ENTITIES AND PUBLIC POLICIES
POLICIES TO TACKLE
HARMFUL ALCOHOL
USE
Thematic public report
Public policy evaluation
Summary
June 2016
DISCLAIMER
This summary is intended to facilitate the understanding and use
of the report produced by the Cour des Comptes.
Solely the original report is legally binding on the Cour des
comptes.
Responses from government agencies and stakeholders are
provided at the end of the report.
Contents
Summary of the thematic public report by the Cour des comptes
Introduction
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
1
No consensus on alcohol policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
2
Public measures are struggling to change behaviour . . . . . . . . . . .11
3
Insufficiently coordinated and evidence-based policies . . . . . . . . .15
4
Make preventing harmful alcohol use a public policy priority
. . .17
Conclusion and recommendations
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
3
Drinking is a sensitive issue in France, where alcohol is associated with celebrations,
lifestyle and culture. This social and cultural heritage is further strengthened by
alcohol's economic clout, and results in a general tolerance towards drinking.
This largely explains the challenges in designing and implementing a long-term
integrated public health and safety policy.
The French Monitoring Centre for Drugs and Drug Addiction (OFDT) estimates
that of the country's 8.8 million regular drinkers, 3.4 million are at risk, only 10%
of whom are in care. According to the only recent study available in France,
which was published in 2013, approximately 49,000 deaths were attributable to
alcohol in 2009, or 13% of deaths among men and 5% among women. A study
released in 2015 noted that alcohol was the primary cause of hospitalisation
(580,000 patients, estimated cost of €2.6 billion) and that excessive drinking was
related to around 60 diseases.
Based on these findings, and pursuant to Article L. 111-3-1 of the Code of
Financial Jurisdictions, the Cour des comptes decided to conduct an evaluation of
public policies aimed at tackling harmful alcohol use. Conducted in conjunction
with the main stakeholders through a support committee, this evaluation sought
to assess the impact of these public policies on society, considering positive and
negative factors with reference to appropriate foreign examples. Based on the
evaluation recommendations have been drawn up to address areas where room
for improvement has been identified.
The evaluation consisted in examining data availability, in analysing patterns of
harmful alcohol use with regard to the most up-to-date clinical and epidemiological
knowledge, in reviewing the main tools employed by relevant stakeholders in the
areas of product distribution rules, price-setting, as well as public health and public
safety, and in documenting the outcomes. Every effort has been made to ensure
that all findings were traceable and verifiable.
Introduction
Summary of the thematic public report by the Cour des comptes
5
Introduction
Categories of alcohol use
The French Society for the Study of Alcohol identifies five categories of alcohol
use in France:
-
non-consumption
, i.e. non-drinkers; according to the OFDT (2.3 million people
aged between 11 and 75 had never drunk alcohol in 2014);
-
social or low-risk alcohol consumption
, which covers 8.8 million regular drinkers
o/w 4.8 million daily drinkers; intake in this category is below 21 units
a week or
three units a day for men, 14 units a week or two a day for women, four units
during one session, with pregnant women abstaining completely;
-
the misuse of alcohol
, which comprises three sub-groups of regular drinkers:
1)
at-risk use
, defined as drinking that exceeds the abovementioned levels, resul-
ting in an increased risk of developing cancer, liver disease (cirrhosis), cardiovascu-
lar and digestive problems, and psychiatric problems such as depression or
anxiety; people in this group are referred to as regular excessive drinkers of whom
there were an estimated 3.4 million in 2014;
2)
use leading to somatic, psychological or social complications
linked to
drinking without alcohol dependence;
3)
use with alcohol dependence
, characterised by loss of control of consumption
and associated with a variety of complications.
Among the different types of at-risk use, heavy episodic drinking, commonly called
binge drinking, is generally defined as the consumption of five or more units in one
session for men and four or more units for women, i.e. 50g or 40g of pure alcohol
consumed over a short period (two hours or more).
