Under the influence
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.f7646 (Published 08 January 2014) Cite this as: BMJ 2014;348:f7646All rapid responses
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Was the government consultation on introducing a minimum unit price for alcohol in England and Wales really a “sham”? [1] Consultations described as “shams” are usually those where the decisions subject to consultation have already been taken. But that doesn’t seem to be the case here: you show that the alcohol industry had meetings with ministers after the close of the consultation. The government therefore can rightly claim that the consultation results “influenced” their subsequent decisions.
On tobacco, the Department of Health showed that the “influence” exerted by the results of a consultation on its decisions can be whatever it chooses it to be. In July 2013, the government delayed making a final decision on plain packaging for cigarettes in England, citing the “differing views” in the responses to its 2012 consultation on the policy as reason to wait for the results of the recent introduction of plain packaging in Australia. [2] Who’d have thought that the outcome of the UK-wide consultation seeking responses from interested people, businesses and organisations – and extended to four months – would be “differing views”?
The ambiguity of the word “influence” means that it is easy for government to assert that the results of a consultation “influenced” their subsequent decisions.
1. Gornall J. Under the influence. BMJ 2014;348:f7646. (8 January.)
2. Department of Health. Consultation on standardised packaging of tobacco products. 2013. www.gov.uk/government/news/consultation-on-standardised-packaging-of-tob....
Competing interests: No competing interests
Under the influence show us how the drink industry can strongly influence public health policy, in part due to the extraordinary access granted to their representatives to MPs and many government departments1. It seems that the Public Health Responsibility Deal has favoured the corporate power by giving corporations a prominent seat at the health-policy table and by asking the private sector to co-finance the health promotion campaigns made by the government2. The Spanish Government seems to be following the same trend. On December 19th 2013, the Ministry of Health launched a prevention campaign on alcohol use among minors funded by the Spanish Alcoholic Drinks Federation3. The precautionary principle argues against that kind or public private partnership with companies that get profit from increasing consumption of unhealthy commodities, like alcohol4. The U turn in the United Kingdom to introduce a minimum price for a unit of alcohol, despite what appeared to be an unequivocal commitment of the British government in favour of that policy, show us how risky for the citizens’ health can be that kind of collaborative strategy. This is a cautionary tale that all involved in the public health arena should pay attention to. In Spain, like in UK, the drink industry influence could be undermining the current efforts to draft an effective law to prevent alcohol use among minors. In fact, the measures under consideration announced by the health ministry focus on promoting education and better information rather than changing the environment to avoid or effectively difficult alcohol access for minors3. Furthermore, the Spanish recent experience regarding to the public private partnership with the food industry encouraged by the National Strategy for Control of Obesity [Nutrition, Activity, Obesity, and Health (NAOS), for its acronym in Spanish] make me feel pessimistic. In March 2012, the former Coca-Cola Iberia manager of scientific and normative affairs and a former member of the Spanish Soft Drinks Association was appointed as executive director of the Spanish Food Security and Nutrition Agency, the agency in charge of the NAOS strategy5. In December 2012, in close collaboration with the food industry, the Food Security and Nutrition Agency launched the new code for self-regulation of food advertising targeting children6. This code, not only ignored the scientific evidence and the recommendations of the WHO to reduce the exposure of children to marketing of foods high in saturated fats, trans-fatty acids, free sugars, or salt, but also failed to meet one of the key requirements of the bill on Food Security and Nutrition passed on July 20116. The bill established that the code must regulate all food and drink commercials targeting at children under 15, but the new code, when referring to television commercials, only applies at children under 12. Again, that remind us why corporate power is a public health priority and the need for the public health community to take action to address this issue7.
References
1. Gornall J. Under the influence. BMJ 2014;348:f7646
2. Wise J. Is the UK turning the clock back on public health advances? BMJ 2010;341:c6691.
3. La ministra presenta la campaña para prevenir el consumo de alcohol por parte de los menores de la Federación Española de Bebidas Espirituosas (FEBE). December, 19th 2013. Available at: http://www.lamoncloa.gob.es/ServiciosdePrensa/NotasPrensa/MinisterioSani... (January 17th 2014, date last accessed)
4. Moodie R, Stuckler D, Monteiro C, Sheron N, Neal B, Thamarangsi T, Lincoln P, Casswell S; Lancet NCD Action Group. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet 2013;381:670-9.
5. Bes-Rastrollo M, Ruiz-Canela M. Regulation and the food industry. Lancet 2013;381:1902.
6. Royo-Bordonada MA. Can the advertising and food industries help prevent childhood obesity and promote healthy lifestyles? Gac Sanit 2013;27(6):563.
7. G Hastings. Why corporate power is a public health priority. BMJ 2012; 345:e5124.
Competing interests: No competing interests
A long-delayed response to a Freedom of Information request submitted on October 28 has finally arrived from the Treasury. Unfortunately, it sheds light on little other than the government’s determination to keep secret discussions it had with industry lobbyists at the height of the alcohol industry’s campaign to sabotage the policy of minimum unit pricing.
