Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Policy driven evidence gathering is not convincing
- stephen Black (27 March 2009)
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No world crisis for the alcohol businesses
- Alain Braillon (27 March 2009)
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Patients support clinical champions for action on alcohol harm
- A Rogers (1 April 2009)
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Evidence and public health policy
- John C Duffy (5 April 2009)
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A taxing problem
- Dominic C Horne (7 April 2009)
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Re: A taxing problem
- Ellen CG Grant (8 April 2009)
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A sample of 2009 Scottish Medical Graduates: their views on proposed changes to the sale of alcohol .
- Jan S Gill, Caroline Gibson, Maggie Nicol (8 April 2009)
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stephen Black, management consultant london sw1w 9sr
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My natural liberal inclinations reacted badly to the Chief Medical Officer’s (CMO) latest campaign against alcohol. I tend to believe that free societies should concentrate on keeping people informed and have no remit to coerce them into making good (or healthy) choices. But, I was prepared to be convinced that perhaps something could be done about England’s problematic relationship with booze. I assumed that the CMO would have carefully gathered original evidence and marshalled a strong case for his proposed interventions. I was open to being persuaded by some real evidence. So I read the various pieces of background material. Instead of being convinced that action is required I’m no longer sure we have the problem he says we have, I’m convinced his proposed solutions will be ineffective and I’m extremely worried that scientific integrity has been brought into disrepute by the cavalier way evidence has been handled to arrive at a Daily-Mail pleasing policy recommendation (actually I think the real process starts with policy and then seeks evidence). Let me illustrate the problem by looking at three areas: the supposed nature of the problem; the effectiveness of the proposed solutions; and the advice we give to parents. A naïve reader might assume that the various reports will have identified who the problem drinkers are and the differential rates of disease they suffer (we might need this information to know whether targeted measures will be more effective than blanket measures). But no such research appears. The social problems of booze (noise, bad behaviour near pubs, vomiting in the street) are conflated with the medical conditions related to long term abuse (like cirrhosis). Are they related? I didn’t know before the CMO’s report and I don’t know now. I don’t even know whether the incidence of cirrhosis relates to a tail of the consumption distribution (ie very heavy drinkers) or whether the rate would be similar if we all drank a uniform amount of double what the government recommends (we still have no actual scientific basis for those limits, of course, as a former BMJ editor admitted). These are all important things to know if we need to choose the right policy. According to the BMJ editorial on the CMO’s report, the obvious drivers of consumption are availability, price and promotion. So we have presumably done some good primary research about the long term effect of those drivers in the context of the UK or Europe (where very different mixes of government policy exist). In the short term, it is pretty obvious that changing price, for example, will change consumption, but it is the long term that matters and there is plenty of comparative evidence in plain sight that doesn’t fit the obvious ideas. There are two obvious examples from other European countries. The most prohibitionist countries—the Scandinavians—seem to have the worst binge-drinking behaviour, so even their draconian pricing isn’t guaranteed to stop the public disorder we hate so much. And the cheap-booze Mediterranean crowd don’t drink more than the English despite the cheapness and ready availability of alcohol. But there is another example staring us in the face directly from England. The prohibitionist tendency told us that the evidence pointed to availability being a big driver of consumption so the licensing hour relaxation was predicted to be a public health catastrophe. Maybe I missed something, but the volume of alcohol consumed has declined significantly since that relaxation despite increasing affordability. The very evidence the CMO quotes to show how bad the problem is in England—the increase in consumption in England is contrasted with a sharp decline in France over the last 3 decades—throws up questions about his proposed remedies and his use of evidence. I don’t think France has dramatically restrained availability or raised prices over that period. It would have been nice to see some evidence about what caused their decline, but I couldn’t find any. The CMO reminds us of just how cheap the cheapest alcohol is in supermarkets. A connection is assumed with the nasty public-order side effects of binge drinking: violence, street disorder, vomit, drunks lying in the street etc. Perhaps we could have some real evidence about this as I can see some cause for skepticism. For example, it is bars and nightclubs that seem to be associated with drunken louts, not supermarkets, and those late night establishments are not renowned for their cheap alcohol. The CMO confidently asserts that a minimum price per unit would reduce alcohol consumption by 7%. He does have some evidence for this, but must be hoping not many people will read it as it really isn’t that good (the work is based on a literature review and an econometric model from Sheffield University. The reports are available from http://www.dh.gov.uk/en/Publichealth/Healthimprovement/Alcoholmisuse/D H_4001740 ). It is also worth noting that the evidence base for estimating the relationship between price and consumption in the model is based on a period of increasing consumption in England and stops before the recent consumption decline started, though affordability has continued to increase. The trouble is international studies on pricing are old, mostly non- European and often deeply flawed in their methodology (the literature review admits this, though the report on the model is less sceptical). And many of the examples are simply asking the wrong question. Even the most hardened skeptics don’t doubt that total consumption is reduced in the short term if we jack up the price, but the evidence about what that means in the long term is much less clear. And