Summary of the thematic public report by the Cour des comptes
6
1
No consensus
on alcohol policy
Summary of the thematic public report by the Cour des comptes
7
Because of the special place occupied
by alcohol in France's history, culture,
economy and social life, there is
widespread tolerance when it comes
to the consumption of alcoholic
beverages, whose adverse effects are
heavily underestimated.
A long-standing tradition
of production and consumption
The economic clout of the alcoholic
beverages sector explains the high
level of sensitivity of stakeholders
towards any attempt to challenge
the status of alcohol – especially
wine – on public health grounds.
Wine and alcohol in general form
an integral part of the French life-
style, which makes it difficult to
enforce an effective alcohol control
policy by drastically reducing the
effectiveness of crackdown action
and prevention measures.
Consumption is on the decline
but remains higher than
in other countries
Average alcohol consumption in
France has fallen steadily by 1.7% a
year since 1960. In 2014, it stood at
approximately 12 litres of pure
alcohol per person per year, according
to the latest data provided by the
OFDT. Even so, this is considerably
higher than the average of European
member countries of the Organisation
for
Economic
Cooperation
and
Development (OECD).
The decline is essentially attributable
to a reduction in wine consumption. At
the same time, however, binge drinking
has risen, as have cases of repeated
and regular drunkenness , particularly
among women and young people.
Moreover, despite the overall decline in
consumption, persistent risky behaviour
on the part of pregnant women, young
people and socially vulnerable people
must not be overlooked; nor should
the 8.8 million regular drinkers be
underestimated .
The consequences of harmful
alcohol use have not been
thoroughly assessed
The effects of harmful alcohol use
have only been partially assessed due
to the limited information available.
In the first place, alcohol consumption
has short, medium and long-term
health consequences.
No consensus on alcohol policy
Yet the
data
on
alcohol-related
deaths have only been the subject of
two recent studies in France, making
rigorous epidemiological monitoring
impossible. When it comes to alcohol-
related morbidity, it is only possible to
identify the number of people benefiting
from 100% coverage
by the Social
security
system(which is the case in
France for a range of severe diseases)
for every alcohol-related disease,
either partially or entirely. The data are
therefore heavily underestimated.
In addition, the frontier between low-risk
and dangerous drinking is hard to draw,
and scientists increasingly question the
notion that no-risk consumption does
Summary of the thematic public report by the Cour des comptes
8
not exist. For this reason, the question of
drinking guidelines is highly controversial
but crucial when targeting prevention
messages. For example, many countries
revised their recommended limits
following the discovery that cancer
risks emerge at levels of consumption
below the guidelines.
Alcohol abuse can also lead to violence,
particularly among relatives, be the
cause of anti-social behaviour, crimes
and offences, and considerably lessen
road safety. While the role of alcohol in
road traffic accidents is well measured,
its role in personal injury is less clearly
identified, since very few studies are
available.
Change between 2000 and 2014 in levels of regular use of the main active
ingredients, people aged 17, Metropolitan France (%)
Source: HBSC 2010, data employed by OFDT, ESPAD 2011 high school years, OFDT-INSERM-MEN
The challenge of striking a
balance between economic,
public health and safety issues
There is no consensus in France
about the need for a specific public
policy
about
alcohol.
Producers
stress their economic and social role,
while health authorities point to the
risks associated with harmful use.
In this respect, public players are at a
disadvantage compared with the
alcoholic beverages sector, which has
easy
access
to
European
and
National Institutions.
The lack of a comprehensive plan to
address harmful alcohol use in France
has brought about this imbalance
between business and public players
and deprived health sector stakeholders
of an integrated roadmap involving
public authorities.
Summary of the thematic public report by the Cour des comptes
No consensus on alcohol policy
9
A number of issues relating to harmful
alcohol use in France remain highly
controversial. In particular:
- the overall economic appraisal of
harmful alcohol use is not framed
dispassionately;
- there is no consensus on what
constitutes moderate drinking;
- there is a lack of consensus about
fields of investigation, guidelines and
results of clinical and epidemiological
research, with each camp drawing
differing conclusions.