I asked the Treasury for more information about seven meetings in January and February last year between Sajid Javid, the Economic Secretary to the Treasury, and representatives of the alcohol industry. As the meetings had taken place either during or immediately after the consultation into the level at which minimum pricing should be set, it seemed reasonable to assume the topic might have been raised - not least because the BMJ had unearthed other evidence to show that at about the same time the policy was the subject of meetings sought by the industry with the Department of Health.
Javid met with Greene King, the British Beer and Pub Association, the Wine and Spirit Trade Association, the Federation of Wholesale Distributors, the Scotch Whisky Association, the Association of Convenience Stores and the National Association of Cider Makers. The Treasury admits it holds information about the meetings, but - after a delay of more than two months - declines to disclose it on the ground that “the public interest in withholding some of the information at this time outweighs the public interest in disclosure”.
It can do this under an exemption in Section 35(1) (a) of the Freedom of Information Act, as “the information is likely to inform the development of government policy”.
It is, of course, precisely how that policy has been shaped by the intervention of the alcohol industry that is the question at hand. Nevertheless, while it recognises “the public interest in disclosure for greater transparency around the Government’s meetings with alcohol stakeholders”, it is the Treasury’s opinion that that interest is met sufficiently by it having revealed that the meetings took place.
Ministers, it says, “need to be able to discuss policy matters freely and frankly with stakeholders as part of an iterative policy development process”. Disclosure of “the views expressed in these discussions would be likely to inhibit future policy formulation ... as stakeholders would be less candid in expressing their views”.
Meanwhile, the Department of Health has declined to release more information about a meeting that took place between Tesco and the Secretary of State for Health on May 15, 2013. Perhaps that’s because it regrets the information it earlier released about a similar meeting between one of its ministers and seven industry representatives, which took place six days after the MUP consultation closed and formed part of the BMJ’s recent examination of the influence of the alcohol industry on public health policy. [1]
[1] Gornall J. Under the influence. BMJ 2014;348:f7646
Competing interests: I am the author of the BMJ investigation, Under the Influence.
The MUP political debacle should act as a wake-up call to the public health community in England. Political influence needs to be exerted in a co-ordinated way between all relevant public health organisations (PHE, Faculty of Public Health, Association of DPHs, UK Public Health Association and the CMO). There are surely enough combined resources to achieve this!!
If the competing interests of the alcohol industry are to be truly taken on (within a flawed system that allows them such ease of access to the corridors of power) the public health community must play them at their own game. We can either complain about the seemingly unjust system from the side lines or roll our sleeves up and get on the pitch. Effective lobbying must be a skill developed in earnest within our profession. If we are to address the 'organised efforts of society' then that surely means effectively influencing Government itself.
Public Health community - it is time to grow up and play with the big kids...
Competing interests: No competing interests
The forensic analysis by Gornall of the disaster that is the Coalition Government's alcohol policy must surely call into question whether the public health system that we now have in England is any longer fit for purpose. It is also increasingly clear that this lamentable state of affairs has not happened by accident.
The decision of the Department of Health to move industry vested-interests to the centre stage of key aspects of public health policy using the mechanism of the ill-named Responsibility Deal is one of a series of moves that has left the English public health system in tatters.
Centralisation of the majority of the public health workforce into the civil service via Public Health England, the abolition of Regional Directors of Public Health, disappearance of the regional public health observatories, the lowered status of local Directors of Public Health within local authorities and the marginalisation and invisibility of the Chief Medical Officer post, have all served to create a situation where the system that is meant to promote and protect the health of the population is impotent. Reconstructing what was one of the most effective public health systems in the world will be no easy task.
In response to the Coalition's disgraceful record on alcohol the time has surely come for even more vocal opposition to this selling out of our population's health to industry interests. The first step should surely be the withdrawal of all academics, health professionals and NGO representatives from all of the Responsibility Deal steering groups. To remain involved would smack of being complicit.
Competing interests: No competing interests
Dear Sirs,
Look at the example in Brazil. When cachaca
turned expensive, crack, cheaper and more
active, boomed! Is alcohol more harmful than
crack?
Competing interests: No competing interests
Conspicuous by its absence is any mention of the CMO's involvement in all this. As HM Government's principal adviser on all health matters, the CMO's influence would have been crucial, and should be published.
Competing interests: No competing interests
Alcohol addiction is a social malady which can never be controlled or curtailed by legislation or education or social awareness. It is a cultural habit and has become a necessary social habit. For example, in India a prohibition policy did not work in many places. Many states promulgated prohibition of alcohol policy and then lifted it. This is due to many reasons - alcohol manufacturer's lobby is very powerful; the government exchequer is mostly dependent on alcohol sales like the Tamil Nadu State Marketing Corporation (TASMAC) (up to 250 crores till today for the year); TASMAC outlets in Tamil Nadu are everywhere, including near schools and colleges promoting alcohol culture.
Under the influence of alcohol no other influence stands.
