned, ongoing, or unpublished studies (26 February 2020).

SELECTION CRITERIA

In line with Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria, we included the following study types: randomized controlled trials (RCTs), cluster-randomized controlled trials (cRCTs), non-randomized controlled trials (nRCTs), controlled before-after (CBA) studies, and interrupted time series studies. We included studies that evaluated the effects of taxes on the fat content in foods. Such a tax could be expressed as sales, excise, or special value added tax (VAT) on the final product or an intermediary product. Eligible interventions were taxation at any level, with no restriction on the duration or the implementation level (i.e. local, regional, national, or multinational). Eligible study populations were children (zero to 17 years) and adults (18 years or older) from any country and setting. We excluded studies that focused on specific subgroups only (e.g. people receiving pharmaceutical intervention; people undergoing a surgical intervention; ill people who are overweight or obese as a side effect, such as those with thyroiditis and depression; and people with chronic illness). Primary outcomes were total fat consumption, consumption of saturated fat, energy intake through fat, energy intake through saturated fat, total energy intake, and incidence/prevalence of overweight or obesity. We did not exclude studies based on country, setting, comparison, or population.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for all phases of the review. Risk of bias of the included studies was assessed using the criteria of Cochrane's 'Risk of bias' tool and the EPOC Group's guidance. Results of the review are summarized narratively and the certainty of the evidence was assessed using the GRADE approach. These steps were done by two review authors, independently.

MAIN RESULTS

We identified 23,281 records from searching electronic databases and 1173 records from other sources, leading to a total of 24,454 records. Two studies met the criteria for inclusion in the review. Both included studies investigated the effect the Danish tax on saturated fat contained in selected food items between 2011 and 2012. Both studies used an interrupted time series design. Neither included study had a parallel control group from another geographic area. The included studies investigated an unbalanced panel of approximately 2000 households in Denmark and the sales data from a specific Danish supermarket chain (1293 stores). Therefore, the included studies did not address individual participants, and no restriction regarding age, sex, and socioeconomic characteristics were defined. We judged the overall risk of bias of the two included studies as unclear. For the outcome total consumption of fat, a reduction of 41.8 grams per week per person in a household (P < 0.001) was estimated. For the consumption of saturated fat, one study reported a reduction of 4.2% from minced beef sales, a reduction of 5.8% from cream sales, and an increase of 0.5% to sour cream sales (no measures of statistical precision were reported for these estimates). These estimates are based on a restricted number of food types and derived from sales data; they do not measure individual intake. Moreover, these estimates do not account for other relevant sources of fat intake (e.g. packaged or processed food) or other food outlets (e.g. restaurants or cafeterias); hence, we judged the evidence on the effect of taxation on total fat consumption or saturated fat consumption to be very uncertain. We did not identify evidence on the effect of the intervention on energy intake or the incidence or prevalence of overweight or obesity.

AUTHORS' CONCLUSIONS

Given the very low quality of the evidence currently available, we are unable to reliably establish whether a tax on total fat or saturated fat is effective or ineffective in reducing consumption of total fat or saturated fat. There is currently no evidence on the effect of a tax on total fat or saturated fat on total energy intake or energy intake through saturated fat or total fat, or preventing the incidence or reducing the prevalence of overweight or obesity.

Equity impacts of interventions to increase physical activity among older adults: a quantitative health impact assessment

BACKGROUND

Behavioural interventions may increase social inequalities in health. This study aimed to project the equity impact of physical activity interventions that have differential effectiveness across education groups on the long-term health inequalities by education and gender among older adults in Germany.

METHODS

We created six intervention scenarios targeting the elderly population: Scenarios #1-#4 applied realistic intervention effects that varied by education (low, medium high). Under scenario #5, all older adults adapted the physical activity pattern of those with a high education. Under scenario #6, all increased their physical activity level to the recommended 300 min weekly. The number of incident ischemic heart disease, stroke and diabetes cases as well as deaths from all causes under each of these six intervention scenarios was simulated for males and females over a 10-year projection period using the DYNAMO-HIA tool. Results were compared against a reference-scenario with unchanged physical activity.

