NO: Mr Jim McManus

YES: Dr Lise Llewellyn

 

NO: Mr Jim McManus is Director of Public Health for Hertfordshire

When asked to do this piece I blew the dust off a publication I co-authored in 2003 and got rather depressed that not a lot had changed in policy terms.

Alcohol is a commodity that is both good and enjoyable and carries major risks at the same time. Surely our public policy aim should be to reap the benefits (enjoyment, pleasure, culture, friendship, jobs, economic benefit) while minimising the harms (avoidable disease and misery) and ensuring that those who won’t don’t or can’t drink don’t feel excluded.

What is alcohol policy in England trying to do? I mean, really? Someone please tell me because it feels like we’re still in a mess.

The history of how we deal with alcohol tells a story of a system that is more often at the mercy of population trends rather than providing any thought through coherent system of policy. Human behaviour is complicated, and the truisms and clichés about how some other nations have better drinking cultures than England (and some much worse), abound without us seeming to learn from it.

One thing history tells us is that we Brits like our booze. We have had an intimate and often unhealthy relationship with it since long before Sir Walter Scott bemoaned the Claret that “was oft pissed up against Half of Edinburgh’s walls.” I suggest the key lesson of history is both sensible regulation measures and culture change are needed.

So why can’t we get our act together to make alcohol policy support a culture of safe and pleasurable enjoyment? In my most cynical moods it feels like every development in alcohol policy is a bit like a lamppost for a drunk; providing unsatisfactory support to lurch unsteadily forward rather than illumination for a thought-through path.

We’re told that there has been a fall in the proportion of frequent drinkers (22% to 14% in men and 13% to 9% in women) in England between 2005 and 2012. And some people see this as cause for celebration (singles all round, then.) And yes, in and of itself we should welcome it, so far as it goes. It seems great on the surface that people are drinking more moderately.

Perhaps we could even imagine that they are drinking to enjoy without causing health risks, which surely, is a good thing?

Before we turn rose tinted, this isn’t the whole story. The proportion of men has reduced more than the proportion of women, and there are other indicators that alcohol related harm is still on the increase because there is a time lag.

So welcome what we have yes, but let’s realise one population change does not mean a whole culture shift. We still need to think through what else we need to do to reduce harm from alcohol while getting the best benefits. We’re still drinking more than we were twenty years ago and health related costs, disease and disability from alcohol is actually going up in many areas, not down.

I don’t see how this welcome reduction can be attributed to our cobbled together, confused, contradictory and piecemeal approach to alcohol regulation and our deeply conflicted approach to alcohol as a substance. And to that extent, I don’t feel cause for celebration. And most alcohol trends in England have at some point in history reversed themselves. Enough to drive you to drink, right?

Whenever I hear anyone tell me that “this sign in alcohol trends is to be welcomed” I immediately want to make people reach for the History books. History, at least on alcohol use and trends in the UK, keeps repeating itself, largely because we don’t seem to be listening it. James Nicholls in an article in History and Policy will tell you that alcohol consumption in the UK has been fluctuating for many decades. In particular, on the latest trend, he sounds a warning note:

“... since the 1970s liver disease – for which alcohol is the primary determinant – has risen dramatically in England (and especially Scotland) as it has fallen elsewhere in Europe. Across the UK, alcohol-related mortality doubled between 1992 and 2006, justifiably pushing alcohol up the political agenda.

"However, recent falls in consumption seem to be having an impact: deaths fell by around 13% between 2008 and 2012 and continue to decline, albeit with important regional variations. Nevertheless, they remain around 70% higher than twenty years ago."

It’s very easy to assume that because drinking levels seem to be decreasing, this is a sign that the harm from alcohol to our population is decreasing. This is just not borne out by the facts. If history teaches us anything about the history of alcohol policy, it is to teach us suspicion about these easy conclusions. Where is the modelling about the impact of austerity on this? And what we understand about the impact of existing measures on reducing alcohol related violence and disorder?

I think we face three major challenges in alcohol policy which we have not sorted out as a nation:

We need a genuinely thought through regime of appropriate regulation for alcohol at national and local level – including given more powers to licensing committees – which lets us join up. Systems thinking, not piecemeal proposals is what we need.
We need to make policy build and support a culture of safe and pleasurable enjoyment of alcohol.
We must really get to grips with early intervention on harm. All the reduction in frequent drinkers in the world, welcome though it is, doesn’t negate the rise in people whose lives are being wrecked by alcohol in many areas. We must sort this out.
The latest reduction is a welcome sign among other unwelcome trends. But if we think we’re out of the woods or we can stop pressing for better and more coherent policy, then History will sadly once again prove us wrong.

Competing interest declaration: None 

 

YES: Dr Lise Llewellyn, Strategic Director of Public Health for Berkshire

When it comes to alcohol, us Brits love nothing more than a bit of self-flagellation. For years we have lapped up our media’s regular depiction of drunken Britain. We love to watch British men fighting in city centres while our even drunker women shout “leave it Wayne, he’s not worth it!” before toppling unglamorously into an underwear exposing heap.

We also love to point enviously across the English Channel to our European cousins, slurping their fine wines with a sophisticated sobriety and an elevated appreciation of how alcohol should be enjoyed.

But is this indulgent self-depreciation still warranted? Furthermore, is it helpful? The fact is that drinking patterns are changing for the better in the UK, and by failing to celebrate that fact; we are also failing to reinforce and encourage further positive change.