The lack of consensus stands in the
way of unified public action.
2
Public measures are struggling
to change behaviour
Summary of the thematic public report by the Cour des comptes
11
The evaluation by the Cour des
comptes reveals that by inadequately
harnessing the available tools – from
distribution rules and taxation to
penalties
for
driving
under
the
influence of alcohol (DUI), prevention
and provision of health care – Central
Government has failed to properly
use tools aimed at changing risky
behaviour.
Distribution rules are out of step
with changing consumption habits
Rules fail to take account of market
developments
Access to alcoholic beverages is made
easier nowadays by the increased
number of temporary licensed premises
or locations offering takeaway sales,
which the current rules do not capture.
The so-called "quota" rule of one licensed
premises per 450 people does not apply
to takeaway sales (by supermarkets and
convenience stores) or to online sales.
Furthermore, takeaway sales, particularly
by late-night grocery stores, and sales
to minors are not covered by checks.
Successive challenges to the Évin Act
In 1991, France passed the Évin Act,
which introduced rules governing the
advertising of alcoholic beverages and
a ban on the sale of alcoholic beverages
to minors aged 16 or under. These
arrangements have been held up as an
example in Europe.
Successive amendments have diluted
the law's effectiveness. The authorisation
given to sporting groups to sell alcohol
was lifted in 1999. Stricter conditions
of sale introduced by the HPST Act
of 21 July 2009 were accompanied
by rules for online advertising.
Article 13 of the Health System
Modernisation Act of 26 January
2016 introduced measures to relax
these requirements, in the name of
supporting local produce and wine
tourism.
Despite
the
restrictive
legislative
framework,
alcohol
brands employ a wide range of
channels, including social networks,
to deliver their advertising, tailoring
their messages to different target
groups. An INPES study in 2015
found that French people feel that
advertising
is
everywhere
and
represents a threat to young people.
Lobby groups are lightly regulated
Alcohol lobbying is not sufficiently
regulated in France. The current rules,
which apply only to members of
Parliament, need to be expanded and
bolstered.
Unclear taxation goals
Taxation of alcoholic beverages is
closely
regulated
by
European
directives. Indirect taxes include
VAT and excise duties. Social levies
are also applied to some highly
alcoholic beverages. Revenues from
these
taxes,
which
amount
to
around €6.6 billion including VAT,
are partially earmarked for farmer
welfare.
Public measures are struggling to change
behaviour
There is no link between consumption,
revenues and the level of taxation per
beverage category. Accordingly, wine
accounts for 58% of consumption,
71% of non-export revenues but just
3.6% of excise duties.
Furthermore, excise duty rates are not
strictly
proportionate
to
alcohol
content or to the specific harmful
effects of different alcoholic beverages,
except in the case of spirits and and
premix drinks. Public health objectives
therefore seem to have had little
influence on the goals of the tax
regime.
Systems of checks and penalties do a
poor job of containing risky behaviour
This is particularly true for drink driving
and drunk and public drunkenness.
Testing for drink drivingI has been
declining for a number of years
because of policing issues and the
cumbersome nature of the procedure.
Meanwhile, penalties either do not
offer a sufficient deterrent (fines) or
are hard to implement (suspension of
license).
Police action agains public drunkenness
also runs into several difficulties: aside
from the fact that law enforcement
representatives
are
exposed
to
aggressive and violent behaviour,
these activities are a heavy drain on
human resources, and follow-up
measures are not in place to assist
people in finding primary care
assistance once they sober up.
Insufficient evaluation
of health and road safety
education initiatives
Health and road safety education
initiatives play an important role,
but not enough is known about their
outcomes.
Summary of the thematic public report by the Cour des comptes
12
Spirits are most heavily taxed
Source: Cour des comptes
Public measures are struggling to change
behaviour
Summary of the thematic public report by the Cour des comptes
13
Insufficient assessment of health
education initiatives
While INPES is responsible for most
preventive activities, other entities
are also involved, especially those
working in specific environments,
such as school and workplace health.
