The government is committed to introducing a national alcohol strategy. It gave the undertaking in Our Healthier Nation, the green paper it issued in 1998. The Department of Health enlisted the help of Alcohol Concern which carried out a far-reaching consultation before formulating a set of proposals for this strategy. This is a document of some 150 pages, covering all aspects of the subject. Some of these - such as the suggestion that promotions such as "happy hours" be banned - have already attracted the attentions of the press.
Given the government's rejection of a strategy to reduce per capita consumption, the first objective in Alcohol Concern's proposals may not be welcomed by ministers. It reads: "Should the annual national consumption of pure alcohol rise to more than 8 litres per head of the population, the highest recorded level since 1965 being 7.8 litres, accompanied by evidence of a rise in alcohol misuse, [the objective will be] to reduce levels of consumption to those rates pertaining when the strategy came into operation." This is a modest aim since the latest figures available show that 7.6 litres of pure alcohol were consumed per head of the entire population (9.4 litres for those aged 15 and over).
Other European countries have taken closer note of the World Health Organisation's aims as set out in the first European Alcohol Action Plan (EEAP) which was to reduce consumption by an ambitious 25 per cent. Whilst this has been met in only three countries, others are taking measures to approach the target, possibly by the end of the second EEAP in 2004. In France the intention is, by the turn of the millennium, to reduce the average consumption of alcohol by people over 15 by 20 per cent. In Spain, the Health Minister recently declared that a reduction in the per capita consumption of alcohol was the "path that we have to follow if we do not wish to pay the high price implied by the scientific evidence. This evidence categorically shows that higher levels of consumption go with higher rates of sickness and mortality."
The Institute of Alcohol Studies made a submission to the Department of Health in support of Alcohol Concern's proposals. Whilst applauding the wide scope of Alcohol Concern's work, the IAS set out to emphasise a number of points:
The nature and scale of the problem and future prospects
It is known that deaths from alcohol-related disease increased by over a third in the 10 years from 1984 to 1994. Deaths from chronic liver disease and cirrhosis increased by two thirds during this period. The increase was especially steep in young adults aged 15-44, in whom the death rate doubled.
Since 1994, the death rate from chronic liver disease and cirrhosis, conven-tionally taken as an indicator of the general extent of alcohol-related health damage, increased in men by over a further 30 per cent, and in women by a further 24 per cent. Liver disease is of course only one example of a wide range of health problems associated with alcohol consumption. These problems affect not just the individual drinkers concerned but also impose a heavy burden on the health service.
However, important though health problems are to individuals and to society, we believe strongly that it is a mistake for national alcohol strategy, and messages about 'sensible drinking', to be dominated by health issues to the exclusion of other considerations and, especially, for these health issues themselves to be limited to chronic problems such as alcoholic liver disease.
In relation to the numbers of people affected and the total burden on society, the problems of acute intoxication are undoubtedly more important than the chronic health conditions, important though these are to those who experience them.
In societies such as ours alcohol is more accurately described as a social problem that can have medical complications than the other way around. For example, the strong associations of alcohol with crime and anti-social behaviour are well known.
One of the disadvantages of an undue focus on the health aspects is that it tends to divert attention away from the ways in which problematic drinking can impair and destroy relationships, and can have highly adverse effects on people other than the drinkers themselves. In our recent report on behalf of EUROCARE to the European Union, we estimated that there are probably around a million children in the UK experiencing often severe problems from parental alcohol consumption.
Crime and family problems associated with alcohol consumption are particularly important examples of social problems which impose huge burdens on individuals and society but which are ignored totally by burden of disease studies designed to ascertain whether the supposed cardioprotective effects of alcohol result in less, as many, or more deaths being prevented as caused by alcohol consumption. Such studies are concerned with only a small part of the total picture. For most people, most of the time, alcohol problems mean problems in their lives, not the causes of their deaths. Moreover, in many cases the person with the problem is someone other than the person doing the drinking. These aspects of the problem were almost entirely ignored in the Report of the Interdepartmental Working Group on Sensible Drinking, which, when it was published, was described as governing national alcohol policy for the foreseeable future.
The aims and terms of reference of a national policy
Our view, contrary to the implicit assumption of the interdepartmental Working Group, is that the need and justification for a national alcohol policy arises not from the fact that drinkers may damage themselves but, from the excessive and inappropriate consumption of alcohol harming other people as well as the drinkers and placing an enormous burden on society at large.
We believe that this should be made explicit in a statement of national policy. The statement should refer in particular to alcohol problems as they affect families.
Trends in alcohol consumption
After a period of relative stability during the early 1990's, per capita alcohol consumption is now rising again to historically high levels. Taking into account the consumption of unrecorded imports of alcohol, legal and illegal, from across the Channel, per capita consumption in 1998 was probably higher than at any time since the turn of the century.
Despite the 'Health of the Nation' targets set by the previous Govern-ment, there is no sign at all of any reduction in the numbers of those exceeding the recommended limits of regular consumption. On the contrary, the proportion of women exceeding the limits has increased by 55 per cent since 1984 and is still rising. The latest available information suggests that the proportion of men exceeding the limits is now also increasing.
Barring an unwanted turn-down in the economy, there is no reason to believe that this growth in average consumption, heavy drinking and in alcohol problems will come to a halt spontaneously, still less go into reverse.
A strategy on alcohol or on alcohol problems?
