From its activist and morally motivated beginnings alcohol policy has grown over the past 25 years into a political and scientific discipline capable of identifying, planning and monitoring effective measures to reduce harmful alcohol consumption. Slovenia is among the countries that have significantly strengthened 147.000.000 € their activities in the field of alcohol policy. We have adopted the recommendations OVENIA € of experts and decided to follow the path of establishing a safer and healthier medical expenses per year society in which there will be less space for alcohol advertisement, and more for introducing and implementing evidence-based measures to prevent hazardous and harmful alcohol consumption. Projects such as MOSA (Mobilising community for responsibility towards alcohol) and SOPA (Together for a responsible attitude towards alcohol consumption) already place us among societies in which everyone can very easily access basic information on whether they or a family member needs 40% professional help, as well as advice on where to find such help. The seed we planted in this field a quarter of a century ago has sprouted. Now all of us together must of 15-year-olds COHOL POLICY IN SL ensure that it will bear fruit. have consumed AL alcohol at the age Zdenka Čebašek Travnik, president of the Medical Chamber of Slovenia of 13 or less. ALCOHOL POLICY IN SLOVENIA OPPORTUNITIES FOR REDUCING HARM, COSTS AND HEALTH INEQUALITIES IN POPULATION 2019 Data show that consumption of alcohol and its consequences do a lot of harm to the people, to the economy, to the society. World Health Organization recognizes Alcohol increases and applauds to the Slovene authorities for their efforts that have already led to the risk of certain some very good achievements. There is a strong leadership and commitment to types of cancer. change the unfavourable situation with alcohol. Much has been invested with visible effect into health services’ response, community and workplace actions, drink-driving policies and regulation of alcohol availability. Thanks to working closely with the civil society, public awareness about negative consequences of drinking and alcohol intoxication has grown. However, there are areas where improvements can be made in terms of policies, namely pricing, marketing, illicit alcohol and informally produced alcohol. There is a need of a comprehensive Drinking any alcohol strategy, involving all the key stakeholders. alcohol is hazardous. Darina Sedláková, WHO, Regional Office for Europe, Country Office Slovenia Slovenia has not yet implemented In an average week: at least all effective 18 deaths due to alcohol. alcohol policy measures. ALCOHOL POLICY IN SLOVENIA OPPORTUNITIES FOR REDUCING HARM, COSTS AND HEALTH INEQUALITIES IN POPULATION English edition 2019 2 ABOUT THE PUBLICATION The aim of the publication, entitled ALCOHOL POLICY IN SLOVENIA – opportunities for reducing harm, costs and health inequalities in population, is to equip policy-makers from different sectors at national and local-community level and others striving to reduce alcohol-related harm in Slovenia with credible data on the extent of the alcohol problem in the country, and to inform on effective, evidence-based alcohol-related policy measures. The publication was prepared by experts working in the field of alcohol at the National Institute of Public Health and the Ministry of Health of Slovenia in cooperation with colleagues from the MOSA network (Mobilizing society for more responsible attitudes towards alcohol), the Alcohol Policy Youth Network and the Institute for Youth Participation, Health and Sus-tainable Development. We strive to always present the latest available data; therefore, we are constantly updating the publication. This publication was supported within the framework of the Biennial Collaborative Agreement for 2018–2019 between the World Health Organization, Regional Office for Europe and the Ministry of Health of the Republic of Slovenia. 3 LET’S REDUCE ALCOHOL-RELATED HARM IN SLOVENIA! ALCOHOL IS A SERIOUS PROBLEM Alcohol consumption brings certain risk and can lead to harmful consequences of drinking. The more alcohol you drink, the greater the risk. The harmful effects of alcohol use are many. In Slovenia: ◊ 43% of adults, aged 25–64 drink highly hazardously;¹ ◊ every second 17-year-old engaged in binge drinking at least twice in their life;² ◊ there has been an increasing trend in hazardous drinking among young women over the past years;³ ◊ every year, an average of 927 people die as a result of the harmful effects of alcohol use on health and in traffic accidents caused by drunk drivers.4,5 GOVERNMENT FUNDS ARE STRONGLY AFFECTED BY COSTS RELATED TO ALCOHOL USE For the 2012-2016 period, alcohol-related health costs in Slovenia were estimated on average at 147 million EUR per year6; adding the costs resulting, for example, from traffic accidents, crime, domestic violence and theft, brings the amount up to 228 million EUR.6-9 Reduced productivity and the anguish felt by close family members, especially children, are also the costs that need to be taken into account. WORLD HEALTH ORGANIZATION RECOMMENDS EVIDENCE- BASED MEASURES To reduce alcohol-related harm, World Health Organization recommends taking evidence-based action to:10-15 ◊ limit alcohol availability, for example, by restricting sales to certain days/hours, and by increasing the age limit for the purchase and use of alcohol; ◊ reduce the affordability of alcohol, for example, by increasing minimal alcohol tax rates and by introducing minimal alcohol prices, bans on happy hours and promotional pricing of alcohol; ◊ limit the marketing and advertising of alcoholic beverages; ◊ ensure early identification and treatment of hazardous drinkers; ◊ provide treatment for alcohol-related mental and behavioural disorders, as well as other alcohol-related diseases and conditions; ◊ prevent drunk driving; ◊ increase the responsibility of serving personnel. 