There is surely plenty to celebrate. The latest UK statistics on alcohol show that, between 2005 and 2012, the proportion of men who drank alcohol in the week before being interviewed fell from 72% to 64%, and the proportion of women fell from 57% to 52% (HSCIC, 2014)(1). Applied to the whole population – these percentages represent serious numbers.

Maybe even more encouraging is the decline in drinking among younger people. The national data indicates that in 2012, 43% of school pupils (aged 11-15) said that they had drunk alcohol at least once, which continues the downward trend since 2003, when 61% of pupils had drunk alcohol (HSCIC. 2014). In this sense, the future looks bright – and certainly more sober.

The suggestion that we celebrate these promising trends is not to suggest a naivety or denial of the continuing harm alcohol still inflicts on society. Alcohol related admissions to hospital and deaths remain higher than they were 10 years ago, as do the number of deaths caused by alcohol. As Alcohol Concern’s former Chief Executive Eric Appleby warned: "Any reduction in the number of people drinking is welcome; however, large numbers of men and women continue to drink regularly at levels which seriously risk their health.”(2)

So how can we possibly celebrate? Surely until we see significant reductions in alcohol related harm should we even consider raising a glass to our success?

Well, yes we should. Celebrating success today will make it more likely that we are also celebrating tomorrow. To understand this we need to dust off our books on social cognition and behaviour change. In his Theory of Reasoned Action, Fishbein (2008) (3) highlights how the likelihood of someone adopting a certain set of behaviours depends on the extent to which they believe that others are engaging in that behaviour and whether it is a 'socially desirable' thing. In other words, we are more likely to behave in a certain way if we think others (especially those we admire) are also behaving in that way.

You see, we aren’t quite as independently minded or rebellious as we would like to think we are. Deep down we strive to be like those around us. We follow social norms, whether by wearing the latest fashions, reading the bestselling book, or watching the box office busting film. We do what we others are doing, and quite frankly, why shouldn’t we?

One practical application of this principle came from the HMRC Behaviour Change Team (Cabinet Office, 2012)(4) who tested the influence of social norms on tax debt payments. Letters were sent to thousands of taxpayers, with some receiving the standard letter with no mention of social norms (the control group) while others included one extra piece of information – that ‘9 out of 10 people pay their tax on time’. The letters with this additional information also varied in whether this statistic applied to Britain as a whole, the taxpayers’ postcode, or taxpayers’ home town.

The results showed that while 67.5% made payments in the control group; 72.5% made payments when informed about national social norms; 79% for postcode social norms and, finally, 83% for home town social norms. It is estimated in the report that the difference between the standard letter and the highest performing home town social norm letter could advance £160 million of tax debts to HMRC over a six-week period. Not bad really.

So with this in mind, what would we expect to happen if we dismiss the latest reductions in alcohol consumption as insignificant? What message do we send to our population? Wouldn’t that be the equivalent of sending a letter asking people to pay their tax with a note at the end saying “although no one else is paying in your area – so why should you?”

Rather, let’s celebrate the recent trends. Let’s analyse them, interpret them, communicate them and generally make a whole heap of fuss about them.

In particular, the figures showing a decrease in drinking among young people deserve our attention. We should be very publicly asking why this has happened, starting by asking young people themselves.

One recent study did just that (Herring et al., 2012)(5). Young people aged 16-24 in the UK were asked about their views on drinking alcohol and on being drunk. The subject of personal control came up frequently, with one young man saying:

‘I really didn’t get much from it, I just felt I was intoxicated, I didn’t know where I was, I didn’t know what I was doing, I couldn’t control my actions.’
Another young person observed that when she was drunk:

‘It really made me lose control over who I am.’
It’s likely that, rather than seeing these trends as a false dawn, young people will tell us about their desire to be in control of their lives and how being blind drunk doesn’t really fit with that plan. They may tell us how the people they admire these days are strong, confident and independent – not the drunken, slurred ‘pseudo-rebels’ of old. They may make us realise that, instead of pointing across the English Channel for examples of how we should be, we should be pointing at them.

So let’s allow ourselves to celebrate the latest downward trend in alcohol consumption. In doing so, we don’t need to deny the ongoing impact of alcohol misuse on society, or the fact that more measures are needed to counter that impact. On the contrary, our awareness of the impact of alcohol should make us cheer even louder at any indication that things are changing and that there may be light at our end of the channel tunnel.

Competing interest declaration: None

 

Viewpoints contributors are guest authors, they do not receive a payment of any kind for this and are not a part of The Drinkaware Trust.

 

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References -

(1) Statistics on Alcohol - England, 2014 https://www.jrf.org.uk/file/42196/download?token=OAEHiNg-&filetype=full-report

(2) The Guardian: Alcohol consumption in UK adults continues to fallhttp://www.theguardian.com/society/2013/dec/17/three-in-five-adults-drank-alcohol-past-week

(3) Fishbein M (2008) A Reasoned Action Approach to Health Promotionhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2603050/

(4) Cabinet Office study description taken from British Psychological Society Behaviour Change Advisory Group Briefinghttp://www.bps.org.uk/system/files/Public%20files/tax.pdf

(5) Herring et al 2012http://www.jrf.org.uk/sites/files/jrf/young-people-drinking-choices-full.pdf