Our favourite drugBMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7351.1410 (Published 15 June 2002) Cite this as: BMJ 2002;324:1410
Failure to develop a national strategy against alcohol misuse should encourage local initiatives
Alcohol watchers must surely be aware by now that no political party intends to do anything about alcohol misuse. Repeated calls for a national alcohol policy have been rebuffed since at least the 1980s, and successive ministers have dismissed the need for action on the grounds that the public is happy, in fact the more alcohol the merrier. It is only fair to say that Health of the Nation did set a modest target of a one third reduction in the numbers of people drinking over sensible limits by 2005.1 Ten years on, the number of heavy drinkers has increased. Initiatives from Europe have fared no better. In 1993, Britain was one of the 26 member states that agreed in principle to a 25% reduction in alcohol consumption by the end of the century.2 The government must have known that such a step was a non-starter, given its reliance on alcohol taxes, a commitment to increasing the availability of alcohol, and not least a powerful drinks industry. Predictably, consumption has risen. We, and other countries, have accepted that controls on advertising need tightening and that young people's drinking should be reduced, but in the first case the voluntary code continues to be broken, and the second is probably a lost cause given that drinking by children, heavy consumption by young adults, and bingeing are all rites of passage. An evidence based recommendation to lower the blood alcohol limit for driving to 50 mg/100 ml (10.9 mEq/l) has been rejected; deaths from drink driving are on the increase.
Labour talked tough when it was elected in 1997, especially over the scandal of targeting alcopops at children, and it began to encourage the idea of a national alcohol strategy. A commitment in Our Healthier Nation was welcomed as long overdue by members of overstretched and underfunded alcohol services, who looked enviously at the amount of money being poured into the fight against drugs.3 It soon became clear that nothing was likely to be achieved before the end of 1999, and the coup de grâce appeared in the NHS Plan, which put back implementation to 2004, the year of the next general election.4 The government is not entirely to blame. Most people enjoy a drink, and there is little sign of public anxiety, except possibly over violence and crime. Effective ways of controlling consumption by increasing cost and reducing availability, especially of cheap alcohol, are unlikely to be popular in these hedonistic times. The view from the pub is that misuse is confined to a minority of “alcoholics” and shock-horror statistics are a turnoff because they don't apply to the regulars.
Doctors, who arguably should lead the campaign for safer drinking, commonly lack the know how, and they can be antagonistic. A disappointing report from the Royal College of Physicians, for example, more or less abandoned any role for doctors.5 Its tone was caught by one of the members, who said, “Doctors at present regarded alcoholics as a bad bunch and don't want anything to do with them.” It seems impossible to put across to doctors, the public, and the drinks industry the message that relatively few people who misuse alcohol will have physical damage and become addicted; they will be expensive to manage and largely untreatable. Against this, as many as seven million people in Britain drink more than is good for them and are liable to harm themselves or others; early detection of excessive drinking and brief interventions are relatively simple, cheap, and demonstrably cost effective.6 If doctors wish to undertake this satisfying job they will have to jettison their ignorance and prejudice.
Health professionals who work with alcohol misusers are not only frustrated by government inaction and lack of resources; they need guidance on priorities among the many challenging problems that confront them. Assuming that this will never come from government, a way forward might be for primary care trusts to take alcohol agencies under their wing. Since the classic study of Tether and Robinson,7 community owned services have been regarded as an ideal way of managing alcohol misuse, and in the early 1990s Alcohol Concern began setting up voluntary agencies with the help of government grants. Over 300 of these now cover most of the country and could form the core of local services. In time it should be possible to supply each general practice and hospital with one or more alcohol workers or specialist nurses whose function would be to identify and treat problems and to support staff. Such a scheme has already been successfully pioneered in practices in Cornwall (G Smerdon, personal communication) and in the accident and emergency department at St Mary's Hospital in London.8 No doubt we would have to beg a little more money: according to the latest figures, government expenditure on treating alcohol problems is £1.1m (£291.1m on drug problems)—peanuts when set against the estimated £7bn that alcohol misuse costs society.
The author is an adviser to Alcohol Concern and a former chairman of its medical committee.