4 EFFECTIVE MEASURES NOT YET IN PLACE IN SLOVENIA In the past years in Slovenia, we are the most successful in the field of drink driving policies and countermeasures, leadership, awareness and commitment, limiting alcohol availability (it has to be stressed that some steps back were taken in the last years), health service response (early identification of harmful and hazardous drinkers and addiction treatment) and preventing negative consequences of drinking and alcohol intoxication. We are currently less successful in the fields of limiting the marketing and advertising of alcoholic beverages, reducing the public health impact of illicit alcohol and informally produced alcohol, and reducing the affordability of alcohol.16-19 BENEFITS OF REDUCING ALCOHOL-RELATED HARM Investment in the prevention of hazardous and harmful alcohol use leads to better population health and well-being, lower morbidity and mortality rates (also among youth and the working population), fewer traffic and other accidents, less violence, fewer unhappy families, less absenteeism, higher work efficiency, and better economy for the individual and the country.18 EFFECTIVE ALCOHOL POLICY DEPENDS ON COOPERATION AMONG KEY STAKEHOLDERS To facilitate the coordination of interventions and the mobilization of all key stakeholders, World Health Organization recommends adopting alcohol strategies at the national and local-community levels, including action plans with clear goals, priority areas and activities.15-19 PUBLIC SUPPORT OF ALCOHOL-POLICY MEASURES The Slovenian population strongly supports introducing new measures to limit alcohol use, such as zero tolerance for all drivers (65%), information on ingredients and nutritional value on alcohol containers (83%) and total ban on alcohol advertising (52%).20 5 WHAT IS THE SCOPE OF THE ALCOHOL PROBLEM? In recent years, many researches have confirmed a variety of adverse effects of alcohol use .15,18,21,22,133,134 6 ALCOHOL INCREASES THE RISK OF CERTAIN TYPES OF CANCER Cancer risk exist for the majority of people who drink alcohol, even if drinking small quantities. Research shows that the risk is higher even in low-risk drinkers compared to abstainers – women who drink one drink per day already have increased risk of developing breast cancer.23 Alcohol consumption is also related to a higher risk of oral, pharyngeal, oesophageal, liver, colon and rectal cancer.24-28 Alcohol increases the risk of developing cancer, as it: ◊ damages the cells, ◊ increases the risks caused by smoking, ◊ negatively affects the hormonal system (linked to breast cancer), ◊ breaks down into cancer-causing substances.28-30 The risk decreases substantially if we abstain from alcohol.133 THE ADVERSE ALCOHOL EFFECT ON THE CARDIOVASCULAR SYSTEM In the past, it was thought that moderate alcohol drinking can have some benefits on the circulatory system, but more recent research shows that these benefits have been far overestimated.31-33 We now know that the overall effect of alcohol use on the global burden of cardiovascular diseases is negative, especially in the societies prone to heavy episodic drinking.23 Alcohol damages the heart muscle, negatively affects the cardiac rhythm (causes arrhythmias), elevates blood pressure and blood lipids, increases body weight and the risk of a haemorrhagic stroke.15,31,32,34 7 EVERY ALCOHOL CONSUMPTION IS HAZARDOUS In general, the more alcohol people drink on one or more occasions, the greater the risk they put upon themselves, their families and others.133 People differ in the amounts of alcohol they drink, types of alcoholic beverages they drink and in the frequency of their drinking during the course of their lives.1,35-37 Some drink regularly, others occasionally, some never do. In Slovenia only every fifth resident, aged 25–64 years, has not consumed any alcohol in the previous year. On average approximately 70% of the population, however, drink up to two units (men) and up to one unit (women) of alcohol per day.3,37,38 One unit of alcoholic beverage contains approximately 10 grams of pure alcohol, which is contained in 1 dcl of wine or 2.5 dcl of beer or 0.3 dcl of spirits.39 Approximately 10% of the population, aged 25–64 years, drink more than two units (men), and more than one unit (women) of alcohol per day.3,37,38 Adding those who at single occasion drank more than 5 units (men) and more than 3 units of alcohol (women), we can conclude that 43% of the Slovenian population, aged 25–64 years, exceed the limits of low risk drinking or engage in heavy episodic drinking at least once a year.1 The fact that in surveys people usually underreport their actual alcohol consumption,45 it can be assumed that the alcohol problem in Slovenia is even bigger. 8 The consequences of alcohol consumption are extensive and multi-levelled:15,21 9 EXCEEDING THE LOW RISK DRINKING LIMIT IS THREE TIMES HIGHER IN MEN Percentage of the Slovenian population aged 25–64 years that drink more than 2 units of alcohol per day (men), and more than one unit of alcohol per day (women).3 Percentage of the Slovenian population aged 25–64 years engaging in heavy episodic drinking* 1-3 times per month or more often.3 *Men who drink more than 5 units of alcohol and women who drink more than 3 units of alcohol on single occasion. GENDER DIFFERENCES ARE NARROWING The percentage of men that drink more than two units of alcohol per day is decreasing, while the percentage of women, especially those with higher education, that drink more than one unit of alcohol per day is increasing.3 10 DEATHS CAUSED BY ALCOHOL ARE PREVENTABLE Harmful alcohol consumption is present when damage related to alcohol use occurs.21 It represents one of the main preventable risk factors for chronic diseases, injuries, accidents, assaults, violence, murders, and suicides. It is also one of the most important risk factors for morbidity, disability, disablement, and mortality.15,22,46,47 Harmful alcohol use is the sole or additional causal factor of more than 200 known medical conditions and injuries.15 Diseases (e.g. alcohol addiction, alcohol liver cirrhosis, alcoholic gastritis, etc.), injuries, and deaths caused exclusively by alcohol can be prevented, since drinking alcohol is avoidable.48 In Slovenia every day at least two people die due to reasons exclusively attributable to alcohol.49 4361 such deaths were recorded between 2011 and 2015; 3417 men and 944 women died.5 The number of those deaths decreased in this period, none-the-less, 826 deaths were recorded in 2016, more than half of it before the age of 65.5 The mortality rate due to causes exclusively attributable to alcohol in men was 6 times higher than in women. The mortality among the Slovenian population is above the European average.43,49,50-54 Mortality by selected alcohol-related causes, per 100.000 population, (age-standardised death rate), Slovenia, EU43,54 Source: WHO/Europe, European HFA Database Alcohol contributes to premature mortality. Due to deaths exclusively attributable to alcohol in 2016 in Slovenia at least 4655 years of potential life were lost, or an average 10.5 years of potential life lost per every person that died before the age of 65; on average 8 times higher in men than in women.5 Between 2004 and 2017 every year on average 55 additional people died because of traffic accidents caused by intoxicated persons.4 In total these are at least 927 deaths per year that could be prevented.4,5 11 The number of hospital