We commend Ireland for their progressive approach in prioritising public health,’ is how the WHO responded to Ireland becoming the first country to commit to mandatory labelling for alcohol products back in 2023 (DDN, June 2023, page 4).
The Public Health (Alcohol) (Labelling) Regulations, which were signed into law in May that year, form part of the wider Public Health (Alcohol) Act (PHAA), section 19 of which – covering pre-watershed bans on TV and radio ads for alcohol – came into force last month (see news, page 5).
The labelling regulations stipulate that all alcohol labels would need to clearly show not just the number of calories and grams of alcohol contained, but also health warnings about the risk of liver disease, alcohol-related cancers and drinking while pregnant (DDN, June 2023, page 4). Campaigners in the UK have long been calling for similar measures here, and Labour previously committed to mandatory labelling that included nutritional information and up-to-date low-risk drinking guidelines while in opposition (DDN, July/August 2019, page 5). So what lessons can we learn from Ireland’s experience?
Labelling guidelines
The labelling guidelines are set to be introduced next May after a three-year lead-in period, but in 2023 the Alcohol Action Ireland (AAI) charity called on the alcohol industry ‘not to cause any further delay’ and to demonstrate their commitment to better business practices by adopting the new labelling ahead of the implementation date.
Few people will be surprised to learn that no company has voluntarily done this. In fact there’s been ‘an ongoing campaign disparaging the need for labelling,’ AAI’s CEO Sheila Gilheany tells DDN, which even includes calling into question the evidence around alcohol and cancer. ‘The industry will always say things like it’s only at very high levels of alcohol consumption that there’s any possible problems, but that’s not the case. They’re certainly continuing to do that, and they’ve certainly sought meetings with government officials and ministers. Another thing they do very well is hoover up ex-TDs [teachta dála – members of the Irish parliament’s lower house] or ex-senators and employ them as lobbyists. We see a lot of that.’
As many have pointed out, the alcohol industry’s playbook is not dissimilar to that of the gambling sector – that the problem lies with a small group of people who don’t use the products responsibly (DDN, December/January, page 11).
‘It’s always about putting the responsibility onto the individual, and trying to ensure that the business which profits from the sale of its product or services isn’t held in any way responsible,’ says Gilheany. ‘It’s a deeply unfair thing, especially when this is an industry that has tried very hard to hide evidence of the harms.’
Large numbers of people are still unaware of many of the risks related to alcohol, she points out – ‘whether that’s cancer or other harms, and they’re certainly encouraged to drink alcohol in a way that’s even more likely to cause those harms because of the saturation marketing. You see all this stuff about responsible drinking and we’d be always saying, “Well, what about responsible trading and marketing?”
Marketing perception
Aside from its ubiquity, alcohol marketing affects everyone’s perception of the product as it’s ‘always shown as a risk-free activity that’s often central to things that are important to you’, she states ‘– whether that’s sport or music or family or friends, or in our case national identity.’
Indeed, Ireland has long had an image as a country where booze can be seen as inextricably linked with having a good time – something that the drinks industry is inevitably keen to promote. ‘The tourist board here frequently does surveys, and people say they mainly come for things like the scenery,’ she says. ‘Obviously they may well drink while they’re here, but it’s not the primary reason they visit. The industry will also claim that it’s essential to Ireland’s economy, whether that’s trade or tourism or employment. But if you look at the facts, Ireland’s alcohol exports are about 1 per cent of total exports, so it’s a tiny fraction of our economic activity.’ And when it comes to employment the industry will also ‘count every possible job and ascribe it to alcohol’, she says. ‘They always include hotels and restaurants, even though those aren’t businesses that are solely dependent on the sale of alcohol.’
While industry pushback on everything from MUP to tackling sports sponsorship or product labelling is inevitable, the general public are actually behind many of these things, she points out. ‘Typically when we do polling for things like restrictions in advertising – such as the broadcast watershed – you’d have more than 70 per cent in favour. And that’s really not surprising, because of the scale of the problem here. There’s no family that’s been left untouched by an alcohol issue – people are harmed in a multitude of ways. So there’s not really anyone saying, “I want to see more alcohol ads”. But of course we do see more alcohol ads.’
Deep industry pockets
It’s always instructive to look at advertising as a proportion of industry spend, she says. ‘If you’re a typical business – you’re selling coffee, you’re selling shoes – you’d probably spend about 10 per cent of your turnover on marketing. That’s kind of an industry standard. But the alcohol industry spends much, much more. Diageo was spending in the order of 18, 19 per cent of turnover at one point.’
And it’s these very deep industry pockets when it comes to advertising and marketing that create another significant issue, she says, and one that’s rarely discussed. ‘It means you have a whole other industry – actually two industries – very much bound up in this product. You have marketers and marketing companies, but you also have the publishers. Whether that’s online, print, TV or radio, they’ve become very big players in all this.’