surely it is the long term that matters. The last recommendation to illustrate the scientific problem is the one that got headlines a few weeks ago: parents should never give alcohol to their children. Again, though it seems obvious to some that this is good advice, there are plenty of reasons to look for proper confirmation that it is effective. For example, prohibitionist attitudes are known to be ineffective in other areas: Abstinence-only sex education isn’t very good at encouraging abstemious behaviour. A cursory comparison of liberal versus prohibitionist countries in Europe would suggest that the liberal ones probably have lower levels of binge-drinking and social disorder. So, again, it seems reasonable to expect that the CMO to have commissioned some carefully conduced research so that he can offer us parents credible and proved advice. But, again there is no original work, just a literature review (actually a review of reviews. Available here: http://publications.dcsf.gov.uk/default.aspx? PageFunction=productdetails&PageMode=publications&ProductId=DCSF- RW043& ). And the literature review, though expressed in fuzzy language and heavily hedged actually disagrees with his policy. There is some evidence that early introduction to booze in safe environments encourages children to be more responsible with alcohol later (this quote from page 3: “children who first use alcohol in a home environment and learn about its effects from parents are less likely to misuse alcohol…”)! Maybe I’ve misunderstood his goals, but I would have thought that encouraging a mature self-regulating attitude to the demon drink might actually be good for society. Instead, we get a set of recommendations designed to please Daily Mail readers and which are not obviously going to actually work (at least not if you count actual scientific evidence as important). So three key components of the CMO’s recommendations seem to emerge from something like policy driven evidence gathering (where we trawl for anything that backs the policy we have already determined). An alternative way to spend public money would be to commission some better quality, open ended research that doesn’t presuppose a Daily Mail Friendly answer. Judging from the quality of much of the literature we are in desperate need of better quality original work (even the Sheffield academics recommend this). The BMJ editorial jumps on the bandwagon by demonising evil alcohol companies and their dangerously effective advertising (I don’t mind badmouthing the big corporates, but the problem with demonising them is that is distracts policy and individual attention away from the real problems). Worse, it paves the way to suppress proper debate as all criticism of the CMO’s arguments can be written off as sponsored by the evil industry. Industry may have a lot to answer for, but they don’t deserve the blame for Anglo-Saxon booze abuse: the industry is rich and powerful because we drink a lot; we don’t drink a lot because we are manipulated by a persuasive industry. The real problem is not external evils or agents, it is our culture. It feels good to blame something else, but it distracts us from the harder problem of building a better society. That battle requires better thinking than the poorly evidenced, headline grabbing, and ineffective policies advocated by the CMO. Competing interests: Alcohol consumer who (outside Lent) consumes more than the government recommends |
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Alain Braillon, public health 80000 Amiens France
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Gordon Brown rejected Sir Liam Donaldson’s proposal for a minimum charge per unit of alcohol to be imposed on beer and wine (March 16th). French members of the National Assembly, despite it is the lower house, stroke higher. They allowed advertising on the Internet for alcoholic beverages for the first time (March 16th). Therefore, Pope Benedict XVI had to state that condoms use is aggravating the AIDS epidemic, to get any audience. It was not easy to find out, considering previous statements from Pope John Paul II. Thanks to fear and ignorance as well as cowardice and corruption: no crisis for medicine. Competing interests: None declared |
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A Rogers, Chief Executive British Liver Trust
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Your editorial is absolutely correct: the health harm from alcohol must not be ignored and the positive health impact of a minimum price per unit must be recognised. The Chief Medical Officer’s annual report was welcome in putting forward concrete recommendations rather than the hand- wringing aspirations we have seen in the past. The public policy agenda has focused too heavily on the impact of alcohol on crime and disorder rather than health, and the media too have run with the angle of ‘binge drinking’ rather than the serious long-term health consequences including liver disease. Liver disease is now the fifth largest cause of death in the UK, killing 15,203 people a year [British Liver Trust analysis of Office for National Statistics mortality statistics, January 2009]. Alcohol-related liver disease alone killed 7,251 people in 2007 in England and Wales, approximately twice as many men as women. These figures have doubled since 1996. The Trust is particularly concerned with the stark increase in deaths amongst younger people. While alcoholic liver disease peaks in the late 50s, there have been particular increases in the 35-54 age range. For men, this has increased from a 13.4 per 100,000 risk of death to 30.2 [figures from ONS bulletin on alcohol deaths, 27 January 2009]. The increase in alcohol-related liver deaths is not inevitable, and has not been replicated in other developed countries. These mortality figures are shocking, but the wider burden of disease on patients and their families, on the NHS and in particular on specialist liver services, is of equal concern. The case for effective public policy action to reduce the health harm from alcohol is clear. Patients and their families are relying on the medical community not just for their care but to act as champions in this debate, willing to confront the health consequences of cheap alcohol. Competing interests: None declared |
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John C Duffy, Statistician Scottish Funding Council EH12 5HD