Competing interests: No competing interests
The relationship between childhood parental influence on the consumption of alcohol by their children in adult life noted by Jonathan Gornall is an important reason for the introduction of minimal pricing for alcohol.1 Reducing consumption through price increases has the potential to break such familial cultural norms of behaviour and reducing the detrimental health and economic effects of alcohol.
However, during these discussions we should not ignore other reasons why people drink. My surgery is located in an affluent suburb of Birmingham. Superficially alcohol does not appear to be a problem. In our area we do not experience fights, drunken individuals in the street nor obvious crime or family problems as a result of alcohol. However, my public health colleagues inform me that my patients drink excessively at home. Initially I found this hard to believe until we started checking liver function tests with the widespread introduction of statins several years ago – and discovered a large number of patients with elevated GGT levels. On further exploration, many were drinking up to a bottle of wine a night. This is used to treat anxiety symptoms arising from stress at work and from high expectations in personal lives, which then impacts work effectiveness, family life and increases health risk. The drinking is often hidden. This use of alcohol to treat stress has also been demonstrated by Dawson et al.2 Further, my patients do not consider themselves to have an alcohol problem and therefore do not seek help to stop drinking. Ling et al. have also noted that their respondents considered public health messages to be of no relevance to them, rather they reinforced perceptions that their own alcohol use was controlled and acceptable.3
My patients’ choice of wine as their preferred drink suggests that they are unlikely to be effected by minimal alcohol pricing strategies and alternative methods need to be employed. In particular, such methods would need to be directed at the cause of their drinking – long working hours, high levels of stress, an uncertain economic environment that makes it difficult to organise lives to reduce stress, and in many cases added stresses such as looking after elderly relatives in the face of a cash-strapped social and welfare system. Whilst the government may not be able to dramatically increase funding or prefer not to pass new employment legislation, it should concentrate upon stabilising the working environment for such people so that they can effectively use their own resources to organise their lives to reduce stress.
1. Gornall, J. Under the influence, 2012. BMJ 348:f7646.
2. Dawson, D.A., Grant, B.F., Ruan, W.J., 2005. The association between stress and drinking: Modifying effects of gender and vulnerability. Alcohol and Alcoholism 40:453-460.
3. Ling, J., Smith, K.E., Wilson, G.B., Brierley-Jones, L., Crosland, A., Kaner, E.F.S., Haighton, C.A., 2012.The ‘other’ in patterns of drinking: A qualitative study of attitudes towards alcohol use among professional, managerial and clerical workers, 2012. BMC Public Health 12:892.
Competing interests: No competing interests
Re: Under the influence
There is now a huge amount of observational data globally showing an association between increasing the minimum unit price of alcohol and reductions in alcohol intake at a population level (1). Furthermore a modelling study by Purshouse and colleagues published in the Lancet in 2010 clearly demonstrated a dose response relationship between increasing unit prices and reductions in mortality and morbidity (2). In public health terms, increasing the minimum unit price of alcohol ought to be an easy sell.
So why isn't it? Apart from the deluge of marketing and lobbying by the alcohol industry (and perhaps because of it), alcohol has become so engrained in our culture that we've collectively forgotten that it's a potent drug associated with liver disease, cancer, hypertension, trauma, domestic violence, and the list goes on. There are few other risk factors that can attributable to such a wide variety of maladies and premature mortality. Anyone who's worked a day in A&E (or read the Global Burden of Disease Study (3)) is all too aware of this.
But sections of the medical profession itself appear to have blinded itself to both the evidence around alcohol policy and the urgent need to revise it. A recent BMJ poll showed that 55% of respondents did not believe minimum unit pricing for alcohol would save lives. This clearly flies in the face of the evidence.
So what might be influencing this position? Could it be that alcohol has become so engrained within medical culture that we've become collectively inept at tackling this epidemic? Excessive alcohol consumption has since time immemorial been accepted as part of socialising into the profession, right from day one of medical school. At the same time the BMA, which has campaigned hard for improving alcohol policy, estimated that 1 in 15 doctors will at some point in their lifetime develop problems with alcohol or other drugs that may affect the care of their patients. While that should be a very frightening statistic, on reflection it isn't surprising. So perhaps while we advocate for better population health through evidence-based reforms of alcohol policy, we should also be advocating for a change in the medical profession's own attitude towards alcohol. Both our colleagues, our patients and the populations we serve are depending on it.
1. Wagenaar AC, Tobler AL, Komro KA. Effects of alcohol tax and price policies on morbidity and mortality: a systematic review. American Journal of Public Health: November 2010, Vol. 100, No. 11, pp. 2270-2278.
2. Purshouse RC, Meier PS, Brennan A, Taylor KB, Rafia R. Estimated effect of alcohol pricing policies on health and health economic outcomes in England: an epidemiological model. The Lancet, Volume 375, Issue 9723, Pages 1355 - 1364, 17 April 2010
3. Lozano et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet, Volume 380, Issue 9859, Pages 2095 - 2128, 15 December 2012
4. BMA response to BBC research on alcohol and drug abuse among doctors. Accessed at: https://web.bma.org.uk/pressrel.nsf/wall/A4E4FCB3ED44BB748025701F0033938...
Competing interests: No competing interests