RESULTS

Under scenarios #1-#4, approximately 3589-5829 incident disease cases and 6248-10,320 deaths could be avoided among males over a 10-year projection period, as well as 4381-7163 disease cases and 6914-12,605 deaths among females. The highest reduction for males would be achieved under scenario #4, under which the intervention is most effective for those with a high education level. Scenario #4 realizes 2.7 and 2.4% of the prevented disease cases and deaths observed under scenario #6, while increasing inequalities between education groups. In females, the highest reduction would be achieved under scenario #3, under which the intervention is most effective amongst those with low levels of education. This scenario realizes 2.7 and 2.9% of the prevented disease cases and deaths under scenario #6, while decreasing inequalities between education groups. Under scenario #5, approximately 31,687 incident disease cases and 59,068 deaths could be prevented among males over a 10-year projection period, as well as 59,173 incident disease cases and 121,689 deaths among females. This translates to 14.4 and 22.2% of the prevented diseases cases among males and females under scenario #6, and 13.7 and 27.7% of the prevented deaths under scenario #6.

CONCLUSIONS

This study shows how the overall population health impact varies depending on how the intervention-induced physical activity change differs across education groups. For decision-makers, both the assessment of health impacts overall as well as within a population is relevant as interventions with the greatest population health gain might be accompanied by an unintended increase in health inequalities.

To what extent could cardiovascular diseases be reduced if Germany applied fiscal policies to increase fruit and vegetable consumption? A quantitative health impact assessment

Objective:

This study aimed to dynamically model and quantify expected health effects of four scenarios: (i) a reference scenario with an unchanged fruit and vegetable intake, (ii) the removal of value-added tax (VAT) on fruits and vegetables, (iii) the implementation of a 20 % subsidy on fruits and vegetables and (iv) a guideline scenario with a population-wide fruit and vegetable intake of five portions per day.

Design:

Baseline fruit and vegetable intake data was derived from the GEDA 2012 study. We used price elasticities for Germany to calculate the change in fruit and vegetable consumption under the zero VAT and the 20 % subsidy scenario. All scenarios were modelled over a 10-year projection period using DYNAMO-HIA.

Setting:

Germany.

Participants:

A projected real-life population.

Results:

Cumulated over the 10-year projection period, an estimated 4450 incident ischaemic heart disease (IHD) cases, 7010 stroke cases and 13 960 deaths would be prevented under the zero VAT scenario. Under the 20 % subsidy scenario, 17 990 incident IHD cases, 27 390 stroke cases and 54 880 deaths would be averted. Although this corresponds to only a fraction of the incidents that would occur under the reference scenario, the averted cases translate to 2 % (for the zero VAT scenario) and 9 % (for the 20 % subsidy scenario) of IHD, stroke and death cases that would be prevented if the whole population consumed the recommended five portions of fruits and vegetables per day.

Conclusions:

Fiscal policies on fruits and vegetables provide a non-negligible step towards the removal of the health burden induced by low fruit and vegetable intake.

Economic Evaluation of Five Tobacco Control Policies Across Seven European Countries

Introduction

Economic evaluations of tobacco control policies targeting adolescents are scarce. Few take into account real-world, large-scale implementation costs; few compare cost-effectiveness of different policies across different countries. We assessed the cost-effectiveness of five tobacco control policies (nonschool bans, including bans on sales to minors, bans on smoking in public places, bans on advertising at points-of-sale, school smoke-free bans, and school education programs), implemented in 2016 in Finland, Ireland, the Netherlands, Belgium, Germany, Italy, and Portugal.

Methods

Cost-effectiveness estimates were calculated per country and per policy, from the State perspective. Costs were collected by combining quantitative questionnaires with semi-structured interviews on how policies were implemented in each setting, in real practice. Short-term effectiveness was based on the literature, and long-term effectiveness was modeled using the DYNAMO-HIA tool. Discount rates of 3.5% were used for costs and effectiveness. Sensitivity analyses considered 1%–50% short-term effectiveness estimates, highest cost estimates, and undiscounted effectiveness.

