Reducing the harms of alcohol in the UK
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39426.523715.80 (Published 20 December 2007) Cite this as: BMJ 2007;335:1271
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Dr Haris is right to a point. The scarcity or complete absence of specialist comunity alcohol services does inhibit the routine exploration of the role of alcohol in presenting problems because GPs fear that afterwards there will be no way of getting the worms back in the can & that they will be expected to do a difficult specialist job for which they aren't equipped.
This overlooks the fact that many people whose health is affected by their drinking do not need a specialist service & can make changes with relatively little input & for whom a doctor's advice can be supplemented by good online help.
Whether patients require simple advice or referal-on, they have to be identified first & Prof Drummond's 2005 Alcohol Needs Assessment Review Project demonstrated depressing, but in my view avoidably, low levels of detection of hazardous & harmful drinking by GPs.
In my limited experience of trying to interest both medical & non-medical workers in alcohol interventions, 2 things themes repeat themselves:
1. With some honorable exceptions, GPs' responses tend to be, a) We haven't got time but b) We'd like to be paid more to do it.
2. Non-medical workers have fewer inhibitions about embracing alcohol screening & brief interventions enthusiastically & are often genuinely puzzled that doctors seem so reluctant to do the same, especially when they can see the effects of alcohol on the health & wellbeing of the nation.
Competing interests:
I am a community psychiatric nurse working in an NHS alcohol treatment service
Competing interests: No competing interests
Some of the serious health effects due to excessive alchohol
consuption are
related to Thiamine defiency.
I wonder if it might be a good profylactic intervention to distribute free
Vitamine
B to alcoholics - for instance at through the GP office, the soup kitchen
or
through the Salvation armee.
VItamine B is quite a cheap remedy, and I have not registered that
its use is
assosiated with any serious side effects.
I may like to promote this idea to the Norwegian Health Department,
and are looking for information about similar invervention.
Do any of you know if this kind of intervention has been tried or
considered
elsewhere?
Regards,
Marit Schou Hauger,
Norway
Competing interests:
None declared
Competing interests: No competing interests
Such emphasis is put upon the cost of early intervention in the
treatment of alcohol misuse but a simple chat about it costs nothing. As a
training GP I was alarmed to hear the shocking statistic that 1 in 5 of
the people I will see in a normal morning surgery may be excessive
drinkers but surveys suggest that 65% of GP’s see only up to 6 excessive
drinkers in a year! If a brief intervention lasting 5-10 minutes can
reduce alcohol consumption by up to 20%, role on longer consultations!
Competing interests:
None declared
Competing interests: No competing interests
It is right to highlight the complex and conflicting issues in
alcohol harm, but we need to grasp them and deal with them, rather than
shrink away from logiical analysis. Moderate drinking may be less harmful
than complete abstinence, but this debate is about hazardous and harmful
drinking, ie levels of consumption and patterns of drinking that do have
higher mortality than either moderate drinking or teetotalism.
Another statistic to put in the mix; the UK now has a rising rate of liver
disease, most of this attributable to alcohol. In all the other major
Western European countries, the rate of liver disease is falling.
The pro-alcohol lobby might be well-advised to consider the need to be
careful not to appear as blinkered as it alleges the anti's to be. We may
wish the nanny state not to dictate to us about our lovely alcohol, but we
do also expect our taxes to be spent wisely, and with foresight.
Alcoholic liver disease is costly, the costs are set to rise further, and
we are all paying the price. Current alcohol policy initiatives are a
long way from even envisaging the sorts of measures that are now widely
accepted by the public to reduce smoking. The actions being advocated in
the article to reduce alcohol consumption are not draconian, they are just
cost-effective.
Competing interests:
None declared
Competing interests: No competing interests
Environmental versus public health? a distinction without difference, surely. Combining the two groups to cleanse our hospitals might prevemt 30 times the supposed number of deaths due to drink driving each year, I am told, and seems a more profitable goal.
Professions naturally see slanted population samples - an obvious drink/illness link as a cause/effect for a medical man might be no more than the policeman's refusal to have children since they turn out badly - the ones he sees do at any rate.
