It is important for Member States governments to recognise, therefore, that actions or inactions that result in increased national consumption are likely to increase problems for families as well as other kinds of health and social problems. Conversely, policies that reduce alcohol consumption are likely to benefit families.

However, and as stated above, it is also clear that per capita consumption is not the only factor influencing the level of harm: patterns of consumption also seem to play an important role. Indeed, some surveys have found a stronger relationship between family problems and frequency of intoxication than the level of consumption as such.(12)

Fortunately, there is good evidence that there are methods available for controlling alcohol problems. One relates to the price of alcohol.

Price and tax as system of control

Within the EU, studies of the effects of price changes on alcohol consumption have been carried out in Belgium, Denmark, Germany, Finland, France, Ireland, the Netherlands, Portugal, Spain, Sweden and the UK. Similar studies have also been undertaken in North America.(13)

The main conclusions of these studies are:

• Alcohol behaves basically like other commodities - if prices go up, consumption goes down, and if prices go down consumption goes up provided other things remain unchanged.
• The effects of price changes are enhanced or reduced by any concurrent changes in disposable income.
• Price elasticities are not the same for all times and places or for all beverages. In particular, the traditional beverage of choice (wine in wine producing countries etc) tends to be less price elastic than other beverages.
• Normally, increases in alcohol taxes increase Government revenue.
• Heavy and even alcohol-dependent drinkers are influenced at least as much if not more than lighter drinkers by price changes.

This last finding contradicts the claim often made by representatives of the alcohol industry that higher alcohol prices only penalise responsible, moderate consumers while having no effect on heavy and problematic drinkers. It also challenges the claim that price increases only impose an additional burden on the families of problem drinkers.(14)

There is no good evidence that alcohol taxes bear more heavily on the poor.

The most recent scientific review of these issues concludes:

"The contention that alcohol taxation is irrelevant to public health is factually unsustainable. The evidence is clear: other things being equal, a population's consumption of alcohol will, to a usually significant degree, be influenced by price. Moreover, given that heavier as well as lighter drinkers are affected, price changes are likely to translate into changes in the prevalence of alcohol problems."(15)

It is worth noting at this point that the European Commission has already accepted the principle that alcohol taxes have a public health dimension. The original proposed minimum tax rates on alcohol products were increased by 10 per cent to allow for the health aspect; the Commission has stated that it will allow each member country to determine its own level of taxation on substances that may influence the nation's health and the Commission's White Paper on "Growth, Competitiveness and Employment", commenting on the need to reduce budget deficits, states:

"An increase of excise duties on tobacco and alcohol provides a source of additional budget revenue and a means of preventing widespread social problems, and can help social security budgets to make savings (by reducing the need to treat cancer and alcoholism)".

The strategies for action agreed at the 1995 Inter-Governmental Paris conference "Health, Society and Alcohol" included to "Promote health by controlling the availability , for example for young people, and influencing the price of alcoholic beverages, for example, through taxation."

This was agreed and endorsed by the health ministries of all 49 member states of WHO European Region, and including all but one member state of the European Union.

Physical and legal availability

There is a considerable amount of evidence to show internationally that increasing the physical and legal availability of alcohol tends to encourage increased consumption, and conversely that restrictions on availability tend to reduce consumption and related problems.(16)

Availability here refers to the location and density of outlets, hours of sale and licence and service restrictions such as the legal drinking age.

Restrictions or lack of restrictions on availability presumably reflect the culture and requirements of the different countries and it is not being suggested here that there is a blue-print that could or should be imposed across the whole of the European Union.

What is being suggested is that, particularly in the northern states where the current trend appears to be towards de-regulation of the alcohol retail system, there is a clear danger that increased availability will result directly or indirectly in increased consumption and related problems, including harm to families.

Existing restrictions may therefore be seen as safeguards which it may be unwise to remove.

The legal age for purchase and consumption

The above consideration applies with particular force to the question of the legal age for purchasing and consuming alcohol. There is no uniform set of age limits across the Union (see appendix 3) and the different limits presumably reflect cultural differences in attitudes to drinking by children and young people.