Findings

Nonschool bans cost up to €253.23 per healthy life year, school smoking bans up to €91.87 per healthy life year, and school education programs up to €481.35 per healthy life year. Cost-effectiveness depended on the costs of implementation, short-term effectiveness, initial smoking rates, dimension of the target population, and weight of smoking in overall mortality and morbidity.

Conclusions

All five policies were highly cost-effective in all countries according to the World Health Organization thresholds for public health interventions. Cost-effectiveness was preserved even when using the highest costs and most conservative effectiveness estimates.

Implications

Economic evaluations using real-world data on tobacco control policies implemented at a large scale are scarce, especially considering nonschool bans targeting adolescents. We assessed the cost-effectiveness of five tobacco control policies implemented in 2016 in Finland, Ireland, the Netherlands, Belgium, Germany, Italy, and Portugal. This study shows that all five policies were highly cost-effective considering the World Health Organization threshold, even when considering the highest costs and most conservative effectiveness estimates.

An effectiveness hierarchy of preventive interventions: neglected paradigm or self-evident truth?

Non-communicable disease prevention strategies usually target the four major risk factors of poor diet, tobacco, alcohol and physical inactivity. Yet, the most effective approaches remain disputed. However, increasing evidence supports the concept of an effectiveness hierarchy. Thus, 'downstream' preventive activities targeting individuals (such as 1:1 personal advice, health education, 'nudge' or primary prevention medications) consistently achieve a smaller population health impact than interventions aimed further 'upstream' (for instance, smoke-free legislation, alcohol minimum pricing or regulations eliminating dietary transfats). These comprehensive, policy-based interventions reach all parts of the population and do not depend on a sustained 'agentic' individual response. They thus tend to be more effective, more rapid, more equitable and also cost-saving. This effectiveness hierarchy is self-evident to many professionals working in public health. Previously neglected in the wider world, this effectiveness hierarchy now needs to be acknowledged by policy makers.

Alcohol consumption's attributable disease burden and cost-effectiveness of targeted public health interventions: a systematic review of mathematical models

Background

Around 6% of total deaths are related to alcohol consumption worldwide. Mathematical models are important tools to estimate disease burden and to assess the cost-effectiveness of interventions to address this burden.

Methods

We carried out a systematic review on models, searching main health literature databases up to July 2017. Pairs of reviewers independently selected, extracted data and assessed the quality of the included studies. Discrepancies were resolved by consensus. We selected those models exploring: a) disease burden (main metrics being attributable deaths, disability-adjusted life years, quality-adjusted life years) or b) economic evaluations of health interventions or policies, based on models including the aforementioned outcomes. We grouped models into broad families according to their common central methodological approach.

Results

Out of 4295 reports identified, 63 met our inclusion criteria and were categorized in three main model families that were described in detail: 1) State transition -i.e Markov- models, 2) Life Table-based models and 3) Attributable fraction-based models. Most studies pertained to the latter one (n = 29, 48.3%). A few miscellaneous models could not be framed into these families.

Conclusions

Our findings can be useful for future researchers and decision makers planning to undertake alcohol-related disease burden or cost-effectiveness studies. We found several different families of models. Countries interested in adopting relevant public health measures may choose or adapt the one deemed most convenient, based on the availability of existing data at the local level, burden of work, and public health and economic outcomes of interest.

Potential gains in health expectancy by improving lifestyle: an application for European regions

Background

Prevention aiming at smoking, alcohol consumption, and BMI could potentially bring large gains in life expectancy (LE) and health expectancy measures such as Healthy Life Years (HLY) and Life Expectancy in Good Perceived Health (LEGPH) in the European Union. However, the potential gains might differ by region.

Methods

A Sullivan life table model was applied for 27 European countries to calculate the impact of alternative scenarios of lifestyle behavior on life and health expectancy. Results were then pooled over countries to present the potential gains in HLY and LEGPH for four European regions.

