Category Archives: Alcohol

Mentor UK, Diageo and Me – A Personal Ethical Perspective

Jim McCambridge and his colleagues at the London School of Hygiene and Tropical Medicine have usefully explored in various publications the operations of the alcohol industry in trying to influence alcohol policy. For example, (http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001431) they have drawn attention to the behaviours of a number of economic operators to misrepresent evidence on Minimum Unit Pricing as the policy was being considered by the Scottish Government in 2008. In a recent article in the European Journal of Public Health, Lyness and McCambridge continued their investigations,(http://eurpub.oxfordjournals.org/content/early/2014/06/09/eurpub.cku076.short ). However, in doing so, I feel that they may have inadvertently damaged by insinuation and misrepresentation the reputation of Mentor UK, the charity of which I was Chief Executive from 2000 – 2009. I think it’s therefore important to provide some clarification. This is a personal perspective, and I am not writing in my capacity as Director of SHAAP (Scottish Health Action on Alcohol Problems).

I was Chief Executive of Mentor UK from 2000 – 2009. Mentor UK, as a drug (including alcohol) misuse prevention charity, always found it difficult to get funding. Year on year, there was always a worry about whether we would even have sufficient unrestricted income to make it into the next year. Not unusual, of course, for a small charity. We had to fundraise from trusts, foundations, individuals and government, just as other charities do. However, it was always difficult to bring in unrestricted income and most funding was restricted for project work. Our focus throughout all of our work was on expanding the evidence base for prevention and we always therefore included evaluation, ideally by external experts, in all of our projects.

In 2006, with other colleagues at Mentor, I designed the CHAMP Awards project which gave three cash awards each year to local projects working in the field of prevention and with three categories – young people-led, school and community. In addition, we provided external support, with equivalent funding to the awards, to help agencies evaluate and review their activities and disseminate their findings. The funding was provided by Diageo, the global drinks producer. We were totally up-front about Diageo’s involvement. This was at my insistence, so that there could be no accusations of inappropriate behaviour or relationships. As stated by Mentor UK on its website,
( http://www.mentoruk.org.uk/2014/06/where-does-mentors-funding-come-from/ , accessed 28th June 2014):

“The company’s sponsorship of the competition was wholly transparent: it was published in our annual accounts, as well as mentioned in press releases, annual reports and at the Awards ceremony itself, which was attended by Diageo representatives.”

Mentor UK trustees debated the ethical issues associated with accepting funding from Diageo before going forward with the arrangement and the project was consistently reviewed in line with the charity’s written ethical policy.

The winners of the CHAMP awards were selected by a jury with substantial prevention expertise. At no stage was Diageo involved in shaping the project, influencing the criteria for decision making or selecting the winners. To the best of my knowledge, ie even now, four years after my own involvement, they never tried to influence what we were doing.

My understanding is that the CHAMP Awards project had a significant impact on improving the operations of some of the agencies with which we worked. For example, the Greater Easterhouse Alcohol Project expanded its delivery from 38 to 100 primary schools.

From looking now at Mentor UK’s website (http://www.slideshare.net/Mentor_UK/champ-awards-achievements , accessed 28th June 2014), it seems that the project supported the development of the evidence base for effective prevention:

“The evaluation would not have gone ahead without this money”

and in some cases, even kept small local charities afloat:

“ I don’t know how we would have paid for what we did. It kept us going – it meant we could pay our bills.”

In fact, the funding also helped Mentor UK stay afloat, given the funding pressures to which I have alluded above.

The only other involvement I had with Diageo when I was at Mentor UK was when they came to events, in making a brief video about the awards scheme and when I facilitated a workshop for their staff about evidence-based prevention. Bearing in mind Mentor UK’s mission, this focussed on evidence for effective individual interventions and education. This was not to ignore the importance of actions on Price, Availability and Marketing and in my current role as Director of SHAAP (Scottish Health Action on Alcohol Problems – http://www.shaap.org.uk ), I have consistently challenged industry opponents, including Diageo on these issues. It is however erroneous, as claimed or implied by many who argue for population level measures that there is no evidence of effectiveness of individual and educational interventions. Rather, it is the case that too few projects are evaluated and there is consequently a lot of poor practice. Mentor in the UK and internationally plays an important role in trying to improve the quality of prevention work.