Non-profit associations also have a
role to play.
INPES, the main public organisation
operating in the field of prevention, has
sought to adapt, despite declining
financial resources.
There is no overarching vision of the
different
initiatives
in
place
for
schools, synergies between health and
education personnel are struggling to
emerge, and interventions by law
enforcement representatives are not
evaluated.
In post-secondary education, there is a
shortage of resources for preventive
medicine and health promotion services.
In the workplace, the dearth of data on
harmful
alcohol
use,
workplace
practices and alcohol-related accidents
makes it impossible to design an
appropriate strategy.
Insufficient evaluation of road safety
education
Preventive road safety measures are
now chiefly divided between national
communication campaigns conducted
by the central government road safety
and
traffic
control
Delegation
(DSCR) and measures undertaken as
part
of
département-level
road
safety
action
plans
(PDASRs).
However the effectiveness of these
measures is not evaluated sufficiently.
Moreover, self-test solutions, such as
mandatory alcohol sensors and
alcolocks, though useful, are not
widely used.
Primary care physicians do not play
enough of a role
Patients who drink to excess or suffer
from alcohol-related diseases may be
cared for at several different levels,
without necessarily having a formal
treatment pathway. This situation suffers
from a lack of involvement by primary
care physicians, particularly general
practitioners, but also from the
fragmented approach to specialised
treatments and the lack of interaction
in many cases among medical and
socio-medical services.
For example, a survey by IFOP
commissioned by the Cour des
comptes found that two-thirds of
general
practitioners
surveyed
were unfamiliar with the alcohol
screening and. brief intervention
mechanism, and that just 2% of
them used it in a formal manner.
Efforts made to structure hospital-
based care, care overly fragmented in
the socio-medical and non-profit sector
While hospital-based care is now
fairly well organised, other types of
care are overly fragmented. Care is
shared between the medical and
hospital
sector,
the
specialised
socio-medical sector, which includes
addiction treatment, support and
prevention centres (CSAPAs) and
drug user risk reduction drop-in and
support centres (CAARUDs), and
the non-profit sector.
Public measures are struggling to change
behaviour
Summary of the thematic public report by the Cour des comptes
14
Testing and penalties for DUI
Summary of the thematic public report by the Cour des comptes
15
3
Insufficiently coordinated
and evidence-based policies
Not enough is known about the
health, economic and social costs
arising from harmful alcohol use. In
France, there is no comprehensive
policy but merely a series of measures
placed side by side with a view to
preventing harmful alcohol use.
Without the necessary coordination
to address conflicts between measures,
outcomes are broadly disappointing
and inadequately evaluated.
Costs have still to be measured
Unlike some countries, France does
not adequately measure alcohol's
health and social costs.
Health costs are broadly underestimated,
given that estimates by the national
health insurance fund for salaried
workers (CNAMTS) include just three
sets of diseases that are entirely
attributable to alcohol (alcoholic
cirrhosis, aerodigestive tract cancers
and alcohol-related mental illnesses).
Prevention costs, meanwhile, are hard
to isolate, since they are spread
across a wide array of participants,
including interministerial structures,
central
government
directorates,
health agencies, social security, devolved
and decentralised departments, and
subsidised non-profit associations.
Finally, the economic and social
costs of harmful alcohol use are not
measured by the public authorities
but by researchers, such as Professor
Pierre Kopp, an economist, who
estimated in 2015 that the social costs
of alcohol abuse in 2010 amounted to
€120 billion.
The Cour des comptes notes that
other countries, such as Sweden,
Norway, the UK and Italy, have equipped
themselves better, setting up tools that
monitor data on harmful alcohol use
more effectively, more routinely and
on a more centralised basis than the
solutions employed in France.
A lack of investment in training
and research
In France, instruction and research in
the field of alcohol have not been
given priority in recent years.