Results

Simulations show that up to 4 years of extra health expectancy can be gained by getting all countries to the healthiest levels of lifestyle observed in EU countries. This is more than the 2 years to be gained in life expectancy. Generally, Eastern Europe has the lowest LE, HLY, and LEGPH. Even though the largest gains in LEPGH and HLY can also be made in Eastern Europe, the gap in LE, HLY, and LEGPH can only in a small part be closed by changing smoking, alcohol consumption, and BMI.

Conclusion

Based on the current data, up to 4 years of good health could be gained by adopting lifestyle as seen in the best-performing countries. Only a part of the lagging health expectancy of Eastern Europe can potentially be solved by improvements in lifestyle involving smoking and BMI. Before it is definitely concluded that lifestyle policy for alcohol use is of relatively little importance compared to smoking or BMI, as our findings suggest, better data should be gathered in all European countries concerning alcohol use and the odds ratios of overconsumption of alcohol.

Electronic supplementary material

The online version of this article (10.1186/s12963-018-0181-5) contains supplementary material, which is available to authorized users.

What are the potential preventive population-health effects of a tax on processed meat? A quantitative health impact assessment for Germany

The International Agency for Research on Cancer considers processed meat to be carcinogenic. Further, processed meat is associated with diabetes, ischemic heart disease (IHD) and all-cause mortality. We aimed to assess health gains of four processed meat taxation scenarios in comparison to the reference and a minimum-risk-exposure-scenario. To estimate the shift in processed meat intake following respective taxes, we calculated price elasticities for processed meat. DYNAMO-HIA was used to dynamically project policy-attributable differences in the prevalence of diseases and deaths. In projection year 10, an extra 9300 males and 4500 females would be alive under the lowest tax scenario (4% tax), compared to the reference scenario. Prevalent IHD, diabetes and colorectal cancer cases in males would be 8400, 9500 and 500 lower, respectively, and there would be 4600, 7800 and 300 less cases in females. Of the respective death and disease reduction that would be achieved under the minimum-risk-exposure-scenario, the lowest tax reaches 2.84% (colorectal cancer in males) to 6.02% (diabetes in females). Under the highest tax scenario (33.3% tax), an extra 76,700 males and 37,100 females would be alive, compared to the reference scenario. Prevalent IHD, diabetes and colorectal cancer cases would be 70,800, 77,900 and 4900 lower in males and 29,900, 48,900 and 2300 lower in females, which represents 27.84% (colorectal cancer in males) to 37.76% (diabetes in females) of the maximal preventable death and disease burden. Further research needs to examine to what extent these health benefits are outweighed by a simultaneous tax-induced decrease in fish intake.

Estimating the cost-effectiveness of brief interventions for heavy drinking in primary health care across Europe

Background

Screening and Brief Interventions for alcohol are an effective public health measure to tackle alcohol-related harm, however relatively few countries across the European Union (EU) have implemented them widely. This may be due to a lack of understanding of the specific financial implications of such policies within each country.

Methods

A novel 'meta-modelling' approach was developed based on previous SBI cost-effectiveness models for four EU countries. Data were collected on the key factors which drive cost-effectiveness for all 28 EU countries (mean per capita alcohol consumption, proportion of the population to be screened over a 10-year SBI programme; per capita alcohol-attributable mortality; per capita alcohol-attributable morbidity; mean cost of an alcohol-related hospitalisation and mean SBI-delivery staff cost). Regression analysis was used to fit two meta-models estimating net programme costs and Quality-Adjusted Life Years (QALYs) gained, to calculate cost-effectiveness estimates specific to each EU country.

Results

Costs are dependent upon the proportion of the population covered by the screening programme, the country-specific per capita mortality and morbidity rate and the country-specific costs of GP care and hospitalisation. QALYs depend on the proportion of the population screened and per capita alcohol consumption. Despite large inter-country variability in factor values, SBI programmes are likely to be cost-effective in 24 out of 28 EU countries and cost-saving in 50% of countries.

Conclusion

Implementing national programmes of SBI in primary health care would be a cost-effective means of reducing alcohol-attributable morbidity and deaths in almost all countries of the EU.