I left Mentor UK in 2009. I understand that Diageo ceased its funding of the CHAMP Awards a short time after that. Lyness and McCambridge’s article states that:

“In 2008/9 Mentor UK received 25% of its income from Diageo and continues to receive funding for CHAMPS”.

In the interests of clarity and fairness, it would have been appropriate to stress that the 2008/9 funding was restricted for the CHAMP project. The statement that they continue to receive funding for the project is simply untrue.

It is important to recognise that relationships with funders often present challenges for charities. However, at Mentor UK, I felt more directly under pressure from Home Office politicians not to criticise the UK Government’s drug policy while they funded the Drug Education Forum, which we hosted and I chaired, than I ever did from Diageo.

The only other contact I had with Diageo before joining SHAAP was when I was commissioned by Comic Relief to undertake a confidential review of their relationships with the alcohol industry. This indicated their recognition of the need to think carefully about these matters.

The first publication produced at SHAAP after I joined (http://www.shaap.org.uk/UserFiles/File/SHAAP%20Irresponsibility%20Deal%20AmendedMay13.pdf ) was titled “The (Ir)responsibility Deal?: Public Health and Big Business”. The title deliberately alluded to the ethical tightrope that has to be walked in managing relationships with economic operators. Our paper drew attention to similarities between large parts of the Alcohol, Tobacco and Food industries and challenged specifically,

“some tactics employed by the alcohol industry to subvert or circumvent legitimate public health policy interventions …in spite of the precedence given in domestic and EU law to the protection of human health over economic interests.”

I was not involved with Mentor UK when the UK’s Responsibility Deal was set up. I am not able to comment on whether it was appropriate for Mentor UK to join it or to remain in it. However, I disagree with Mentor UK’s assertion (http://www.mentoruk.org.uk/2014/06/where-does-mentors-funding-come-from/, accessed 28th June 2014) that:

“It is…disingenuous to assume that the alcohol industry is deliberately using corporate philanthropy to gain influence inside government and sow division in the public health community.”

Although this may not be the only reason for alcohol industry corporate giving, my experience as a player in the battles on Minimum Unit Pricing in Scotland and at EU level lead me to conclude that it is often, perhaps always, a motivating factor. With colleagues, I have headed our assault on what we believe to be outrageous behaviours by some alcohol industry operators, including Diageo, in challenging evidence-based public health measures to reduce alcohol-related harms. (For example, http://www.youtube.com/watch?v=TR6c2ZXrlVw&feature=youtu.be , http://www.gcph.co.uk/latest/blogs/504_alcohol-related_harm_in_glasgow_a_national_city_and_neighbourhood_perspective ).

Notwithstanding this, in my view, it does not benefit the Public Health cause to misrepresent the ethical positions and actions of charities like Mentor UK, which have left the charity feeling accused of (http://www.mentoruk.org.uk/2014/06/where-does-mentors-funding-come-from/, accessed 28th June 2014),

“a dishonesty that could damage our reputation as a leading voice against alcohol misuse among young people.”

I am certain it was not the intention of the researchers to do this. However, and also as a researcher myself, I am always conscious that I operate in a complex and political environment. I therefore have a responsibility in relation to checking out what I assert in publications and thinking about the resultant impact. That’s my personal ethical position.

Brewing up a storm – Carlsberg admit influencing EU Alcohol Policy

McCambridge et al (“Industry Use of Evidence to Influence Alcohol Policy: A Case Study of Submissions to the 2008 Scottish Government Consultation”, PLOS Medicine, 2013) have asserted that whereas the tobacco industry has been excluded from direct influence in policy making in many countries, alcohol industry actors continue to exercise a strong influence on alcohol policies across the world. Protecting their profits, they consistently oppose whole-population approaches, promoting instead targeted interventions that focus on a supposedly problematic minority of drinkers and emphasising the role of individual responsibility. In Scotland, hiding behind the ‘gloss’ of Scotch Whisky, as a front to purvey their cheap vodkas, Big Alcohol has blocked the implementation of Minimum Unit Pricing, despite the legislation being enacted to introduce this life-saving policy with no Parliamentary opposition (apart from the one unfortunate MSP who pressed the wrong button when voting).