But seriously, a strong association between two variables does not prove a causal link; otherwise you will believe rings cause marriages, bad teeth cause low IQ, or Saturday causes crowding on the High. People with different diseases do many other things in common as well as drink moderately - and many other things differently:- overwork, different genetic backgrounds, different food in youth and so on. Their problems may well have complex multifactoral causes. Indeed, the presence of alcohol could be a self-medication for relief for some of them. Worse, given this claim for alcohol's ubiquity, it could be no more significant than walking or beathing is as a cause - both of which they all do.
It is extremely difficult to demonstrate cause and effect unambiguously in biological science, because of the vast range of variables involved in living things. And statistical generalisation is not the same as repeatable laboratory demonstration of a causal link, even if the variability of living things allowed that. How do you run a person's life through again without the drink?
Competing interests:
None declared
Competing interests: No competing interests
Certain groups within the medical community have a disturbing
tendency to
completely ignore critical issues in policy debates that fall outside
their areas
of expertise. There are several in the debate about alcohol.
One is an astonishing tendency to ignore the implications of their
proposals
on individual freedom and responsibility. Yes we could impose draconian
restrictions on peoples' ability to buy alcohol, but are such measures
acceptable in a free society?
Another is a wilful tendency to quote statistics in a way that
undermines
honest discussion and, for that matter, public trust in government
statistics. I
may have missed it, but in the above debate I saw no mention of the well-
known fact that mortality is significantly higher in the UK for
teetotalers than
for moderate drinkers. Most statistics were quoted to attempt to
illustrate
that alcohol is unambiguously always bad and that its bad affects are
enormous and large for society.
There is also little discussion of the diversity of individuals'
responses to
alcohol: some tolerate it well and others do not. Australian aboriginals
north
american natives and many asians can't tolerate the stuff and should
probably
avoide it. Europeans from races who have had farming for a long time are
ususally much more tolerant (but with high individual variability). So
blanket
advice to mixed populations will rarely be right.
But the biggest error is one of logic. Yes, a lot of crime and social
disorder is
associated with alcohol, but is it caused by alcohol? The critical
experiment is
this: imagine it were possible to eliminate the supply of alcohol (even
Saudi
Arabia has never achieved that) would the rate of wife-beating, child
abuse or
violence actually go down that much (Saudis are not notably more friendly
to
their women despite the religious prohibition of alcohol)? I suspect they
might go down a bit (say 10%) but not by the amount implied by the anti-
alcohol brigade. An example: possibly the majority of crime (from
burglary to
GBH) has alcohol as a factor. But do we really think that normal people
drink
and then suddenly decide to burgle their neighbour? It seems a lot more
likely
that they decide to burgle and then drink because it takes the edge off
their
guilt or makes them bolder in committing their crime. The same is true for
other social disorders. Perhaps we should tackle the problems that drive
people to be violent and they will drink less as a side effect. Pinning
the
blame for a host of social problems on booze is passing the buck not
addressing the real problems (and the debate is dishonest if it doesn't
even
acknowledge this as potential confounder of the reported statistics).
But the killer statistics in the UK should be that alcohol
consumption has
slightly declined since we introduced more freedom in the licensing rules
desite the jerimiads from the anti-alcohol bodies. Perhaps people do have
inbuilt restraint after all and don't have to be told what to do by the
nanny
state.
Competing interests:
I'm drinking a lovely Australian
Shiraz as I write
Competing interests: No competing interests
It would appear that the responsive Mr Parsons may be confusing
Environmental Health Officers (whose activities he has reasonably
accurately described above) with Public Health Directors who are concerned
with any condition which affects the health of the public on a widespread
scale. As a causative factor in disease, alcohol is second to none in its
range, affecting as it does almost every system of the body, from nervous
(peripheral neuropathy, Wernicke's encephalopathy, Korsakoff's psychosis,
alcoholic dementia) to gastrointestinal (peptic ulcer, oral and gastric
cancer, liver cirrhosis and cancer) cardiovascular (hypertension,
cardiomyopathy, ischaemic heart disease) reproductive (increased risk of
sexually transmitted disease, foetal alcohol syndrome) - to name a few -
and it ranks equally highly as a factor causing illness in others - to
remind Mr Parsons of the article to which we are all responding, I quote:
'Drinking alcohol is a factor in more than half of violent crimes and a
third of domestic violence. Between 780 000 and 1.3 million children are
affected by their parents’ use of alcohol—30-60% of child protection cases
and 23% of calls to the National Society for the Prevention of Cruelty to
Children about child abuse or child neglect involved drunken adults.'