A rapid evidence review of the effectiveness and cost-effectiveness of alcohol control policies: an English perspective

This paper reviews the evidence for the effectiveness and cost-effectiveness of policies to reduce alcohol-related harm. Policies focus on price, marketing, availability, information and education, the drinking environment, drink-driving, and brief interventions and treatment. Although there is variability in research design and measured outcomes, evidence supports the effectiveness and cost-effectiveness of policies that address affordability and marketing. An adequate reduction in temporal availability, particularly late night on-sale availability, is effective and cost-effective. Individually-directed interventions delivered to at-risk drinkers and enforced legislative measures are also effective. Providing information and education increases awareness, but is not sufficient to produce long-lasting changes in behaviour. At best, interventions enacted in and around the drinking environment lead to small reductions in acute alcohol-related harm. Overall, there is a rich evidence base to support the decisions of policy makers in implementing the most effective and cost-effective policies to reduce alcohol-related harm.

Further examination of the temporal stability of alcohol demand

Demand, or the amount of a substance consumed as a function of price, is a central dependent measure in behavioral economic research and represents the relative valuation of a substance. Although demand is often utilized as an index of substance use severity and is assumed to be relatively stable, recent experimental and clinical research has identified conditions in which demand can be manipulated, such as through craving and stress inductions, and treatment. Our study examines the 1-month reliability of the alcohol purchase task in a sample of heavy drinking college students. We also analyzed reliability in subgroup of individuals whose consumption decreased, increased, or stayed the same over the 1-month period, and in individuals with moderate/severe Alcohol Use Disorder (AUD) vs. those with no/mild AUD. Reliability was moderate in the full sample, high in the group with stable consumption, and did not differ appreciably between AUD groups. Observed indices and indices derived from an exponentiated equation (Koffarnus et al., 2015) were generally comparable, although P_max observed had very low reliability. Area under the curve, O_max derived, and essential value showed the greatest reliability in the full sample (rs=0.75-0.77). These results provide evidence for the relative stability over time of demand and across AUD groups, particularly in those whose consumption remains stable.

Potential health gains and health losses in eleven EU countries attainable through feasible prevalences of the life-style related risk factors alcohol, BMI, and smoking: a quantitative health impact assessment

BACKGROUND

Influencing the life-style risk-factors alcohol, body mass index (BMI), and smoking is an European Union (EU) wide objective of public health policy. The population-level health effects of these risk-factors depend on population specific characteristics and are difficult to quantify without dynamic population health models.

METHODS

For eleven countries-approx. 80 % of the EU-27 population-we used evidence from the publicly available DYNAMO-HIA data-set. For each country the age- and sex-specific risk-factor prevalence and the incidence, prevalence, and excess mortality of nine chronic diseases are utilized; including the corresponding relative risks linking risk-factor exposure causally to disease incidence and all-cause mortality. Applying the DYNAMO-HIA tool, we dynamically project the country-wise potential health gains and losses using feasible, i.e. observed elsewhere, risk-factor prevalence rates as benchmarks. The effects of the "worst practice", "best practice", and the currently observed risk-factor prevalence on population health are quantified and expected changes in life expectancy, morbidity-free life years, disease cases, and cumulative mortality are reported.

RESULTS

Applying the best practice smoking prevalence yields the largest gains in life expectancy with 0.4 years for males and 0.3 year for females (approx. 332,950 and 274,200 deaths postponed, respectively) while the worst practice smoking prevalence also leads to the largest losses with 0.7 years for males and 0.9 year for females (approx. 609,400 and 710,550 lives lost, respectively). Comparing morbidity-free life years, the best practice smoking prevalence shows the highest gains for males with 0.4 years (342,800 less disease cases), whereas for females the best practice BMI prevalence yields the largest gains with 0.7 years (1,075,200 less disease cases).

CONCLUSION

Smoking is still the risk-factor with the largest potential health gains. BMI, however, has comparatively large effects on morbidity. Future research should aim to improve knowledge of how policies can influence and shape individual and aggregated life-style-related risk-factor behavior.