Instruction on alcohol addiction in
medical and paramedical training
courses varies from region to region
but is broadly inadequate.
Compared with what is going on abroad,
research is unambitious, whether in the
medical field or in public health.
Summary of the thematic public report by the Cour des comptes
16
Insufficiently coordinated
and evidence-based policies
Incomplete coordination
of participants
Interministerial steering arrangements
remain unclear
In France, an interministerial unit, the
MILDECA, was given responsibility
for designing and implementing
the 2013-2017 drug and addiction
prevention plan, which covers all
addictions, although alcohol, unlike
tobacco, does not have its own specific
programme. However, the Health
Directorate (DGS) is responsible for
alcohol-related public health policy
and plans.
There is no national strategy for
drink-related delinquency and violence,
but rather public action plans containing
varying measures to prevent harmful
alcohol use.
Local steering arrangements
are shared between prefects
and regional health agencies (ARS)
Ever since HPST law was passed in
2009, the ARS have been responsible
for designing and implementing their
own strategic health priorities in their
region based on the national framework.
The prefects of the
département
,
meanwhile, are responsible for applying
other national policies, particularly in
terms of road safety, by coordinating the
various territorial bodies tasked with
putting these policies into practice.
This dual governance arrangement,
combined with the non-alignment of
decision-making
levels,
has
many
disadvantages, especially since other
local participants, including municipal
authorities
and
département
and
regional councils, also act within the
scope of their own responsibilities. This
situation undermines the clarity of
local policies aimed at addressing
harmful alcohol use.
Compounding this complexity, funding
for local initiatives is heavily restricted
and insufficiently targeted.
Summary of the thematic public report by the Cour des comptes
17
4
Make preventing harmful
alcohol use a public
policy priority
The evaluation by the Cour des
comptes makes it clear that harmful
alcohol use has highly detrimental
effects on public health and public
safety and that the health and social
costs far exceed alcohol-related tax
revenues. Similarly, the fragmented
nature of previous policies and the lack
of targeted objectives and instruments
to measure the effectiveness of initiatives
on the ground mean that France falls
short of the best practices recommended
by the World Health Organisation
(WHO) and the OECD.
A unified policy to address harmful
alcohol use would help to raise
awareness among consumers about
the damaging effects of alcohol on
health and social life, and make people
more personally accountable in terms
of their relationship to alcohol. This
kind of awareness is a pre-requisite for
effective public policy.
Given
the
existing
fragmented
governance
arrangements,
steps
should be taken to implement a
consistent long-term plan at the
highest level of government.
Draw up a programme to reduce
harmful alcohol use
To address the urgent need for
public action, an interministerial
action programme needs to be
drawn up and led at the very highest
level, i.e. by the Prime Minister, as is
the case, for example, in the UK. This
programme should be backed by the
necessary resources and
regularly
evaluated.
A comprehensive and regularly
evaluated programme
The strategy to prevent harmful
alcohol use prepared as part of this
nationwide programme should be
based on objectives derived from
epidemiological and socio-economic
data and identify the most appropriate
tools for each action area.
Action taken under the programme
should be followed up using pre-deter-
mined indicators, rounded out by spe-
cific monitoring for certain measures.
An assessment every three or four
years would be used to measure pro-
gress, taking account of the latest
scientific advances, and make any
necessary adjustments. An undeniable
identification of the health and socio-
economic costs due to harmful alcohol
use would support this assessment.
Summary of the thematic public report by the Cour des comptes
18
Make preventing harmful alcohol use a public
policy priority
A programme based on scientific
evidence
To be effective over the long run, a
health policy for alcohol will require
efforts to continue to advancing
knowldege through an evidence-
based medicine approach. This will
entail examining the scientific literature
with a view to identifying the most
appropriate level of intervention for
each patient.
Ensure that the programme
is steered effectively
Programme implementation will require
clear governance. The programme will
be
steered
at the
national
level.