admissions due to consequences of harmful alcohol use has decreased in recent years, but data derived from medical practice show, that those admitted to hospitals are in severer medical conditions.50,55 Harmful alcohol use is also related to numerous other diseases, such as cancer, musculoskeletal and cardiovascular diseases, gastro-intestinal diseases, etc. Alcohol is an important risk factor for developing those diseas-es46 and as a result there are actually many more alcohol-related deaths. According to research data of the Global Burden of Disease Study 2016, there are almost 2000 deaths related to alcohol in Slovenia.133 ALCOHOL CONSUMPTION CAN CAUSE ADDICTION Alcohol addiction is defined by the joint presence of at least three of the following phenomena in the preceding year:56 ◊ higher tolerance, increasingly higher quantities of alcohol needed to reach the same effect; ◊ physical disorders resulting from alcohol withdrawal (abstinence crisis); ◊ a barely manageable desire to drink alcohol; ◊ difficulties in controlling alcohol use; ◊ a continued use of alcohol despite harmful consequences; ◊ neglect of other activities due to alcohol use. In Slovenia the treatment of alcohol addiction is carried out within the health system; support and psychosocial rehabilitation is also provided by social security services and non-governmental organisations (e.g. clubs for treated alcoholics, Alcoholics Anonymous, self-help groups).57-66 SOURCES FOR HELP ARE AVAILABLE AT: www.infomosa.si www.sopa.si www.nalijem.si mobilna aplikacija Prvi stik (First Contact) 12 ADOLESCENTS AND YOUNG ADULTS ARE AMONG THE MOST VULNERABLE The younger people are when they start consuming alcohol, the higher the risk of developing alcohol related problems later in life.67,68 Alcohol has a neurotoxic effect (it is harmful to the central nervous system) at all stages in life. Researchers have found that the brains of children and adolescents are more vulnerable to damage caused by exposure to alcohol. The higher vulnerability is a consequence of developmental changes, especially brain maturation.67-69 To adolescents it especially pertains that every alcohol consumption is hazardous.69 Researchers have found that the brains of chil- dren and adolescents are more vulnerable to damage caused by exposure to alcohol. ADOLESCENTS HAVE NO TROUBLE BUYING ALCOHOL Despite the legal ban on selling and serving alcohol to minors70, alcohol is easily accessible to young people.71-77 Most often they come by alcohol at their friends and at home, they even have no trouble buying it in shops, bars or gas stations. Majority of adolescents perceive drinking alcohol as a way of fun and relaxation.78-81 13 A SIGNIFICANT PART OF ADOLESCENTS ALSO USES OTHER PSYCHOACTIVE SUBSTANCES BESIDES ALCOHOL Approximately 40% of 15-year-olds have already tried more than one psychoactive substance* at some point in life.82 Most of them first tried alcohol, then tobacco, and later cannabis. The use of more psychoactive substances in adolescence is related to a higher risk of other hazardous behaviour, addiction and numerous other negative consequences.83-86 *In the survey adolescents responded to questions about the consumption of alcohol, tobacco and cannabis. DRINKING ALCOHOL IN QUANTITIES ABOVE THE LIMITS OF LOW RISK DRINKING* IS INCREASING AMONG YOUNG ADULTS (25-34 YEARS), ESPECIALLY IN HIGHLY EDUCATED WOMEN3 *Men that drink more than 2 units of alcohol per day and women that drink more than one unit of alcohol per day. 14 ALCOHOL AND PREGNANCY Hazardous alcohol consumption among young adults (25-34 years old) is increasing3, which is alarming, considering that the birth rate is the highest during this age.87 Alcohol consumption during pregnancy has the potential to cause significant foetal damages, which can lead to a wide range of physical, behavioural, and learning problems.46,88-91 Also alcohol consumption during breastfeeding can have a harmful impact on the development of the child. It’s best for pregnant women, women that are breastfeeding and those that are planning to become pregnant not to drink alcohol. Their partners, friends and family should support them on their decision.92-95 15 ALCOHOL RELATED COSTS ARE HIGH Between 2012 and 2016 the health costs related to alcohol consumption in Slovenia average €147 million per year.6 Adding a rough estimate of other costs (e.g. traffic accidents, domestic violence, crime - theft, vandalism) this number rises to €228 million.6-9 On the other hand, annual revenue from excise tax on alcohol and alcoholic beverages in recent years has amount-ed only to approximately €103 million.96-98 The higher the level of alcohol use in Slovenia, the greater the harm caused, and the greater the costs. 16 WHAT IS ALCOHOL POLICY? Alcohol policy addresses the relationship between alcohol consumption, individual well-being and health and public welfare. It combines national measures aimed at preventing and reducing alcohol-related harm. Alcohol policy is only successful if different stakeholders cooperate in creating and implementing it: policy and decision makers (e.g. National Council, National Assembly, ministries), as well as experts (e.g. expert organisations, institutes, expert associations, faculties), civil society (e.g. non-governmental organisations, local communities), and the media.18,19,99 In Europe, the development of alcohol policy started in the 1990s and has been steadily gaining in importance99. The turning point was reached at the WHO European Ministerial Conference on Young People and Alcohol (2001) through the adoption of the Declaration on Young People and Al-cohol100 warning about the international dimension of the problem. This was followed by numerous research studies on the burden of hazardous and harmful alcohol use and analyses of the effectiveness of individual alcohol-policy measures. New findings mobilized experts and civil society working in this field and, consequently, the reaction of international and national policy-makers. Alcohol policy in Slovenia is funded by the national budget, the Health Insurance Institute of Slovenia, European funds, sources of the cooperation with the World Health Organization and other bilateral funding. 