McCambridge et al state that the alcohol industry is actively involved in drafting policy documents in low-income countries. However, we ought not to be complacent about what happens closer to home, and in Europe specifically. Alcohol is the world’s number one risk factor for ill-health and premature death among 25-59 year-olds, a core of the working age population. Europe is the heaviest drinking region of the world and alcohol is a major threat to the public health, safety and economic prosperity of EU citizens. Consumption levels in some EU countries are around 2.5 times higher than the global average. There is clear and comprehensive evidence that reducing alcohol-related harm across the EU requires regulation to reduce alcohol consumption, through the whole population. This includes actions on availability, marketing and price, all of which are consistently opposed by global alcohol producers.

The World Health Organisation has provided clear guidance that the alcohol industry’s activities should be restricted to their core roles as developers, producers, distributors, marketers and sellers of alcoholic beverages and that they should have no role in the formulation of alcohol policies, which must be protected from distortion by commercial or vested interests.

My current experience in Europe indicates that the governance arrangements to ensure that this happens may be insufficient to protect this position.

I represent Public Health interests as a member of the EU Alcohol and Health Forum, which also includes industry representatives. The governing document of the Forum and all guidance related to it makes clear that EU policy on Alcohol should be determined by member states, with no interference from industry. Current events, however, demonstrate that industry knowingly influences policy. Member states are currently working on an EU Action Plan, which conveniently ignores measures to reduce alcohol consumption across the whole population. In line with industry’s priorities, the focus is on binge or problem drinking, young people and reducing foetal alcohol harm. No danger to Big Alcohol’s profits if the rest of us keep on drinking as usual, encouraged by their advertising and promotions.

The main business of the Forum is to deliver and report on commitments in relation to existing EU policy. However, this week its members have been asked to supply commitments in relation to the draft objectives in the latest draft of the new Action Plan, although the latter has not yet been signed off by member states. By asking for commitments before objectives are finalised, the Commission is opening the door for Forum members – including the alcohol industry – to influence which objectives end up in the final version of the plan. (For example, if SAB Miller look at draft Objective 1 and make 20 commitments to it, you would expect that draft Objective 1 would be likely to stay and be prioritised.)

EU Commission officials continue to hold the line that the Forum does not influence policy. However, the industry are confident of their ability to do this. In an email sent to me in error yesterday by Carlsberg’s representative, (in Danish), discussing my objections to what is going on, he stated:

“It is an absurd discussion around policy in general. Of course we all influence policy.”

Eric Carlin: Young people, alcohol and (the troubling concept of) ‘resilience’

BSA Alcohol Study Group Blog

I’m delighted to have the opportunity to present in Cardiff some thoughts about young people and alcohol drawn from my PhD research which is exploring the usefulness of theories of ‘social exclusion’ and ‘resilience’ to describe contemporary youth transition experiences in Pilton, a disadvantaged neighbourhood of Edinburgh.

My fieldwork was conducted between July 2012 and March 2013 and I am currently analysing findings and writing up.  I recruited young people (aged between 16 and 23) and people who work with them from youth centres and colleges and advertising in the local community newsletter. I also held two focus groups with local mothers.

The theoretical context has been strongly influenced by the sociology of Norbert Elias, who believed that human beings are engaged in a ‘civilising process’. He argued that we should study the constantly changing figurations that  individuals, families and others in society engage in with each other. I therefore…

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Glasgow Pride? Yes, but for some LGBT people, get a grip on your drinking behaviours!

I went to my first ever  Glasgow LGBT Pride event on Saturday, rather proud and excited that this city,  for so long riven by sectarianism and daily violence, had changed so much while I was away that it could – safely – host such an event.  I’ve written before about my ambivalence towards this city. Many LGBT people, like myself, had been driven away from the city in our youth, in large part to escape the prejudice and fear that growing up there, or in my case, in one of its feeder towns, Coatbridge, caused us. Nonetheless, I have always remained proud of my West Coast, working-class heritage, which in many ways has helped to define me as much as my sexuality has.

I took my partner along and was explaining to him on the way to Glasgow Green what an enormous shift had taken place in a very short period of time. So far, so good.