Interministerial coordination will be vital,
with the Health Minister occupying a key
role, supported by the Interior Minister
on questions of public safety. Local
implementation of the programme
should be entrusted to regional and
département
prefects, with ARS
handling the health component,
supported by the MILDECA project
leader. Regional and
département
councils and the most involved
municipal authorities would also be
invited to participate.
Earmark the necessary resources
Implementing a programme to reduce
harmful alcohol use will require
human and financial resources to
provide for prevention, other priority
areas, research and training.
Use every tool available
Every available tool must be used,
including information, prevention and
support. Action should also be taken
on pricing, which would entail raising
taxes. Introduction of a minimum
price – a good solution because of its
comparative effectiveness – would have
to include steps ensure compliance
with the Treaty on the Functioning of
the European Union.
Meanwhile, the use of alcohol is subject to
a wide array of rules, chiefly concerning
advertising, product information,
lobbying, product availability and DUI.
These rules need to be strengthened
and improved to combat harmful use,
which remains too widely tolerated in
France.
Come up with more effective
information and preventive measures
An effective strategy needs to be
based both on measures that address
the general population and measures
aimed at clearly identified target
groups. If regular excessive drinkers
are targeted too closely, there is a
danger of overlooking other at-risk
regular drinkers.
It is equally vital to conduct specific
measures particularly for young
people, pregnant women and people
in specific or vulnerable situations.
The preventive message for pregnant
women should be to recommend
complete abstinence, given that it is
not possible to set a level of use that
would be acceptable for the foetus.
In addition to schools, three other
parts of the population deserve special
attention: post-secondary institutions,
the workplace and offenders.
Summary of the thematic public report by the Cour des comptes
19
Make preventing harmful alcohol use a public
policy priority
For the workplace, the Labour Code
should be amended to place a total
ban on bringing alcohol to work, as is
the case in Italy. A limited number of
temporary
exemptions
could
be
authorised over the course of the year.
Two action areas could be usefully
expanded: first, implementation of
the alcohol screening and brief
intervention process by medical staff
at the workplace; second, measures
to provide guidance to people with
drinking problems.
Step up training and involvement
of health professionals to more
effectively identify risky behaviour
First, a target needs to be set for
alcohol-related training in medical
and paramedical courses of study,
followed up by mandatory knowledge
testing.
Also, health professionals, whether
they work in oncology, emergency
units, surgery or maternity wards,
need better training in precisely
identifying alcohol use. Increased
training hours in study courses and
the opening of addiction specialist
positions in universities and hospitals
would be a good step forward.
General practitioners and workplace
physicians could play a much bigger
role in both detection and primary
care.
Various avenues could be used to
encourage general practitioners to
step up their use of alcohol screening
and brief intervention. This procedure
needs to be part of a global approach to
addictions, such as inclusion in public
health objectives-based remuneration
(ROSP), the addition of extended
consultations for addiction detection
and care to the list of procedures, and
development of shared case manage-
ment
by
physicians
and
clinical
nurses.
Hospitals, notably emergency units,
also need to be part of efforts to step
up primary care involvement. It is
important to encourage emergency
units to do more to spot patients
with alcohol problems and guide
them towards primary care through
channels that are coordinated with
addiction services. These arrangements
need to be adjusted on a case by case
basis to reflect the intervention
capabilities of addiction liaison and
treatment teams (ELSAs) and the scope
for cooperation among interested
services.
Raise prices to reduce harmful use
Pricing and tax-based measures are
mentioned in all recent papers
(including the OECD's most recent
study in 2015) as among the most
effective ways to promote public
health and lower the social costs of
alcohol.
Minimum pricing essentially targets
the consumption of low-cost alcoholic
beverages by regular excessive drin-
kers, who often come from disadvan-
taged backgrounds. Following a refe-
rence for a preliminary ruling brought
by the Scottish Court of Session, the
Court of Justice of the European
Union (CJEU) ruled that the introduc-
tion of a minimum price had to be
conditional on the establishment of
precise public health goals and that
the inadequate effectiveness of natio-
nal
taxation
would
have
to
be
demonstrated.