17 SLOVENIAN MILESTONES 18 EUROPEAN MILESTONES 19 WHY INVEST IN ALCOHOL POLICY? Investing in the prevention of hazardous and harmful alcohol consumption means fewer years of potential life lost due to ill-health, disability or premature deaths. It also means less economic burden on individuals, their families and society due to:18 ◊ fewer suicides and murders, ◊ fewer diseases and cases of intoxication, ◊ fewer traffic, work and other accidents, injuries and disabilities, ◊ fewer premature deaths, ◊ less violence and mental distress, ◊ less social exclusion and poverty, ◊ less absenteeism. Researches in Slovenia have shown that most of the key stakeholders reported that alcohol policy is being implemented to a limited extent, and that there is a lack of political intent to lead on effective alcohol policies.101,102 For better results we need a decision on the political level to adopt a comprehensive national and local strategy, which will better connect key stakeholders, guarantee necessary sources and include effective measures. 20 WHICH ALCOHOL-POLICY MEASURES ARE COST-EFFECTIVE? To prevent hazardous and harmful alcohol consumption a country has a series of effective measures at its disposal,10-12,18,19,21,103-106 which are evidence based and suggested by the World Health Organization. It would be prudent for a country to first adopt measures through which the most can be achieved with the resources invested. MEASURE EFFEC- EXPENSE MEASURE ADOPTED IN SLOVENIA? TIVENESS TO OF MEAS- COUN- URE TRY Preventing driving under the influence of alcohol Gradual lowering of very effec- low PARTIALLY permitted level of tive The highest permitted blood alcohol blood alcohol in all level is 0.50 g alcohol per kg blood drivers to 0.0 g/l (ZPrCP). Introduction of 0.0 very effec- low YES g/l permitted blood tive (ZPrCP) alcohol for young drivers, public-trans- port drivers and drivers of heavy- goods vehicles Random testing very effec- high YES for breath alcohol tive Breath alcohol content in drivers can content equal 0.24 mg/l with the provision that signs of behav ioural changes, which could cause ir responsible behaviour in road traffic, are absent. Professional drivers, driving instructors, young driv- ers, drivers transporting children and some other drivers are not permitted to have any alcohol in their organism (ZPrCP). Gradual acquisition moderately low YES of driver’s license effective People who lose their driver’s license due to drink driving are required to par- ticipate in rehabilitation programmes to regain them (ZVoz). Limiting alcohol availability Specific age limit for very effec- medium NO alcohol consump- tive Offering alcohol to a person under the tion age of 18 in a public space will be fined (ZOPA). State control on very effec- low PARTIALLY retail sale of alcohol tive For the sale or offer of alcoholic bev- (state monopoly on erages at public events the organ- alcohol sales, intro- iser needs to get permission, which duction of alcohol is issued by the administrative office licensing) (ZOPA). 21 MEASURE EFFEC- EXPENSE MEASURE ADOPTED IN SLOVENIA? TIVENESS TO OF MEAS- COUN- URE TRY Lowering the age very effec- no data YES limit of customers to tive Prohibited sale and offer of alcoholic whom alcohol may beverages to persons under 18 years be sold (ZOPA). Limiting the fre- moderately low NO quency of selling effective points Limiting sale to cer- moderately low YES tain hours and days effective Prohibited sale of alcoholic beverag- es between 21:00 and 07:00 hours in shops; prohibited sale of spirits in bars between start of working hours and 10:00 hours (ZOPA). Reducing the affordability of alcohol Taxation - increasing very effec- low PARTIALLY minimum tax rates tive Excise duties have been imposed on in accordance with beer, intermediate beverages and eth- inflation for all alco- ylene alcohol. Excise duties for wine holic beverages; at and fermented beverages have not least proportional to been imposed or are equal to €0 (ZTro- alcohol content 1). Excise duties are not in accordance with inflation. Introduction of minimum alcohol pricing Prohibition of discounts and pro- motional prices Additional tax on alcopops Treatment of persons with hazardous and harmful alcohol consumption, as well as treatment of mental and behavioural disorders due to alcohol consumption Brief interventions very effec- medium PARTIALLY for persons with tive The measure is being implemented in hazardous or harm- the framework of the Drivers Act and ful alcohol con- the National Programme for the Pri- sumption in primary mary Prevention of Cardiovascular Dis- health care and eases. Not all doctors of general/family other settings medicine detect hazardous and harm- ful alcohol consumption, although clinical guidelines on early detection and brief interventions are availa- ble.107-109 Activities are strengthened through the SOPA project - Together for a responsible attitude to drinking.110 Treatment of mental very effec- medium/ YES and behavioural tive high Treatment costs are covered by health disorders and other insurance. diseases due to al- cohol consumption 22 MEASURE EFFEC- EXPENSE MEASURE ADOPTED IN SLOVENIA? TIVENESS TO OF MEAS- COUN- URE TRY Reducing harm in drinking environments Increasing respon- moderately low PARTIALLY sibility of serving effective The juristic person, person responsible personnel for the juristic person, independent en- trepreneur, person responsible for the independent entrepreneur, individual that independently carries out activ- ities, and person responsible for the individual, that serves a person show- ing signs of intoxication, as well as he who enables a person under the age of 18 to consume alcoholic beverages in public space will be fined (ZOPA). Training serving per- effective / PARTIALLY sonnel and manage- Individual programmes have been de- ment for responsible veloped; the field is not legally regulat- serving and ensuring ed. safe environments Limiting marketing communication of alcohol Completely prohib- effective low PARTIALLY iting the advertise- Advertising alcoholic beverages with ment for alcoholic alcohol content over 15% vol. has been beverages banned. Advertising alcoholic beverag- es with alcohol content below 15% vol. is prohibited on radio and television between 7:00 and 21:30 hours, in cin- emas before 22:00 hours (ZZUZIS-A). Advertisement on billboards, posters or neon signs that are within 300 m of kindergartens or schools is prohibited (ZZUZUS-A). The advertisement mes- sage needs to include a message about the harm of alcohol consumption. Legend: ZOPA - Restrictions on the Use of Alcohol Act70, ZVoz - Drivers Act111, ZTro-1 - Excise Duty Act112, ZPrCP - Road Traffic Rules Act113, ZZUZIS-A - Act Amending the Health and Hygiene Safety of Foodstuff and Products and Materials Coming in Contact with Foodstuffs Act114. This synoptic table is based on multiple sources and reproduced with the permission of the authors.10,18,21,104-106 Programmes aimed at informing and raising public awareness do not directly influence the reduction of harmful alcohol consumption, neverthe-less they are an indispensable part of a comprehensive alcohol policy as they influence a better public acceptance of other measures and increase their effect. An important part of the alcohol policy is also treating hazardous and harmful alcohol consumption and addiction outside the healthcare system and providing help for family members; whereas eliminating consequences is much more expensive than measures that can prevent the harm. Health promotion and prevention programmes that strengthen a healthy lifestyle of the population are also important for harm prevention. 