Alcohol and liver disease in Europe--Simple measures have the potential to prevent tens of thousands of premature deaths

In the World Health Organisation European Region, more than 2,370,000 years of life are lost from liver disease before the age of 50; more than lung cancer, trachea, bronchus, oesophageal, stomach, colon, rectum and pancreatic cancer combined. Between 60-80% of these deaths are alcohol related, a disease for which no pharmaceutical therapy has yet been shown to improve long-term survival. The toxicity of alcohol is dose related at an individual level, and is dose related at a population level; overall liver mortality is largely determined by population alcohol consumption. Trends in alcohol consumption correlate closely with trends in overall liver mortality, with 3-5-fold decreases or increases in liver mortality in different European countries over the last few decades. The evidence base for alcohol control measures aimed at reducing population alcohol consumption has been subjected to rigorous evaluation; most recently by the Organisation for Economic Co-Operation and Development (OECD). Effective alcohol policy measures reduce alcohol mortality, including mortality from liver disease. The most effective and cost effective measures have been summarised by the OECD and the World Health Organisation: regular incremental above inflation tax increases, a minimum price for alcohol, effective protection of children from alcohol marketing and low level interventions from clinicians. Simple, cheap and effective changes to alcohol policy by European Institutions and member states have the potential to dramatically reduce liver mortality in Europe.

Health Impact Assessment for Second-Hand Smoke Exposure in Germany--Quantifying Estimates for Ischaemic Heart Diseases, COPD, and Stroke

Evidence of the adverse health effects attributable to second-hand smoke (SHS) exposure is available. This study aims to quantify the impact of SHS exposure on ischaemic heart diseases (IHD), chronic obstructive pulmonary diseases (COPD), and stroke in Germany. Therefore, this study estimated and forecasted the morbidity for the three outcomes in the German population. Furthermore, a health impact assessment was performed using DYNAMO-HIA, which is a generic software tool applying a Markov model. Overall 687,254 IHD cases, 231,973 COPD cases, and 288,015 stroke cases were estimated to be attributable to SHS exposure in Germany for 2014. Under the assumption that the population prevalence of these diseases and the prevalence of SHS exposure remain constant, the total number of cases will increase due to demographic aging. Assuming a total eradication of SHS exposure beginning in 2014 leads to an estimated reduction of 50% in cases, compared to the reference scenario in 2040 for all three diseases. The results highlight the relevance of SHS exposure because it affects several chronic disease conditions and has a major impact on the population’s health. Therefore, public health campaigns to protect non-smokers are urgently needed.

Public attitudes towards pricing policies to change health-related behaviours: a UK focus group study

Background: Evidence supports the use of pricing interventions in achieving healthier behaviour at population level. The public acceptability of this strategy continues to be debated throughout Europe, Australasia and USA. We examined public attitudes towards, and beliefs about the acceptability of pricing policies to change health-related behaviours in the UK. The study explores what underlies ideas of acceptability, and in particular those values and beliefs that potentially compete with the evidence presented by policy-makers. Methods: Twelve focus group discussions were held in the London area using a common protocol with visual and textual stimuli. Over 300 000 words of verbatim transcript were inductively coded and analyzed, and themes extracted using a constant comparative method. Results: Attitudes towards pricing policies to change three behaviours (smoking, and excessive consumption of alcohol and food) to improve health outcomes, were unfavourable and acceptability was low. Three sets of beliefs appeared to underpin these attitudes: (i) pricing makes no difference to behaviour; (ii) government raises prices to generate income, not to achieve healthier behaviour and (iii) government is not trustworthy. These beliefs were evident in discussions of all types of health-related behaviour. Conclusions: The low acceptability of pricing interventions to achieve healthier behaviours in populations was linked among these responders to a set of beliefs indicating low trust in government. Acceptability might be increased if evidence regarding effectiveness came from trusted sources seen as independent of government and was supported by public involvement and hypothecated taxation.

Mortality and life expectancy of people with alcohol use disorder in Denmark, Finland and Sweden

OBJECTIVE

To analyse mortality and life expectancy in people with alcohol use disorder in Denmark, Finland and Sweden.