There is an argument often heard in northern countries that it is preferable for parents to introduce their children to alcohol at an early age and in the family setting. It is widely believed in northern countries that this is what happens in the wine producing countries and that such an introduction to drinking helps prevent alcohol abuse.

These assumptions are false because historically the wine producing countries have had the highest levels of alcohol consumption and harm. Consistent with this, evidence from the northern countries themselves suggests that early regular drinking increases rather than reduces the risk of heavier drinking and of alcohol problems later in life. A recent American study(17) found that children who begin regular drinking by age 13 are more than four times as likely to become problem drinkers than those who delay drinking until 21 or older. A German study(18) also found that early initiation into alcohol use is associated with increasing risk of experiencing alcohol abuse or dependence.

The implication of these studies is again that existing restrictions on drinking by children, both those imposed by parents and those imposed by the state, are safeguards which it would be unwise to weaken or remove. Indeed, there is a clear case for strengthening the existing safeguards.

Interestingly in this context, it appears that French attitudes have changed, and parents are now less likely than both their predecessors and their British contemporaries, to provide their children with alcohol at a young age.(19) Similarly, in Spain, there has been discussion of the desirability of postponing the onset of regular drinking and the Regional Government of Galicia is reported to have introduced new legislation, classing alcohol and tobacco as drugs and raising the minimum purchase age for alcohol and tobacco to 18. The age level for the rest of Spain is 16. In the Netherlands, there is also debate regarding the possibility of raising the legal age for purchase of alcohol to 18.

Controls on drink driving

Clearly, measures that reduce casualties from drinking and driving benefit families as well as society at large. Every year in the European Union around 45,000 people are killed and 1.6 million injured in road traffic accidents. Around 19 per cent of injury accidents and 22 per cent of serious and fatal accidents are alcohol related. (20)

Such deaths and injuries can, of course, have devastating effects on families. In some countries, victim families have been at the forefront of campaigns against drinking and driving, and have played a crucial role in raising public awareness of the issue.

Another important component of countermeasures against drink driving is appropriate management, including treatment, of 'high risk offenders' - those drivers identified as possibly being problem drinkers. In modern, motorised societies, a common indicator of a developing alcohol problem is a conviction for drinking and driving. The normal pattern is that as countermeasures against drinking and driving succeed, large numbers of ordinary social drinkers stop drinking and driving and an increasing proportion of those who continue to drink and drive are habitual heavy or problem drinkers. This pattern is particularly evident in the northern European countries, where around one third of those convicted of drinking and driving show biochemical evidence of problem drinking. There is also ample evidence to show that problem drinkers are particularly dangerous drivers and are responsible for a disproportionate number of road crashes, deaths and injuries.(21)

The essential principle of 'high risk offender' schemes is that drivers who come into this category are disqualified from driving until and unless they can convince the authorities that their drinking habits are no longer a danger to other road users. High risk offenders may be required to undergo a treatment programme.

High risk offender schemes thus provide a means of social intervention into drinking problems at a relatively early stage and, given the importance of the driving licence in modern society, provide a strong incentive for the drivers concerned to arrest the development of the problem or to begin a process of recovery. While the need to improve road safety may provide the principal rationale for such schemes, by providing a means of preventing or treating alcohol problems they also directly benefit family members.

Education / rehabilitation schemes for convicted drink drive offenders are already established in the northern part of the Union (for example Germany, Sweden, the UK) but appear to be virtually unknown in the south.

Workplace alcohol programmes

Similar arguments apply to problem drinking policies in workplaces. While alcohol problems can be associated with unemployment and social exclusion, the majority of problem drinkers appear to be in gainful employment. It is estimated that between 10 and 30 per cent of employees in Europe may be considered to have alcohol problems.(22). Indeed, some industries and occupations are at raised risk of alcohol problems, and such problems can of course severely impair work performance, productivity and safety. Workplaces thus provide a particularly appropriate setting for identifying and tackling alcohol problems and the benefits of doing so extend to the home and families of the employees concerned.