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As far as I am aware the only jurisdiction to have a minimum price policy for alcohol is the province of Alberta in Canada, and there the policy applies only to on-sales and has given rise to negative unintended consequences. There is thus no direct evidence for the effectiveness of a blanket minimum price policy, and it is difficult to imagine a new pharmaceutical treatment being adopted on the basis of the arguments put forward by its proponents. Apart from the lack of direct evidence, there are numerous observations that contradict the assumptions of the models used. In Scotland for example the tonic wine Buckfast is often indicted as the drink of choice of drunken hooligans. In terms of price per unit of alcohol it is relatively expensive - and in fact its price would not be increased by the Scottish Government proposal for a minimum price per unit. The use of whole-population models (as in the Sheffield work) is invalidated by commonplace observation - in many European countries drinking by adults is stable or decreasing while drinking by young people increases. The price elasticity of alcohol is quite low - and since elasticity is a local property the effects of large rises in price cannot be predicted with accuracy. What is incontrovertible is that the income elasticity is very high, which indicates that consumers would spend more on the product if they could afford it. So the consumer would suffer considerable loss of utility if a large price rise meant they had to pay more to drink less (and most consumers will not die of alcohol-related disease,accident or violence). A prominent health economist declared a price rise in Scotland to be a win-win solution but only by completely ignoring this aspect. The point made in an earlier rapid response about licensing reform is absolutely correct. Studies of licensing reform based on empirical data using control comparisons consistently contradict the availability hypothesis but are consistently ignored, not just by the sensationalist media but by alcohol and health advocates and alcohol researchers. The consequences of policy are rarely studied properly, and are too often 'justified' by assertion, analogy and sometimes astonishingly flawed 'research' rather than real evidence or evaluation. These comments are in no way intended to minimise or make light of the serious social and health problems resulting from excessive alcohol consumption. But to say that something must be done, this is something so we'd better do it is no argument. For every complicated problem there is a simple solution and it's wrong. Competing interests: I have no current competing interests. I left alcohol research in 1996. Prior to that time my work had been funded from various sources including the Portman Group, the Medical Research Council and the Alcohol Education and Research Council. |
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Dominic C Horne, GP locum Much Birch Surgery HR2 8HT
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The Prime Minister has stated that he does not wish to punish the 'sensible majority of moderate drinkers' by raising the price of alcohol. This was in the same week that fuel duty increased by 2p per litre (not an April Fool's joke as I first suspected on hearing the news). In today's Britain most have little option but to use private transport. No-one has to drink alcohol. Competing interests: None declared |
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Ellen CG Grant, Physcian and medical gynaecologist Kingston-upon-Thames, KT2 7JU
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Who are the Prime Minister's sensible moderate drinkers? The Million Women Study has revealed that low to moderate alcohol consumption in women increases the risk of certain cancers. For every additional drink regularly consumed per day, the increase in incidence in women up to age 75 years in developed countries is estimated to be 15 cancers per 1000 women including 11 breast cancers.1 1 Allen NE, Beral V, Casabomme D, et al. Moderate alcohol intake and cancer incidence in women. JNatlCancerInst 2009;101:282-3. Competing interests: None declared |
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Jan S Gill, Senior Lecturer Queen Margaret University, Ediburgh. EH21 6UU, Caroline Gibson, Maggie Nicol
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We should like to contribute to the debate around the content of this editorial by presenting a subset of results from an ongoing study conducted by ourselves during the period 2008-09 and funded by the Alcohol Education Research Council. We have been using a questionnaire to explore the knowledge and perceptions relating to alcohol and the use of brief interventions, among healthcare and medical students. In total, we anticipate that around 1000 students will complete the questionnaire. Our questionnaire concludes with four questions which relate directly to key proposals outlined in the publications emerging from the Scottish Government1. Participants have been asked to record their responses to each of these four statements (shown in the left hand column of Table 1) on a Likert, six point scale which ranges from ‘strongly agree’ to ‘strongly disagree’. In this letter we report the results pertaining to the group of 2009 graduating medical students recruited to our online survey from three Scottish university medical schools. Table 1; A sample (n=121) of 2009 Scottish Medical Graduates: their views (expressed as a percentage) on proposed changes to the sale of alcohol
The sample is relatively small (n=121) and this represents only 17.5% of those eligible to complete the online survey. Females comprised 70% of the group while 15.7% were abstainers. (A figure slightly higher than recent population estimates for this age group2). The clearest consensus of opinion related to the proposal that ‘It will be beneficial to reduce the drink drive limit from 80mg to 50mg per 100ml of blood’ ; only 20.0% of the sample disagreed with this statement. More than half the sample (55.4%) disagreed with the view that ‘the raising of the minimum legal purchase age for off-sales purchases to 21 years would reduce the negative impact of alcohol on communities’. The other two proposals (the introduction of a minimum price for a unit of alcohol and a banning of the sale of alcohol at below cost price) had around 60% support within this sample. Measures to reduce the impact of cheap alcohol appear to have some support amongst this small sample of medical graduates. As students they are often linked to the population group most likely benefiting from the ready availability of cheap alcohol but they are soon to join a profession which must deal with its consequences. References; 1. Changing Scotland’s relationship with alcohol. (2008) The Scottish Government. Edinburgh , Scotland. 2. Alcohol Statistics Scotland 2009. NHS National services Scotland. ISD Publications , Edinburgh ,Scotland. Competing interests: None declared |
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