23 STATES ARE ADOPTING EFFECTIVE ALCOHOL POLICY MEASURES Many states work towards reducing alcohol issues and implement policies that reduce alcohol consumption and related harmful consequences.115,116 All EU Member States (henceforth referred to as states) have adopted individual acts and regulations, 21 states have acts and regulations included in a national alcohol policy.115 24 Most states have adopted measures that limit alcohol availability.115 Many states have a partial or total ban on offering or consuming alcohol in public spaces, like healthcare institutions, educational institutions, public transport, work spaces, sports events, parks, etc.116 All states have adopted measures to reduce drink driving.115 Measures to limit the marketing communication of alcoholic beverages.115 25 NOT ALL EFFECTIVE MEASURES YET INTRODUCED IN SLOVENIA After 2000 Slovenia managed to take several important steps towards an effective alcohol policy. Quite a few progressive and effective measure to reduce alcohol consumption were adopted.99 In 2001 the Media Act (ZMed) entirely banned the advertisement of alcoholic beverages, but only for a short period until 2002, when the Act Regulating the Sanitary Suitability of Foodstuff, Products and Materials Coming into Contact with Foodstuffs (ZZUZIS) was adopted. It again allowed the advertisement of alcoholic beverages under specific conditions. In 2003 the Restrictions on the Use of Alcohol Act (ZOPA)70 was adopted, and importantly contributed to limiting the availability of alcohol, especially for young people. In 2005 the Act on Audiovisual Media Services (ZAvMS)117 prohibited the sale of alcoholic beverages on television. Through the commencement of the traffic law amendments, which from 2010 on also include health care measures, the number of traffic accidents involving alcohol was reduced. With the implementation of reference clinics in primary health care the ca-pacities for preventive treatment of people with hazardous and harmful alcohol consumption were increased. This was upgraded by SOPA project,110 an interdisciplinary approach aiming to tackle harmful and hazardous alcohol use. The approach combines partners from the health care and social care sector as well as non-governmental organisations. In 2011 the Health and Safety at Work Act (ZVZD)118 introduces a ban on working under the influence of alcohol. The country’s investment in the web portal MOSA - Mobilising community for responsibility towards alcohol (www.infomosa. si)119, regular expert meetings on national and local levels as well as increasing the investment in health promotion and prevention programmes implemented by non-governmental organisations in cooperation with experts also contributed to better networking among the key stakeholders. With reference to international comparison and recommendations of the World Health Organization, in the past years Slovenia was most successful in the fields of (pillars 1-6 in figure):16,17 ◊ drink driving policies, ◊ leadership, awareness and commitment to action, ◊ monitoring and surveillance of alcohol issues, ◊ limiting alcohol availability (it has to be stressed that some steps back were taken in the last years), ◊ preventing negative consequences of alcohol consumption and intoxication, ◊ treating hazardous and harmful alcohol consumption and addic- tion in the health care sector. Slovenia was less successful in the fields of (pillars 8-10 in figure):16,17 ◊ limiting marketing communication for alcoholic beverages, ◊ reducing the public health impact of illicit alcohol and informally produced alcohol, ◊ pricing policies. 26 10 key action fields of a comprehensive alcohol policy according to the World Health Organization:13,14,19,134 1. DRINK DRIVING POLICIES AND COUNTERMEASURES, 2. LEADERSHIP, AWARENESS AND COMMITMENT, 3. MONITORING AND SURVEILLANCE, 4. AVAILABILITY OF ALCOHOL, 5. REDUCING THE NEGATIVE CONSEQUENCES OF DRINKING AND ALCOHOL INTOXICATION, 6. HEALTH SERVICES’ RESPONSE, 7. COMMUNITY AND WORKPLACE ACTION, 8. MARKETING COMMUNICATION FOR ALCOHOLIC BEVERAGES, 9. REDUCING THE PUBLIC HEALTH IMPACT OF ILLICIT ALCOHOL AND INFORMALLY PRODUCED ALCOHOL, 10. PRICING POLICIES. Principally a country is most successful when the measures listed above are merged into a comprehensive alcohol policy, whose key goals are to protect the population from alcohol-related harm. Comparison of Slovenia with the average of 30 European countries (28 European Member States, Switzerland and Norway) regarding the total number of points (0 to 100) demonstrat-ing to which extend the countries have adopted individual alcohol policy measures that are summarised in 10 action areas of an effective alcohol policy. Source: World Health Organization, Regional Office for Europe.16,17 27 WHERE IS SLOVENIA TAKING STEPS BACKWARDS FROM A HEALTH PERSPECTIVE? PRICES FOR ALCOHOLIC BEVERAGES IN SLOVENIA ARE LOW There is significant evidence to show that higher alcohol prices reduce alcohol consumption and related harm; they reduce the number of deaths due to alcohol, the number of suicides, there is less alcohol-related violence and traffic acci dents.10,18,120 According to World Health Organization data, alcohol prices in Slovenia are low, especially for wine.121 Higher prices for alcoholic beverages are only efficient if a concurrent and effective control on illicit production and trade in alcoholic beverages is ensured. This measure is especially effective on young people and those who drink more than defined limits of low risk drinking.122 THE EXCISE DUTIES IN SLOVENIA HAVE NOT CHANGED IN RECENT YEARS The World Health Organization ranks the increase of excise duties among the successful measures to reduce alcohol related harm.14,123 In Slovenia the rates of excise duties for individual alcoholic beverages have not changed since 2014; and the zero rate of excise duties for wine has been main-tained.112 Furthermore, the excise duty entities, small beer producers and small spirits producers, pay 50% lower excise duties on certain quantities of produced alcoholic beverages (for beer up to 20.000 hl per year, for spirits up to 150 litres of 100 volume percent alcohol per year). In addition to this, a permitted quantity of wine (up to 600 litres per year) and beer (up to 500 