Does cheap alcohol mean lower life expectancy?

That's been a question on my mind since living in France for a year and spending holidays in Spain and Germany.

Working as an English language teaching assistant in a high school in the Paris suburbs, a carafe of red wine was placed on the teachers' table during lunch in the canteen every day.

Most of the staff enjoyed a glass or two or wine with their meal before heading back to the classroom in the afternoon no worse for wear.

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The philosophy professor was convinced a little Beaujolais nouveau helped him convey the finer details of the teachings of Descartes, Voltaire and Rousseau to his Baccalaureate students.

People in the UK would baulk at such a habit, yet in France no one raised an eyebrow.

Yet the latest WHO's European Health Report published in 2021 puts alcohol consumption in France just ahead of the UK's despite being considerably cheaper. On average people in France drink 12.2 litres of alcohol a year per capita, compared to 11.4 in the UK.

Spain and Germany had higher levels at 12.7 and 12.8 respectively.

Nevertheless, a separate study by the OECD in 2021 found the effects of alcohol abuse had a smaller impact on health spending in the Spain and France than in the UK.

OECD simulations estimated that diseases and injuries caused by drinking above 1-1½ drinks per day lead to treatment costs equal to 1.3% of health expenditure in Spain and 1.6% in France but 3% in the UK.

Examining statistics compiled by the European Commission, it seems some of the EU27 members states which have among the lowest price of alcohol, also have the longest life expectancies.

Eurostat draws up an annual price index for goods bought and sold in each country in the bloc, and includes the UK up to 2020, giving a price power parity (PPP) for each item. The EU average price is given as 100.

For alcohol, the PPP in Italy, Spain and France is 92, 98 and 101 respectively. Separate figures published by Eurostat gives each of these countries life expectancies - 85 for Italy, 86 for Spain, and 85.5 for France.

In Germany, life expectancy is 83 with the country also having low alcohol prices - a PPP of 86, according to Eurostat.

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On the other extreme, people in Finland and the Irish Republic have a lower life expectancy than their counterparts in Italy, Spain and France - at 84.5 and 84 - yet both countries have some of the highest alcohol prices in the EU.

Finland has the highest price of alcohol with a PPP of 214 and Ireland is second highest at 203 - both more than double Italy, Spain, France and Germany.

Life expectancy in Scotland was 76.5 years for males and 80.7 years for females in 2020-2022, while the PPP for alcohol is on the higher end of the European table at 139.

So what's going on?

Public Health Scotland's evaluation of minimum unit pricing found that the policy helped reduce problem drinking.

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The document, published in June last year, said: "Evidence shows that MUP has had a positive impact on health outcomes, including addressing alcohol-related health inequalities.

"It has reduced deaths directly caused by alcohol consumption by an estimated 13.4% and hospital admissions by 4.1%, with the largest reductions seen in men and those living in the 40% most deprived areas."

It added: "MUP led to a 3% reduction in alcohol consumption at a population level, as measured by retail sales. The reduction was particularly driven by sales of cider and spirits through the off-trade (supermarkets and shops) products that increased the most in price. Evidence from a range of data sources shows that the greatest reductions were amongst those households purchasing the most alcohol, with little impact on households purchasing at lower levels."

The Herald:

Dr Tara Shivaji, Head of the Drugs Team at Public Health Scotland, told The Herald that the policy of minimum unit pricing does address behaviour around excess drinking - which increases the risk of heart disease and cancer which in turn reduce a person's life expectancy.

However, she said MUP was not a "silver bullet" to the problem of alcohol abuse in Scotland.

"There isn't a single silver bullet that resolves the challenge we see in the UK and Scotland," she said.

"We are in a really bad place in terms of our health. Minimum unit pricing, according to the PHS evaluation, found that the people whose purchasing patterns changed were those who were purchasing the most. Yes we do see it as being useful."

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Dr Shivaji explained that while reducing problem alcohol consumption through MUP maybe one way of increasing life expectancy other factors too have an impact.

"Improving life expectancy is about improving the conditions we are living in. For instance, to prevent cancer [deaths eg] we need to stop exposure to things that cause cancer, we need to detect cancers earlier and get people into treatments," she said.

Poverty, she said, was another determining factor in low expectancy.

So why countries such as Spain, Germany and France have long life expectancy yet low alcohol prices could be to do with a range of other aspects about life in those countries.

"What is happening in Spain and Germany to allow quite a long life expectancy is probably related to many factors including, in Spain the Mediterranean diet and low levels of obesity," she said.

"It could also be related to lower levels of poverty and socio-economic factors."

"Things like having enough money to live on, opportunities when you leave school to remain engaged in education, to be able to get a job which pays a decent wage. These are really important."

Dr Sadie Boniface, Head of Research, Institute of Alcohol Studies in London, and John Holmes, Professor of Alcohol Policy at the University of Sheffield, agreed with Dr Shivaji that higher alcohol pricing does reduce consumption and problem drinking.

“Making alcohol less cheap is the single most effective and cost-effective policy for changing population level alcohol consumption and harm. Decades of research show the relationship between alcohol prices, consumption, and harms, including real-world evidence following the introduction of minimum unit pricing in Scotland and elsewhere," said Dr Boniface.

“Alcohol kills people when they are young, and is the biggest risk factor for ill health, disability, and death among 15-49 year-olds....Deaths from alcohol and inequalities are at record high levels in the wake of the pandemic. We already have evidence on what works, and we urgently need a comprehensive national strategy to make alcohol less cheap, less available, and less heavily marketed, to reduce the harms and save lives.”

Professor Holmes also underlined that increasing alcohol prices "is a very effective way to reduce alcohol consumption and the harm it causes".

But he added that health outcomes like life expectancy arise from a range of causes. 

"That means we should be cautious about arguments that only look at one cause, such as alcohol prices," he said.

"Smoking rates, diet, levels of physical activity, the quality of health services, the extent of poverty and wider social conditions in a country will all affect [a country's population's] average life expectancy. This makes it difficult to see what impact alcohol consumption or alcohol prices are having."

So are there limitations to the policy of minimum unit pricing?

He added that looking at the variation between drinking habits in north and southern Europe he said alcohol prices or alcohol taxes also reflect each country's historical relationship with alcohol. 

"The northern European countries have tended to have high rates of alcohol problems and have introduced relatively high taxes on alcohol to help keep those problems under control," he said.

"The southern European problems have tended to have lower rates of alcohol problems and have seen less need to increase alcohol taxes."

Could people in the UK and Scotland have something to learn from people's drinking habits in countries such as Spain and Italy, Professor Holmes was asked.

"Politicians in Northern European countries, including the UK and Ireland, have long wondered what they can do to make their country drink more like the Mediterranean countries," he said.

"The eminent researcher Robin Room referred to this as 'The Impossible Dream'.  In reality, it is very difficult to change our drinking culture in this way because it is rooted in history, climate and the way we live our lives. 

"Alcohol problems also interact with all of the other factors I list - smoking, diet, physical activity, social conditions.  So we would need to change those as well - a worthy goal and one we should pursue, but certainly not easy to do. 

"So rather than dreaming about being more Italian, we should instead look at what we know works to reduce alcohol problems.  The best evidence we have suggests that is good regulation of the price, availability and marketing of alcohol. Tackling other causes of ill-health will also support this."

It seems higher alcohol prices may reduce alcohol consumption among certain groups but does not address the root problems of alcohol misuse, such as social and economic ills including poverty, unemployment, low education attainment, all which influence poor health and low life expectancy.