When I got to Glasgow Green I was surprised that there was a tent selling alcohol which was cordoned off from the rest of the festival. This meant that, rather than as I had experienced at festivals elsewhere, there weren’t families and groups having picnics, including wine, watching the free concert.  The few people who were drinking outside the cordon were being stopped and warned by the police, a result of a local bye-law to try to prevent alcohol-related disorder. This meant that those who were drinking alcohol legally were fenced uncomfortably, like pigs in a pen. “How ridiculous”, I said to my partner. Surely at an event like this, people could be allowed to celebrate, to let their hair down for one day in the year, to celebrate the huge achievements our community has made. Isn’t it insulting to them to assume that they need to be policed to ensure they behave? How wrong I now realise I was.

In my professional capacity, now working on alcohol policy, I have myself been accused on TV very recently of being a public health kill-joy who wants to restrict the rights of the sensible majority because of the behaviours of a small minority, policing people’s health behaviours with regulations that interfere with their individual choices in an unwarranted fashion. Of course, that’s not the case. However, alcohol is a regulated commodity and a drug and people will differ on what is appropriate. We must all be open to changing our positions based on the evidence that is available to us.

The connection between alcohol and violence has been well-documented by many researchers. They often differ on the causality of the relationship but there is consensus that where violent behaviours occur, alcohol is often somewhere around. In my current PhD research, many young people have described to me how, rather than places of festivity, alcohol often turns their parties into violent occasions. One young man expressed it thus:

“Ye get people that just go out, get full ae drink and just, somebody’ll look at them, somebody’ll just look at ye and that’ll be it. “What are ye looking at?””

Easy for me as a middle-aged man to think that that only happens at young people’s parties. However, at various times in Glasgow on Saturday (and not late at night – I’d made my exit long before that), I saw drunken women fighting with each other, men and women throwing up in the streets, women falling down. Finally, to top it all off, I was personally whacked in the face by a six foot six man’s shoulder as he flew towards me, having been punched in the face and knocked off his feet in an argument he was having with another man in a city centre gay pub. I didn’t know them. Just wrong place, wrong time.

Loic Wacquant’s research in French banlieues and US ‘ghettos’ unearthed experiences of what he calls an “extraordinary prevalence of physical danger and…acute sense of insecurity” (Wacquant 2008,p.54). He contextualises the daily experience of young people in these areas within what he calls “violence ‘from above’” (2008, p. 24). His thesis is that poor urban young people are constantly abused by the impacts of macro—level socio-economic change including, mass unemployment, relegation to decaying neighbourhoods and a heightened stigmatisation in their daily lives. Violent responses to this, though often self-destructive for individuals and communities, are easily comprehensible. 

I am disappointed by what I experienced this week in Glasgow. Is it possible that the Glasgow experiences of social disadvantage, combined with continuing prejudice against LGBT people from establishment figures, including a not-long-departed-in-disgrace Cardinal, influences some of them, instead of celebrating their diversity in a festival of celebration, to ape the worst behaviours of macho, boorish, prejudiced, drunken (mainly) men?

I wasn’t feeling very proud of the LGBT community in Glasgow on Saturday evening. I was proud though of the very considerate and kind bar staff who gave me ice to put on my cheek. Proud also that working-class people in places like Glasgow are standing up for equality. Proud that many people had dressed up and had fun.

I’m very grateful to so many LGBT activists who give so much  time and effort to celebrate our community and to champion equal rights in marriage, employment, immigration and a host of other areas.

To the others, in local parlance, I’d say, “Get a grip!” We can discuss appropriate health behaviours but violence? Really?

 I missed Heather Small who closed the Pride festival on the Green. The words of her song “Proud” may be a little trite but still pertinent:

“What have you done today to make you feel proud?
It’s never too late to try
What have you done today to make you feel proud?
You could be so many people
If you make that break for freedom
What have you done today to make you feel proud?”

Wacquant, L. (2008) Urban Outcasts. Cambridge: Polity Press.

 

Risk and Responsibility

In “World at Risk” (2009), Ulrich Beck asserts that we now live in a Risk Society where the old institutions of industrial society – family, community, social class – have been undermined by the process of global modernisation and where individuals have to learn to navigate society for themselves. Beck does not suggest that we face a world of “unprecedented dangers”; rather that we live in conditions of “manufactured, self-inflicted insecurity.”

Beck’s thesis can provide a backdrop for many current ethical and moral debates. These include discussions about what should be the role of the state in public health interventions and where individuals should be left alone to make their own decisions, based on their individual assessment of risk and with a moral sense of responsibility. This ‘individualism’ conflicts markedly with Elias’ assertion in “What is Sociology?” (1970) that we are interdependent: the term individual can only be understood as referring to interdependent people in the singular, society referring to interdependent people in the plural.