litres per year) for personal use was introduced, which does not require registration and excise duty payment.112 28 IN SLOVENIA A LOT OF ALCOHOL IS PRODUCED THAT IS NOT RECORDED IN NATIONAL STATISTICS According to the latest World Health Organization data, in 2016 the total alcohol consumption globally averages 6.4 l of pure alcohol per capita (15 years or older), the European region of the World Health Organization, which includes Slovenia, still has the highest alcohol consumption with 9.8 l of pure alcohol per capita (15 years or older). For decades Slovenia has had higher averages of recorded alcohol consumption in comparison to international averages.5 Alcohol consumption is divided into recorded and unrecorded. Recorded alcohol consumption Unrecorded alcohol consump- includes the industrial produc- tion is based on imported alco- tion of alcoholic beverages on holic beverages by individuals the territory of the Republic of and local alcohol production Slovenia, the estimation of agri- (private smaller vineyards, home cultural wine production based distillation, home beer produc- on agricultural viticulture, the tion). usage of stocks, and imported alcoholic beverages. It does not include exported alcoholic bev- erages. More unrecorded alcohol consumption means a higher risk for users due to a lack of control from the perspective of product quality and safety, as well as the higher availability of such alcohol.49,124,125 29 Recorded alcohol consumption is registered and monitored by national statistics. In 2018 in Slovenia the recorded alcohol consumption was 9.99 litres of pure alcohol per capita (15 years or older). Consumption declined in comparison to the previous year, which is encouraging, but remains too high from a public health perspective. Recorded alcohol consumption in litres of pure alcohol per person 15+, 2004-2016, Slovenia, European Region WHO and EU. 49,54 Source: WHO/Europe, European HFA Database, National Institute of Public Health Based on calculations of recorded alcohol consumption in 2018 every member of the Slovenian population (15 years or older) drank on average: Unrecorded alcohol consumption (e.g. home production, cross-border import) is not registered in national statistics.49,125 This can present a tenth to a third of the total alcohol consumption.133,134 Unrecorded alcohol consumption is the highest in Eastern Europe, especially in the Baltic states, Bulgaria, and Slovenia.47,49 30 SLOVENIA HAS NO LEGISLATION WHICH WOULD ADEQUATELY LIMIT THE DIGITAL MARKETING COMMUNICATION OF ALCOHOL Marketing communication of alcohol encourages adolescents to reach for alcoholic beverages earlier and in higher quantities.106,126 The growing use of digital media created new opportunities for marketing communication for various products, including alcohol.127,128 Marketing communication is only one of the most visible elements of marketing, which includes also product development, the pricing and selection of distribution channels. It is the most visible part of the marketing mix, which from the perspective of social norms influences the acceptance and normalisation of alcohol consumption in the society. Legislation only partly interferes with the field of marketing communication. In most countries it restricts only certain forms, particularly television advertising. Other forms of marketing communication for alcohol are less regulated. Particularly modern forms of digital marketing communication are unregulated, not only for alcoholic products, but also the drinking culture among young people spread by the entertainment industry. Especially problematic are the forms where a marketing message is concealed. These might ap-pear in blogs and vlogs, accounts of social networking sites (e.g. Facebook, Instagram, etc.), where account users communicate about brands to their followers and do not reveal that they are being paid for using those brands and communicate about them. 31 HEALTH PROMOTION AND PREVENTION PROGRAMMES IN SLOVENIA ARE RARELY ADEQUATELY EVALUATED After 1999 the MOSA base119 registered 70 health promotion and prevention programmes and projects being implemented in Slovenia with an aim to reduce alcohol-related issues. Of these, most: ◊ are intended for children, adolescents and their parents, fewer are intended for young adults and the elderly; ◊ inform and raise awareness about alcohol-related issues, fewer aim to change behaviour; ◊ conduct process evaluation, very few were evaluated from the perspective of influences and effects. In Slovenia many different health promotion and prevention interventions are being implemented, but there are only very few with evidence of their effectiveness.129,130 This is why we started developing Criteria for the Selection and Evaluation of Good Practice based on different, existing European documents and portals of good practice.131 Their purpose is the preparation of clear guidelines for the recognition and selection of good practice in the field of public health, which will also serve as guidelines for the designing, planning and implementation of various interventions. THE ALCOHOL AVAILABILITY WAS INCREASED INSTEAD OF LIMITED IN SOME ENVIRONMENTS IN SLOVENIA In 2017 the amendments to the Restrictions on the use of alcohol act70 permitted the sale of alcoholic beverages of less than 15 volume percent alcohol (e.g. beer, wine, etc.) at public sports events. Alcohol policy makers and experts were opposed, pointing out that sports and alcohol are incom-patible. The sale and offer of alcohol at sports events contribute to higher availability and greater opportunities for marketing communication of alcohol. Consequently, this means a higher alcohol use and more harmful consequences. 32 OPPORTUNITIES FOR IMPLEMENTING MORE EFFECTIVE ALCOHOL POLICY IN SLOVENIA In the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-202012,14 the World Health Organization (WHO) mentions nine goals, including the reduction of harmful alcohol consumption by 10%. The WHO suggests ten action areas of an effective alcohol policy, which have also been identified as crucial by Slovenian experts.12,14,19,99 1. DRINK DRIVING POLICIES AND COUNTERMEASURES ◊ Ensure a consistent implementation of the National Programme for Road Traffic Safety.132 ◊ Ensure broad campaigns that are intended to inform, raise awareness and educate the general public, especially young drivers. ◊ Further lower the permitted level of blood alcohol content in drivers (0.0 for all drivers). 