Reducing harm from alcohol
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1191 (Published 20 March 2009) Cite this as: BMJ 2009;338:b1191All rapid responses
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
A sample of 2009 Scottish Medical Graduates: their views on proposed changes to the sale of alcohol .
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
Competing interests: No competing interests