Alcohol advertising and sponsorship

The European Alcohol Charter states that "All children and adolescents have the right to grow up in an environment protected from the negative consequences of alcohol consumption and, to the extent possible, from the promotion of alcoholic beverages."

Most Advertising Codes prohibit the specific targeting of minors, but the ubiquity of alcohol advertising ensures that it can hardly be missed by them. Indeed, the evidence is that even young children are aware of alcohol advertisements and tend to remember them.(23) Manufacturers further reduce the chances of young people failing to get the message by sponsorship of sports teams and events and music concerts having particular appeal to the young.

There is also evidence that underage drinking and the likelihood of alcohol problems in later life are closely related to positive expectations of benefit from alcohol use, precisely the expectancies advertising is designed to encourage.(24)

The results of scientific studies of the effect of advertising on total alcohol consumption and harm have been mixed. Some have found evidence of an effect, though a relatively small one when compared with factors such as price and income. On the basis of these studies it is suggested that a 10 per cent decrease in advertising could result in up to a 1 per cent decrease in consumption.(25) Such studies cannot reliably be used to forecast the effect of a major change of policy such as the introduction of a ban on alcohol advertising. However, other studies (26) have suggested that countries with broadcast advertising bans have lower levels of alcohol consumption.

There is therefore evidence to support the strategy for alcohol action proposed by the European Charter that each Member State "implement strict controls, recognising existing limitations or bans in some countries, on direct and indirect advertising of alcoholic beverages and ensure that no form of advertising is specifically addressed to young people, for instance, through the linking of alcohol to sports."

Education and information

The scientific evidence suggests that, often, education and information alone are of limited effectiveness and that educational strategies need to be combined with other measures, especially those which have a direct impact on the drinker's environment. (27) However, it may also be argued that education and information are required in order to win public acceptance of these other measures.

Moreover, the issues with which this report is concerned are ones which, in the words of the Portuguese participants, tend to provoke a strong 'ostrich response'.

"We can summarise the situation in regard to alcohol problems and the family in Portugal in some keywords: indifference, ignorance, and shame to speak out. Even in the governmental and non-governmental organisations surveyed, let alone the general public, we observed a tendency to prefer not to recognise the problems, and the majority were ignorant of the terrible extent of the problems and sufferings."

Clearly, the Ostrich response is not unique to Portugal: throughout the Union there is a need for increased awareness of the nature and scale of the problems on the part of the public and politicians as well as organisations and individuals concerned with family welfare.

Schools

Schools have an important role to play in the provision of education and information about alcohol and alcohol problems. The evidence suggests that school alcohol education programmes can increase knowledge and affect attitudes but are of limited effectiveness in regard to changing behaviour. They should not therefore be regarded as a panacea.(28) However, there is also evidence that educational programmes are more likely to affect behaviour if they are based on peer-led approach and are designed to increase social skills - the development of strategies to deal with anticipated drinking situations and to resist social pressure to drink.(29)

However, the potential importance of schools extends beyond classroom teaching to the concept of the school as a health promoting environment, of which a comprehensive alcohol policy is one component. Schools are also employing organisations and there are benefits for them too in workplace alcohol policies. There is also the question of the policy of the school towards the availability and consumption of alcohol on its own premises and at school functions. Lastly, in view of the possible adverse effects of parental problem drinking on children's school performance and attendance, there is an obvious need for school disciplinary and pastoral care systems to be sensitive to the possibility of parental alcohol problems and equipped to take constructive steps to deal with the issues.

Family influences

There are clear implications for society and for policy makers. The findings in relation to family structures and alcohol problems suggest that policies that support the stability of marriage or at least stable relationships between adults may also have beneficial effects in relation to alcohol problems. Conversely, policies that undermine such stability may, indirectly, promote alcohol problems.

There are also clear implications for parents, the most obvious being the importance of providing a good example. In addition, the likelihood of experiencing alcohol problems is reduced by adequate parental support and control during childhood and by delaying the onset of regular drinking preferably until the late teens.