How we organise our social and economic systems relies on the dynamic interweavings in which we engage. The limitations of our linguistic and conceptual abilities lead us into and trap us in dualistic debates about rights versus responsibilities that neglect human complexities and dynamism and how more powerful groups exert power over weaker groups. Thus, for example, poor people rather than globalisation are blamed for their ‘cultures of worklessness’ and the duty of individuals to “drink responsibly” is emphasised over corporations’ responsibility to promote their goods in an ethical fashion.

In 1970, Elias discussed what he saw as the fetishisation of the hydrogen bomb and argued that people projected their fears and blame onto it and the scientists who created it rather than taking responsibility for their own complicity in the reciprocal hostilities which led to its creation. Contemporary discussions about issues such as child abuse follow the same tangent; rather than considering how we have encouraged the development of a culture where sexualised imagery, whether or not involving children themselves, is displayed to them, we lament the discovery that ‘much-loved’ entertainers have been monstrous sexual predators. The individualistic culture responsibilises those monstrous individuals and the ‘victims’, i.e. those who suffer the most demonstrable harm at an individual level are deemed to be unfortunate. We convince ourselves that society has changed, that such abuse is terrible but exceptional.

As individuals and as a society, we carry on as before in our “manufactured, self-inflicted insecurity”.

Alcohol Assertions – Consume with Caution

I attended a conference today. In among some very interesting and perceptive discussions about how important parents could be in supporting young people around alcohol issues and what they needed in turn to enable them to carry out this role, there were some inaccurate or misleading assertions and selective uses of statistics. There were several fairly self-congratulatory statements about the alcohol problem getting significantly better when in fact, as a population, we are drinking vastly more than we did 20-30 years ago and levels of alcohol-related harm, though they may not be at their peak, are still a huge cause for concern. I know that the statistics in relation to alcohol use will always be debated but alcohol industry retailers do not help clarify the position by maintaining their secrecy around sales figures.

Among today’s assertions, this one:

There are fewer young people drinking than ever before.

This was based on the annual schools survey in England and Wales, exclusively self-reported, which doesn’t in fact track back to “forever”. Nonetheless, the positive impression is given when in fact,  the welcome recent reductions in young people’s use have come after a period of sustained year on year increases. As well as this, even though fewer young people may be drinking now than in the recent past, the drinkers are consuming vastly greater quantities than in the past.

If we take the long view, we can see that alcohol consumption in the UK was very high at the beginning of the twentieth century and then dipped significantly mid-century. Our current, albeit improving, situation is still markedly closer to those early twentieth century figures than to the mid-century position. Now, as then and in line with other health-related issues, the harm caused to poor and socially-disadvantaged communities is disproportionate. It is inexcusable and misleading to present only positive short-term improvements and ignore the sustained and serious increases in alcohol-related harms that have crept up and overwhelmed contemporary society.

Across Europe, alcohol is the world’s number one risk factor for ill health and premature death among the 25-59 year old age group and Europe is the heaviest drinking region in the world. The UK government (2012) estimates that in a community of 100,000 people, each year:

  • 2,000 people will be admitted to hospital with an alcohol-related condition;
  • 1,000 people will be a victim of alcohol-related violent crime;
  • Over 400 11-15 year olds will be drinking weekly;
  • Over 13,000 people will binge-drink;
  • Over 21,500 people will be regularly drinking above the lower-risk levels;
  • Over 3,000 will be showing some signs of alcohol dependence; and
  • Over 500 will be moderately or severely dependent on alcohol.

In Scotland, the alarming rise from the early 1990s has now stabilised but alcohol-related harm continues to be at historically high levels with alcohol-related deaths more than doubling since the 1980s and alcohol-related hospital discharges more than quadrupling since the early 1980s. There were over 40,000 hospital discharges in 2007 and alcohol related mortality has more than doubled in the last 15 years. In addition, Scotland has one of the fastest growing rates of liver disease and cirrhosis in the world. The Scottish government (2009) estimates that alcohol misuse costs Scotland £2.25 billion every year.