Summary of the thematic public report by the Cour des comptes
20
Make preventing harmful alcohol use a public
policy priority
More effective rules governing
advertising, product information
and lobbying
Restrictions on advertising are viewed
as an appropriate and effective way to
limit consumption, particularly among
young people, who are a priority group
in France. Restrictions on advertising
need to cover all dissemination
channels, including digital ones.
Lessons also need to be drawn from
the way in which lobbying by producers
has seen public health come off
second-best in decisions on most
measures involving the sale of alcoholic
beverages. There are procedures to
make lobbying as transparent as
possible, along the lines of long-
standing
arrangements
within
European
institutions
or,
more
recently, for tobacco lobbyists.
Overhaul the laws on licensed
premises and set aside resources
to enforce compliance
The rules governing licensed premises
are outdated and not subject to
adequate checks. They need to be
overhauled and enforced, since
some offences, such as the sale of
alcohol to minors, are not subject
to adequate checks.
Improve the effectiveness
of DUI measures
Future measures should be guided by
the need to punish those who drive
under the influence of alcohol more
effectively and decisively and to get
public opinion behind the idea that
drinking and driving do not go together.
Communication campaigns need to
be more effectively directed through
better assessment, while the preventive
aspect of insurance could be more
effectively directed through progressive
penalties for offenders. At the same
time, steps should be taken to build up
a prevention system, primarily by
developing self-test procedures.
Without ruling out the notion of lowering
the blood alcohol concentration limit
for all drivers to 0.2 g/l, the first
priority should be to simplify testing
procedures, which are currently random,
time-consuming and complicated, to
increase the likelihood that individual
drivers may be checked, emulating the
effectiveness of automatic speed
cameras.
To make testing more efficient, standard
fines for offences involving excessive
blood alcohol concentrations need to be
revised, and the maximum level should
be raised from 0.8 g/l to 1.2 g/l. This
would lead to more effective punishment
of the most common cases of excessive
blood alcohol concentration.
Moreover, it would be more efficient to
use a single type of device to measure
blood alcohol concentration and
establish the burden of proof. This
new device would combine the fea-
tures of the existing testing and
measurement units and could thus
identify blood alcohol concentration
if the authorised threshold has been
breached.
The requirement to install alcolocks,
which have shown their effectiveness on
repeat offenders, could be extended by
strengthening the network of garages
authorised to install such devices.
Conclusion
and recommendations
21
Summary of the thematic public report by the Cour des comptes
In concluding this evaluation, the Cour des comptes offers six main findings
and proposes three guidelines to achieve more effective prevention of harmful
alcohol use.
The six findings are as follows:
- first, there is no consensus in France on such basic points as the overall
economic impact of harmful alcohol use or the relationship between consumption
and risk for individuals;
- second, notwithstanding the overall decline in consumption, risky behaviour
is on the rise, particularly among young people, women and vulnerable groups,
and it is now established that regular, non-excessive drinking may also carry risk;
- third, insufficient research is being done to robustly document the damaging
effects of different forms of alcohol use so as to more effectively design appropriate
health strategies;
- fourth, public action is struggling to change behaviour because of insufficiently
effective use of tools that have proven their usefulness in other countries;
- fifth, health responses to harmful alcohol use come too late and are inadequately
coordinated;
- the sixth and final finding relates to policy design and implementation: not
only is there not a clear roadmap for participants in the shape of a specific national
programme focused on preventing harmful alcohol use, but also no authority has
the necessary clout to advocate for public health in the face of business interests and
ensure the necessary interministerial coordination of measures. These governance
problems are found at the local level as well.