2. LEADERSHIP, AWARENESS AND COMMITMENT ◊ Adopt an evidence-based strategy and action plan to encourage cooperation between national experts and civil society, which will provide an infrastructure and financial resources, as well as a means of management and control. ◊ Establish an intersectional coordination body for the development of alcohol policy. ◊ Ensure support of the adoption and implementation of alcohol policy and raise public awareness of the risks of hazardous and harmful alcohol use to the health and welfare of the population and of the benefits of effective action to reduce these risks. ◊ Raise awareness among alcohol-policy stakeholders about effec- tive alcohol policy measures. ◊ Monitor public support for different alcohol policy measures. 33 3. MONITORING AND SURVEILLANCE ◊ Provide a comprehensive monitoring system of the consequences of harmful alcohol consumption and the effective ness of measures taken to prevent it. ◊ Ensure the monitoring of the physical availability and financial affordability of alcohol. ◊ Ensure the assessment of the economic burden of alcohol on the individual and the society, and a system to measure the cost-effectiveness of alcohol policy measures. ◊ Establish a monitoring system of the consequences of hazardous and harmful alcohol consumption and addiction during pregnancy. ◊ Ensure data on the hazardous and harmful alcohol consumption in different population groups (e.g. women, young people, older people, ethnic groups, and unemployed people) with recommended specific measures to counter it. ◊ Ensure comprehensive periodic reports on alcohol consumption, drinking patterns, consequences of harmful alcohol consumption, prevention programmes and implementation of alcohol policy measures on national and regional levels. ◊ Ensure systematic monitoring of health promotion and prevention programmes, research and stakeholders from the field of alcohol issues. ◊ Ensure national expert guidelines and establish a system of evaluating health promotion and prevention programmes and programmes for reducing harm in the field of alcohol issues. 4. AVAILABILITY OF ALCOHOL ◊ Implement improved legislation, especially with regard to facilitat-ing the interpretation of measures aimed at limiting the availability of alcohol and its control. ◊ Investigate the possibility of introducing additional measures to reduce the frequency of alcohol selling points and shorten their opening hours. ◊ Investigate the possibility of prohibiting the sale of alcohol at gas stations and highway rest areas. 34 ◊ Encourage local communities to decide on banning alcohol con- sumption in public areas that are not designated for sale of alcoholic beverages. ◊ Reintroduce ban on the offer and sale of all alcoholic beverages at sports events. ◊ Investigate the possibility of introducing licensing for all providers of alcoholic beverages. 5. REDUCING THE NEGATIVE CONSEQUENCES OF DRINKING AND ALCOHOL INTOXICATION ◊ Dedicate more attention to training serving personnel and ensuring security in drinking environments. ◊ Establish local action groups and implement regional and local action plans to prevent hazardous and harmful alcohol consumption, especially among young people, in drinking environments and in local communities in general. ◊ Investigate the possibility of introducing special licences/permits for the sale of alcohol products (alcohol licensing) with the possibility of revoking licences in cases of law infringement. ◊ Introduce mandatory health messages about alcohol-related risks during pregnancy and other health information on the packaging of alcoholic beverages or foodstuffs that contain alcohol. 6. TREATING HAZARDOUS AND HARMFUL ALCOHOL CONSUMPTION AND ADDICTION IN AND OUTSIDE THE HEALTH CARE SECTOR ◊ Establish a comprehensive system for the early detection of hazardous and harmful alcohol use and addiction, involving the health services, the social security services, employment organizations, educational institutions and non-governmental organisations. ◊ Establish comprehensive and long-term aid programmes for in- dividuals with alcohol addiction and their families, which will also be accessible for vulnerable population groups (e.g. older people, young people). 35 ◊ Establish a system for detecting and monitoring hazardous and harmful alcohol consumption among pregnant women and wom- en of child-bearing age. ◊ Upgrade existing programmes on hazardous and harmful alcohol consumption with programmes for reducing inequalities and for specific population groups (families, young people, women, older people, ethnic groups). ◊ Introduce positive incentives for providers, users and employers, so they will sooner and more often opt to deploy, integrate, or - in case of employers - promote admission to health care treatment. ◊ Include profiles, also outside health care, other than general prac-titioners in the implementation of brief interventions to ensure a higher level of accessibility. IMPLEMENTING AN INTERDISCIPLINARY APPROACH IN TACK- LING HAZARDOUS AND HARMFUL ALCOHOL CONSUMPTION IN SLOVENIA In 2016–2020 the pilot project SOPA - Together for a respon- sible attitude to drinking (www.sopa.si) is being implemented in 18 local communities in Slovenia.110 The SOPA goal is the implementation of an interdisciplinary approach towards detection and support in quitting hazardous and harmful alcohol con- sumption among adult population. This approach, which includes partner of the health care and social care sector as well as non-governmental organisations, will over the long term, contribute to reducing the alcohol is- sues in Slovenia. 7. COMMUNITY AND WORKPLACE ◊ Ensure an overview of health promotion and prevention pro- grammes, projects and activities implemented in local communi- ties, educational systems and work organisations. ◊ Develop national guidelines for and a system of evaluating the above-mentioned programmes, projects and activities. 36 ◊ Adopt local policy-action plans based on recognized local needs and involve all key stakeholders at the local level in joint efforts. ◊ Ensure appropriate tools and training for providers of programmes, projects and activities on the local level, in the educational system and in work organisations. 8. LIMITING MARKETING COMMUNICATION FOR ALCOHOLIC BEVERAGES ◊ Introduce a total ban on advertisement for all alcoholic beverages. ◊ Ban sponsorship and donation activities that aim to promote alcoholic beverages. ◊ Dedicate special attention to banning activities that stimulate alcohol sale. ◊ Ensure a monitoring and evaluation system for marketing commu- nication of alcoholic beverages in all media including the internet, social network services and mobile applications, which ensures a better control and legislation. 9. REDUCING THE PUBLIC HEALTH IMPACT OF ILLICIT ALCOHOL AND INFORMALLY PRODUCED ALCOHOL ◊ Improve control of production and sale of alcoholic beverages, e.g. by introducing tax labels. ◊ Establish an effective system controlling the consumption and quality of unrecorded alcohol. 