It’s taken almost seven years since the pre-watershed restrictions were signed into law for them finally to come into force, and while the labelling restrictions are due to be enacted in 2026, two key parts of the PHAA are yet to be commenced. These are section 18, covering ads in publications, and section 13, which places restrictions on the actual content of ads. And it’s the latter that the industry are ‘ferociously’ resisting, says AAI.
This is because it ‘restricts the contents to facts, stripping out the industry myths which are used to recklessly promote consumption,’ and, again, requires the inclusion of health information and warnings. ‘But even if they were published tomorrow, what happens is they have to go to the European Commission and there’s a process to be gone through there,’ she says. ‘So we’re still a very long way off getting that done.’
Regulation dilution
Is she worried that industry pressure will mean that when they do finally come into force they’ll end up being watered down? ‘That’s always the concern,’ she says. ‘But I’d say the industry game at the moment is to delay them as much as possible.’ The problem with this is that everything – the labelling regulations, the content regulations – is designed to work together. ‘They complement each other and should be brought in at the same time. It’s just desperately frustrating because, among other things, what you could see happening is people saying, “so did it make any difference?” And we’re saying the whole thing is meant to act as a package – it’s not that this is the magic bit and that bit is something else. It’s designed to work together, so it’s undermining the legislation to be doing it in these bits and pieces, without a coherent path.’
Joined-up thinking
Speaking of a coherent path, AAI and others have also been lobbying for the establishment of an Office for Alcohol Harm Reduction in the hope of creating that oft-cited but usually mythical thing, ‘joined-up government’ – on this issue at least. ‘We need people who have the time and resources to be firstly gathering the information that’s needing to be looked at, different policy options, and most of all to be coordinating it across government. Because what we see all the time is we have the Department of Health who are seeking to reduce alcohol use, and then we have a multitude of other departments which act contrary to that – for example proposals from the Department of Justice to increase availability through longer licensing hours.
‘So we’re very keen on this idea of an alcohol office, of needing people with fresh thinking,’ she continues. ‘We need to be looking at things like internet marketing, we need to be looking at other harms and harms to children in particular. Look at the number of children right now living with a parent with an alcohol problem. A quarter of the adult population in Ireland grew up with alcohol harm in the home, and it carries a devastating impact. Think of the costs of that alone – individual costs like mental and physical health and wellbeing – but also on an economic basis. It makes so much sense to look at all of this in the round.’
The friend that won’t leave
Breaking someone’s close bonds with alcohol is no easy matter, Dr Roger Prudham told an audience of GPs.
The ‘really dramatic increase’ in deaths from alcoholic liver disease represented an ‘incredible explosion’ in the toll on the population, Dr Roger Prudham, consultant gastroenterologist, told the recent RCGP and AP conference, Managing addictions in primary care. His chart showed the burden of disease from alcohol dwarfing that of hepatitis B, hepatitis C and metabolic dysfunction-associated steatohepatitis (MASH). ‘Yet the allocation of resources for alcohol doesn’t match that epidemiology,’ he said.
Signs of liver disease in the hands, jaundice, gynaecomastia, ascites, hepatosplenomegaly, abdominal wall varices, oedema, and encephalopathy were all things to look out for during assessment. ‘But you may have nothing at all, or you may look perfectly fine because the liver is an incredibly forgiving organ – it doesn’t give you any pain or discomfort.’
Importantly, that first conversation needed to be ‘brutally candid but also kind and non-judgemental’. He encouraged asking specific questions – ‘“What do you drink?” “How many bottles/cans a day?” “How many times a week do you buy that?” “Does that include what you drink at the pub?” – instead of “How many units do you drink?” When you get into those specific questions, people find it much more difficult to prevaricate.’
Lifestyle advice included a gradual reduction in alcohol consumption, withdrawal support (community-based where possible), chlordiazepoxide to manage withdrawal, thiamine and multivitamins, and nutritional support. Prudham advocated vigilance for worsening oedema, encephalopathy, jaundice, bleeding, and fluid balance and added, ‘I also think it’s sensible to think about alcohol addiction as a disease, not to make a moral judgement or to think that somehow somebody is defective if they’ve got an alcohol-related problem, because it’s a very seductive drug, it’s universally available, and it’s socially accepted everywhere.’
For medical interventions in primary care, he advised spironolactone and furosemide to help mobilise oedema, low sodium, and lactulose for treating encephalopathy. But what really worked was ‘probably not the medicine’ but ‘a brief intervention, a word from a healthcare professional when you’re going from 30 to 40 units a week’.
He believed minimum unit pricing, cognitive behavioural therapy and a multidisciplinary approach were all effective, alongside finding something else to do – ‘Boredom, I think, is the biggest promoter of recidivism,’ he said. ‘You’re going to need something to replace the alcohol.’