METHOD

A population-based register study including all patients admitted to hospital diagnosed with alcohol use disorder (1,158,486 person-years) from 1987 to 2006 in Denmark, Finland and Sweden.

RESULTS

Life expectancy was 24-28 years shorter in people with alcohol use disorder than in the general population. From 1987 to 2006, the difference in life expectancy between patients with alcohol use disorder and the general population increased in men (Denmark, 1.8 years; Finland, 2.6 years; Sweden, 1.0 years); in women, the difference in life expectancy increased in Denmark (0.3 years) but decreased in Finland (-0.8 years) and Sweden (-1.8 years). People with alcohol use disorder had higher mortality from all causes of death (mortality rate ratio, 3.0-5.2), all diseases and medical conditions (2.3-4.8), and suicide (9.3-35.9).

CONCLUSION

People hospitalized with alcohol use disorder have an average life expectancy of 47-53 years (men) and 50-58 years (women) and die 24-28 years earlier than people in the general population.

The alcohol purchase task in young men from the general population

BACKGROUND

The alcohol purchase task (APT), which presents a scenario and asks participants how many drinks they would purchase and consume at different prices, has been used among students and small clinical samples to obtain measures of alcohol demand but not in large, general population samples.

METHODS

We administered the APT to a large sample of young men from the general population (Cohort Study on Substance Use Risk Factors). Participants who reported drinking in the past year (n=4790), reported on past 12 months alcohol use, on DSM-5 alcohol use disorder (AUD) criteria and on alcohol related consequences were included.

RESULTS

Among the APT's demand parameters, intensity was 8.7 (SD=6.5) indicating that, when drinks are free, participants report a planned consumption of almost 9 drinks. The maximum alcohol expenditure (Omax) was over 35CHF (1CHF=1.1USD) and the demand became elastic (Pmax) at 8.4CHF (SD=5.6). The mean price at which the consumption was suppressed was 15.6CHF (SD=5.4). Exponential equation provided a satisfactory fit to individual responses (mean R(2): 0.8, median: 0.8). Demand intensity was correlated with alcohol use, number of AUD criteria and number of consequences (all r≥0.3, p<0.0001). Omax was correlated with alcohol use (p<0.0001). The elasticity parameter was weakly correlated with alcohol use in the expected direction.

CONCLUSION

The APT measures are useful in characterizing demand for alcohol in young men in the general population. Demand may provide a clinically useful index of strength of motivation for alcohol use in general population samples.

Cost-effectiveness of changes in alcohol taxation in Denmark: a modelling study

Introduction

Excessive alcohol consumption is a public health problem in many countries including Denmark, where 6% of the burden of disease is due to alcohol consumption, according to the new estimates from the Global Burden of Disease 2010 study. Pricing policies, including tax increases, have been shown to effectively decrease the level of alcohol consumption.

Methods

We analysed the cost-effectiveness of three different scenarios of changed taxation of alcoholic beverages in Denmark (20% and 100% increase and 10% decrease). The lifetime health effects are estimated as the difference in disability-adjusted life years between a Danish population that continues to drink alcohol at current rates and an identical population that changes their alcohol consumption due to changes in taxation. Calculation of cost offsets related to treatment of alcohol-related diseases and injuries, was based on health care system costs from Danish national registers. Cost-effectiveness was evaluated by calculating cost-effectiveness ratios (CERs) compared to current practice.

Results

The two scenarios of 20% and 100% increased taxation could avert 20,000 DALY and 95,500 DALY respectively, and yield cost savings of -€119 million and -€575 million, over the life time of the Danish population. Both scenarios are thus cost saving. The tax decrease scenario would lead to 10,100 added DALY and an added cost of €60 million. For all three interventions the health effects build up and reach their maximum around 15–20 years after implementation of the tax change.