Therefore the Cour des comptes proposes the following broad guidelines:
- as part of the national addiction plan, draw up a programme to prevent harmful
alcohol use, which should be based on scientific evidence and led at the very top level
of government. This programme should come with indicators so that measures can
be carefully tracked over time, enabling the programme to be regularly evaluated and
adjusted based on actual outcomes;
Summary of the thematic public report by the Cour des comptes
22
Conclusion and recommandations
To the Prime Minister:
1.
design a national programme to
reduce harmful alcohol use; the
programme should come with
adequate indicators and establish
procedures to ensure that it is
effectively steered both at national
and local levels. Regularly evaluate the
programme using an internationally
recognised method and make its
result public;
To
the
Minister
for
Higher
Education and Research:
2.
set up a multi-year policy for
alcohol
research
(fundamental,
translational,
clinical,
public
health, social sciences) with a
focus on interdisciplinary work and
international collaboration;
To the Health Minister, the Interior
Minister, the MILDECA and the
National Public Health Agency:
3.
tailor
messages
targeting
consumers with a risky behaviour
based on the findings of work on
drinking guidelines and current
research on morbidity and mortality
rates attributable to alcohol;
To the Health Minister, the MILDECA
and the National Public Health
Agency:
4.
develop prevention and commu-
nication measures targeting the
most vulnerable groups (young
people, pregnant women with a
view to preventing foetal alcohol
syndrome, people in difficulty);
pay special attention to preventing
violence against women;
To the Labour Minister and the
Health Minister:
5.
legislate to eliminate the autho-
risation to bring and consume
wine, beer, cider and perry in the
workplace, as currently provided
for by the Labour Code, and refer
to company bylaws as regards
implementation requirements and
applicable exemptions;
To the Health Minister and the
Minister for Higher Education and
Research:
6.
expand detection and follow-up
for at-risk drinkers based on the
codified
procedure for
alcohol
screening and brief intervention
within the framework of the medical
- raise awareness and prevent the risks of harmful alcohol use through
appropriate information campaigns and prevention initiatives that are informed
by the latest scientific progress;
- strengthen the impact of existing tools, which are not efficient enough in
many cases. While some tools deserve special attention because they are
currently underused (such as screening and brief intervention or price and
taxation measures), others could be more simply overhauled and adjusted to
meet public policy needs (such as the rules on distribution, lobbying, advertising,
and DUI checks and penalties).
approach. To this end, step up initial
and ongoing addiction training,
involve nursing staff more closely in
implementing alcohol screening and
brief intervention
and systematically
check for the presence of alcohol
when admitting people to emergency
units or healthcare establishments;
To the Minister for the Economy
and Finance and the Health
Minister:
7.
increase the excise duties on all
alcoholic beverages to reduce at-risk
drinking;
To the Minister for the Economy
and Finance and the Health
Minister:
8.
prepare to introduce a minimum
price per unit of pure alcohol
contained in each beverage, consistent
with
European
law,
to
reduce
consumption by alcohol-dependent
people;
To the Minister for the Economy
and Finance and the Health
Minister:
9.
apply restrictions on advertising
alcoholic beverages to all digital
media (internet and social media),
consistent with the judgment by
Cour
de
cassation,
France's
supreme court on 3 July 2013;
To the Minister for Economy and
Finance, the Interior Minister and
the Health Minister:
10.
extend
the
training
rules
applicable to on-premises sales
establishments to all other forms
of sale of alcoholic beverages and
set up a national digital repository
of permanent and temporary
license applications, which may be
consulted
by
law
enforcement
agencies; ;
To the Interior Minister, the
Justice Minister, the Minister for
the Economy and Finance, and
insurance companies:
11.
increase the likelihood of being
checked and receiving on-the-spot
penalties: by using a single approved
portable device for measuring blood
alcohol concentration levels that
breach the thresholds for standard
and more serious offences; by
increasing flat-rate fines for DUI up
to class 5; by applying the regime of
on-the-spot penalties for offences to
blood alcohol concentration levels
of up to 1.2 g per litre of blood.
Conclusion and recommandations
23
Summary of the thematic public report by the Cour des comptes