Competing interests:
None declared
Competing interests: No competing interests
Surely the public health concerns of the "medical community" reasonably relate to such tasks as: - checking the quality of beer on sale, monitoring the cleanliness of hotel kitchens, confirming the absence of sawdust from our bread or e-coli from our meat; or ensuring the sanitisation of public hospitals, the purity of drinking water, the quarantine of infectious diseases and dangerous lunacies and so on. All your grasping of moments and political scheming may go down well in Russia (or why not try North Korea?) but such draconian measures have no part in the framework of peacable choice and a free polity. The thistle of this presumption needs both grasping and rooting out.
Competing interests:
None declared
Competing interests: No competing interests
Ian Gilmore and Nick Sheron succintly highlight the harm alcohol
causes and ask whether tougher measures should be taken, in particular by
governments. Virginia Berridge, in her case studies of public health
activisim exhorts the efficacy of advocacy groups constructing coherent,
evidence based messages; forming wide alliances; harnessing the media and
seizing the political moment (1).
Here in Scotland, alcohol related harm has been recognised as a major, if
not the most serious, public health problem facing us with, for example,
alcohol related death rates for men double those than in the rest of the
UK (2). One example of such recognition is the enshrining of the principle
of protection of the public's health in the forthcoming Scottish licensing
legislation due to come into force in 2009. The new Scottish Government,
in particular, the Cabinet Secretary for Justice, Kenny MacAskill, is
optimising that legislative framework with proposals to ban drink
promotions both in off sales and well as on sales; restrict the display of
alcohol for sale and adopting a 'polluter pays' approach.
The medical community have also recognised the need for action. In 2006,
the Scottish Royal Colleges formed an advocacy group, Scottish Health
Action on Alcohol Problems (SHAAP) and has been putting into practice much
of what Victoria Berridge describes. It has recently published Alcohol:
Price; Policy and Public Health (3), a report of an expert group it
convened. This comprehensively sets out the argument (including the
prevention paradox) and the evidence on both price and tax on alcohol and
outlines policy options at both Scottish and UK levels.
1. Berridge V. Public Health Activism BMJ 335:1310-1312
2. Baker A. Alcohol Related Deaths in the UK
www.statistics.gov.uk/statbase/Product.asp?vlnk=14496
3. Alcohol: Price, Policy and Public Health
www.shaap.org.uk/publications.php
Competing interests:
Member of Executive Group of Scottish Health Action on Alcohol Problems
Competing interests: No competing interests
Re: Reducing the harms of alcohol in the UK
It is known that alcohol consumption in the former Soviet Union rapidly increased after the anti-alcohol campaign (1985-88). Accordingly, the economic reforms during the 1990s were in a sense accomplished under the “anesthesia” of the people not supposed to participate in privatizations. The fact that the state, at various times, encouraged alcohol sales, is known to the international community (1).
Retrospectively, it becomes clear that the anti-alcohol campaign (1985-88) was just another tool used for the same purpose, with a predictable failure and a recoil effect at the required moment. By 1993, the average expectation of life at birth for Russian men was estimated to be 59 years (2). In 2008, the difference in life expectancy between men in some West European countries and Russia was reported to be 20 years (3). Gorbachev's anti-alcohol campaign with its predictable failure contributed to the mortality increase. Apart from alcohol, limited availability of modern health care is a cause of the low life expectancy in Russia (4). Middle-aged men are sometimes especially unwelcome in the state polyclinics.
1. McKee M. Alcohol in Russia. Alcohol Alcohol. 1999;34(6):824-9.
2.Ryan M. Alcoholism and rising mortality in the Russian Federation. BMJ. 1995;310(6980):646-8.
3. Zatonski WA, Bhala N. Changing trends of diseases in Eastern Europe: closing the gap. Public Health. 2012;126(3):248-52.
4. Jargin SV. Health care and life expectancy: A letter from Russia. Public Health. 2012 doi:pii:S0033-3506(12)00406-4.
Competing interests: No competing interests