A couple of today’s speakers usefully drew attention to the impact that easy availability of alcohol has on people’s behaviours. In support of this, WHO (2011) has argued that,

Of all alcohol policy measures, the evidence is strongest for the impact of alcohol prices as an incentive to reduce heavy drinking occasions and regular harmful drinking. The health gains are greatest for heavier drinkers and there are also considerable gains in the well-being of people exposed to the heavy drinking of others.

The BMA has identified minimum price per unit as the most effective of all available price-related policy options for reducing alcohol-related harm. Yet the alcohol industry has consistently tried to block statutory regulation which would impact on sales of the cheapest, most harmful products. Indeed, the Scotch Whisky Association is currently engaged in legal action to try to block the Scottish Government’s planned introduction of Minimum Unit pricing. One of the industry’s speakers today said that he “believed that it wouldn’t work”. This flies in the face of real-life evidence from Canada of the impact of the introduction of Minimum Unit Pricing there (Stockwell et al., 2012).

We need public health focussed interventions in the markets, permitted by national and international law and to my mind, required by laws of social justice, to change our drinking cultures and behaviours.

Instead of this, the overwhelming theme today was the need for more education and information campaigns. As a champion myself for many years of alcohol education and its continuing supporter, I also know that education on its own is not going to achieve very much. We should always interrogate claims that are made about interventions that are deemed to be effective, even where there do appear to be signs of positive impacts. For example, the most notorious high-level failure in drugs and alcohol education was DARE, a high profile multi-million pound programme that was delivered across the USA for decades with no significant impact. Even with Life Skills training, Gorman et al (2007, p.585) have argued that:

far from supporting the evaluators’ claims concerning the rigour of the findings and their generalisability and public health significance, the results are very fragile, of little practical significance and quite possibly analysis-dependent.

This is not to say that Life Skills training should not be promoted – indeed I would strongly argue the contrary case. We must not, however, overclaim for it. Stothard and Ashton (2000) argue that there is insufficient consistency in the findings to be confident that implementing Life Skills will cut legal or illegal drug use, only that it can do and has done, most consistently in relation to smoking.

Regarding information campaigns, the BMA (Hastings & Angus, 2009) has argued that:

while alcohol industry- sponsored marketing seems like a good idea, its public health value is questionable, and given its stakeholder marketing agenda, the effects are likely to be counterproductive. Such activity also focuses attention on individual rather than population level solutions, and can delay more effective statutory measures.

The BMA also argues that messages such as:

We promote responsible drinking and find innovative ways to challenge the national drinking culture and tackle alcohol misuse

reinforce the idea of ‘safe limits’ rather than relative risks and the impression is erroneously given that problems only arise when the product is used in specific ways , for which it is not intended.

Today’s conference facilitator called for more accurate representation of drinking behaviours in the media, arguing that we should celebrate  the fact that the numbers who do drink are (according to him) falling quite sharply. I’m sorry but I think it’s a bit premature to be thinking about cracking open the (non-alcoholic) bubbly!

BMA Board of Science 2012, Reducing the affordability of alcohol, London.

Gorman, D.M., Conde, E., & Huber Jr., J.C. (2007). The creation of “evidence-based” drug prevention: a critique of the Strengthening Families Program Plus Life Skills Training evaluation. Drug and Alcohol Review, (26), 585–593.

Hastings, G. & Angus, K. (2009). Under the influence: The damaging effect of alcohol marketing on young people British Medical Association, London.

Home Office 2012, The Government’s Alcohol Strategy, London.

Scottish Government 2009, Changing Scotland’s Relationship with Alcohol: A Framework for Action, Edinburgh.

SHAAP 2007, Price, Policy and Public Health, Edinburgh.

Stockwell, T. et al. 2012, ‘Does minimum pricing reduce alcohol consumption? The experience of a Canadian province’, Addiction, vol. 107, issue 5.

Stothard, B., & Ashton. M. (2000). Education’s Uncertain Saviour. Drug and Alcohol Findings, (3).

University of Sheffield 2012, Model based appraisal of Alcohol Minimum Pricing and Off Licensed Trade Discount Bans in Scotland using the Sheffield Alcohol Policy Model v2 – Second Update, Sheffield.

World Health Organisation 2009, Global health risks, Geneva.

World Health Organisation Europe 2011, European Alcohol Action Plan 2012-2020: Implementing regional and global alcohol strategies, Geneva.