Conclusion

Our results show that decreased taxation will lead to an increased burden of disease and related increases in health care costs, whereas both a doubling of the current level of alcohol taxation and a scenario where taxation is only increased by 20% can be cost-saving ways to reduce alcohol related morbidity and mortality. Our results support the growing evidence that population strategies are cost-effective and should be considered for policy making and prevention of alcohol abuse.

Estimating the price elasticity of beer: meta-analysis of data with heterogeneity, dependence, and publication bias

Precise estimates of price elasticities are important for alcohol tax policy. Using meta-analysis, this paper corrects average beer elasticities for heterogeneity, dependence, and publication selection bias. A sample of 191 estimates is obtained from 114 primary studies. Simple and weighted means are reported. Dependence is addressed by restricting number of estimates per study, author-restricted samples, and author-specific variables. Publication bias is addressed using funnel graph, trim-and-fill, and Egger's intercept model. Heterogeneity and selection bias are examined jointly in meta-regressions containing moderator variables for econometric methodology, primary data, and precision of estimates. Results for fixed- and random-effects regressions are reported. Country-specific effects and sample time periods are unimportant, but several methodology variables help explain the dispersion of estimates. In models that correct for selection bias and heterogeneity, the average beer price elasticity is about -0.20, which is less elastic by 50% compared to values commonly used in alcohol tax policy simulations.

Modelling obesity outcomes: reducing obesity risk in adulthood may have greater impact than reducing obesity prevalence in childhood

A common policy response to the rise in obesity prevalence is to undertake interventions in childhood, but it is an open question whether this is more effective than reducing the risk of becoming obese during adulthood. In this paper, we model the effect on health outcomes of (i) reducing the prevalence of obesity when entering adulthood; (ii) reducing the risk of becoming obese throughout adult life; and (iii) combinations of both approaches. We found that, while all approaches reduce the prevalence of chronic diseases and improve life expectancy, a given percentage reduction in obesity prevalence achieved during childhood had a smaller effect than the same percentage reduction in the risk of becoming obese applied throughout adulthood. A small increase in the probability of becoming obese during adulthood offsets a substantial reduction in prevalence of overweight/obesity achieved during childhood, with the gains from a 50% reduction in child obesity prevalence offset by a 10% increase in the probability of becoming obese in adulthood. We conclude that both policy approaches can improve the health profile throughout the life course of a cohort, but they are not equivalent, and a large reduction in child obesity prevalence may be reversed by a small increase in the risk of becoming overweight or obese in adulthood.

Financial crisis, austerity, and health in Europe

The financial crisis in Europe has posed major threats and opportunities to health. We trace the origins of the economic crisis in Europe and the responses of governments, examine the effect on health systems, and review the effects of previous economic downturns on health to predict the likely consequences for the present. We then compare our predictions with available evidence for the effects of the crisis on health. Whereas immediate rises in suicides and falls in road traffic deaths were anticipated, other consequences, such as HIV outbreaks, were not, and are better understood as products of state retrenchment. Greece, Spain, and Portugal adopted strict fiscal austerity; their economies continue to recede and strain on their health-care systems is growing. Suicides and outbreaks of infectious diseases are becoming more common in these countries, and budget cuts have restricted access to health care. By contrast, Iceland rejected austerity through a popular vote, and the financial crisis seems to have had few or no discernible effects on health. Although there are many potentially confounding differences between countries, our analysis suggests that, although recessions pose risks to health, the interaction of fiscal austerity with economic shocks and weak social protection is what ultimately seems to escalate health and social crises in Europe. Policy decisions about how to respond to economic crises have pronounced and unintended effects on public health, yet public health voices have remained largely silent during the economic crisis.

The good, the bad, and the ugly of alcohol consumption and taxes

The new contribution in these pages by Lhachimi et al. (2012) tallies up the net effects on mortality from internal and external causes that are likely to derive from changes in alcohol taxes in 11 countries within the European Union. Health economists prefer the efficiency of taxes to quotas or outright prohibition, but there are costs as well as benefits associated with any tax, because it drives a wedge between demanders and suppliers and thus reduces welfare. To guide public policy in this area, researchers should measure costs and benefits broadly defined, and Lhachimi et al. provide a useful first step.