37 10. PRICING POLICIES ◊ Investigate further possibilities of increasing alcohol prices and ensure public awareness on the importance of implementing such measures is raised. ◊ Investigate possibilities of implementing special taxation on alcoholic beverages that are especially attractive to young people - e.g. alcopops. ◊ Raise excise duties in accordance with inflation. ◊ Investigate the possibility of introducing minimum pricing, under which individual alcoholic beverages are not allowed to be sold. ◊ Use revenue from excise duties on alcohol and alcoholic beverages for programmes aimed at reducing hazardous and harmful alcohol consumption. 38 EVIDENCE BASED MEASURES AND POPULATION SUPPORT IN SLOVENIA20 39 Mobilising community for responsibility towards alcohol MOSA is an online meeting point established to provide transparent, dy-namic, clear and easily accessible information about alcohol issues and to encourage various directly or indirectly involved actors in the programmes and/or policies development within alcohol issues in Slovenia. At MOSA (www.infomosa.si) you can find: f weekly news about events in the field of alcohol issues in Slovenia and the world; f various data bases (about health promotion and prevention programmes, researches and actors in the field of alcohol issues in Slovenia); f the MOSA library; f sources of help in the case of alcohol problems; f monthly newsletter; f the option to notify of legal violations (“squealer”); and f space for your suggestions and questions. www.infomosa.si/en Twitter: @MOSA_portal REFERENCES 1. Hovnik Keršmanc M, Zorko M, Macur M. Alkohol. V H Koprivnikar, M Zorko, A Drev, M Hovnik Keršmanc, I Kvaternik, M Macur, Uporaba tobaka, alkohola in prepovedanih drog med prebivalci Slovenije ter neenakosti in kombinacije te uporabe. Ljubljana: Nacionalni inštitut za javno zdravje, 2015, str. 69-107 Pridobljeno 12. 9. 2018 s spletne strani: www. nijz.si/sites/www.nijz.si/files/publikacije-datoteke/uporaba_tobaka_ alkohola_in_drog. pdf. 2. 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Pridobljeno 10. 10. 2018 s spletne strani: www.nijz.si/sites/www.nijz.si/files/publikacije-datoteke/hbsc_2015_e_verzija30_06_2015.pdf. 48 49 ALCOHOL POLICY IN SLOVENIA OPPORTUNITIES FOR REDUCING HARM, COSTS AND HEALTH INEQUALITIES IN POPULATION English electronic edition Original title: ALKOHOLNA POLITIKA V SLOVENIJI Piložnosti za zmanjševanje škode in stroškov ter neenakosti med prebivalci Editors: Maja Roškar1, Maša Serec2, Vesna Kerstin Petrič2, Nataša Blažko2, Marjetka Hovnik Keršmanc1, Darina Sedláková3 Authors: Maja Roškar, Nataša Blažko, Vesna Kerstin Petrič, Maša Serec, Marjetka Hovnik Keršmanc, Mercedes Lovrečič, Barbara Lovrečič, Sandra Radoš Krnel, Tanja Kamin, Tadeja Hočevar, Alenka Tančič Grum, Metka Zaletel, Sabina Sedlak, Aleš Korošec, Jan Peloza, Daša Kokole, Suzana Makarić Professional review: Zdenka Čebašek Travnik Publishers: National Institute of Public Health Design: Primož Roškar, Arhilog d.o.o. Translation: Liza Linde, Mihaela Törnar Webpage: www.nijz.si/en Place and year of publication: Ljubljana, 2019 Copyright: © 2019 NIJZ Complimentary issue. All rights reserved. Reproduction in part or whole in any way and by any media without the written consent of the author is prohibited. Violations will be sanctioned in accordance with copyright and criminal law. This publication was supported within the framework of the Biennial Collaborative Agreement for 2018-2019 between the World Health Organization, Regional Office for Europe and the Ministry of Health of the Republic of Slovenia. ¹National Institute of Public Health, Slovenia, ²Ministry of Health of the Republic of Slovenia, ³WHO, Regional Office for Europe, Country Office Slovenia CIP - Kataložni zapis o publikaciji Narodna in univerzitetna knjižnica, Ljubljana Kataložni zapis o publikaciji (CIP) pripravili v Narodni in univerzitetni knjižnici v Ljubljani COBISS.SI-ID=303055104 ISBN 978-961-7002-85-0 (pdf) 50 From its activist and morally motivated beginnings alcohol policy has grown over the past 25 years into a political and scientific discipline capable of identifying, planning and monitoring effective measures to reduce harmful alcohol consumption. Slovenia is among the countries that have significantly strengthened 147.000.000 € their activities in the field of alcohol policy. We have adopted the recommendations OVENIA € of experts and decided to follow the path of establishing a safer and healthier medical expenses per year society in which there will be less space for alcohol advertisement, and more for introducing and implementing evidence-based measures to prevent hazardous and harmful alcohol consumption. Projects such as MOSA (Mobilising community for responsibility towards alcohol) and SOPA (Together for a responsible attitude towards alcohol consumption) already place us among societies in which everyone can very easily access basic information on whether they or a family member needs 40% professional help, as well as advice on where to find such help. The seed we planted in this field a quarter of a century ago has sprouted. Now all of us together must of 15-year-olds COHOL POLICY IN SL ensure that it will bear fruit. have consumed AL alcohol at the age Zdenka Čebašek Travnik, president of the Medical Chamber of Slovenia of 13 or less. ALCOHOL POLICY IN SLOVENIA OPPORTUNITIES FOR REDUCING HARM, COSTS AND HEALTH INEQUALITIES IN POPULATION 2019 Data show that consumption of alcohol and its consequences do a lot of harm to the people, to the economy, to the society. World Health Organization recognizes Alcohol increases and applauds to the Slovene authorities for their efforts that have already led to the risk of certain some very good achievements. There is a strong leadership and commitment to types of cancer. change the unfavourable situation with alcohol. Much has been invested with visible effect into health services’ response, community and workplace actions, drink-driving policies and regulation of alcohol availability. Thanks to working closely with the civil society, public awareness about negative consequences of drinking and alcohol intoxication has grown. However, there are areas where improvements can be made in terms of policies, namely pricing, marketing, illicit alcohol and informally produced alcohol. There is a need of a comprehensive Drinking any alcohol strategy, involving all the key stakeholders. alcohol is hazardous. Darina Sedláková, WHO, Regional Office for Europe, Country Office Slovenia Slovenia has not yet implemented In an average week: at least all effective 18 deaths due to alcohol. alcohol policy measures.