The alcohol industry expends much time and effort in trying to discredit the scientific consensus that there is a close relationship between per capita alcohol consumption and the level of alcohol-related harm, or more usually simply asserts that this view has already been discredited, which it has not. An equally erroneous argument employed by the industry is that because of the supposedly cardioprotective effects of alcohol, the health of the population could be put at risk by a reduction in the overall level of national alcohol consumption.
The health benefits of alcohol
The argument of the alcohol industry concerning health benefits is invalid. The scientific consensus is that light drinking may have health benefits for some (mainly middle aged and elderly) individuals, although it is of interest that in the one major UK study relevant to these issues, the lowest mortality rate from cardiovascular disease was found in lifetime non-drinkers.
However, at a population level the cardioprotective effects of alcohol 'are essentially cancelled out by increases in other causes of death'. This is exemplified by France, where a particularly low death rate from coronary heart disease coexists with a high overall excess mortality rate in men, largely attributable to alcohol and tobacco.
It is of particular interest that far from the decline in French national alcohol consumption causing any increase in mortality from cardiovascular disease, deaths from this cause have in fact declined as consumption has declined.
The absence of adverse consequences from reduced consumption arises from the fact that, in relation to the cardioprotective effects of alcohol, the optimum level of per capita consumption is estimated to be around 3 litres per annum. There is no valid reason, therefore, to suggest that a reduction from the present UK consumption of more than three times this amount would have any adverse health consequences: on the contrary, any health benefits would remain while the adverse health effects would be reduced.
The whole population model
Despite the statement quoted above, the Interdepartmental Review on Sensible Drinking discounted the whole population theory as `scientifically uncertain and difficult to apply, especially in the UK'. The Review speculated that while the whole population theory might apply to comparisons of one country with another (countries with higher average consumption would probably be found to have more heavy drinkers), it did not necessarily follow that the theory applied within a single country, such as the UK.
Prompted by this challenge, resear-chers analysed information on drinking habits in fourteen regions of England. They found that, exactly as the whole population theory predicted, the regions with the lowest average consumption had the fewest heavy drinkers and vice versa - the regions with the highest average per capita consumption also had the highest proportions of heavy drinkers (defined as those drinking above both the old and the new 'sensible limits') and the highest prevalence of people reporting symptoms of alcohol dependence. This was found for both men and women.
These observations confirm that heavy drinking or 'alcohol abuse' are not purely the result of individual attributes scattered randomly through the population, but are also, and mainly, a reflection of the prevailing drinking culture and the average level of consumption. They also imply that factors encouraging increased average consumption in light to moderate drinkers, - such as longer drinking hours, alcohol becoming cheaper, or, perhaps, governments raising the 'sensible drinking limits' and sending messages about the 'heath benefits' of moderate consumption - are also likely to result in an increase in heavy drinking and alcohol-related problems.
Given these findings, the statement of the Minister of Health that what is required is action against the harm caused by alcohol, not action against alcohol itself needs to be qualified in certain key respects. We share the Minister's distaste for `nannying lectures' but the reality is that for both individuals and whole populations, increased alcohol consumption tends to be accompanied by increased alcohol problems, and reduced alcohol consumption by reduced alcohol problems. It will do no service to the public to base a national alcohol strategy on the absurd delusion that there is no relationship between average consumption and the level of harm, that it is possible to tackle the harm caused by alcohol without tackling alcohol.
Other than in overblown rhetorical declamations, the prospect of depriving millions of moderate drinkers of their alcohol does not, of course, arise. In the real world, the main issue that the national alcohol strategy needs to address is that alcohol consumption and harm are at high levels, are rising and will, presumably, continue to rise unless preventative action is taken. We hope that the Government does not intend systematically to divert attention from this real and pressing issue by conjuring up the entirely bogus threat of prohibition.
We know of no country in which the goal of reduced alcohol-related harm is regarded as compatible with a policy of encouraging increased alcohol consumption. On the contrary, in countries which have formulated national alcohol strategies, the objective, implicit or explicit, is always to reduce or at least stabilise alcohol consumption, this being seen as either the means or the consequence of reduced alcohol-related harm.
In our view, therefore, it would be not just foolish but also dishonest for the Government to base its strategy on the mythology cultivated by the alcohol industry that the level of national consumption is a matter of complete indifference. Measures - the level of excise duties is an obvious example - which affect the drinking population as a whole must necessarily play an important role in an overall strategy.
None of this is to deny the importance of the targeted approach, or that the main need is, to focus on harmful and dangerous patterns of consumption. In our view, the whole population and the targeted approach are complementary: far from its being necessary to make a choice between them, to be fully effective the one requires the other. In the words of a recent, comprehensive international review of the research evidence: `..if the level of alcohol consumption is allowed to run free and go high, more targeted interventions will be rendered null and void.'
A popular strategy based on evidence
Alcohol Concern lists some of the main components of a national strategy.To these we would add public acceptability and an approach based on components are linked.
We agree fully with the Minister's statement that widespread public support is needed successfully to tackle alcohol problems. We would however question the implication of the Minister's statement that public opinion is normally or necessarily hostile to preventative measures. In relation to drinking and driving, for example, it is clear that for several years public opinion has been in favour of rather tougher measures than Governments have been prepared to introduce. It is also clear that a succession of measures has been introduced - and more are being proposed - to weaken the licensing law in defiance of public opinion.
The Government's advice on the need for public support is so obviously sensible and desirable that we can only hope that the Government takes it itself.
We also make the possibly optimistic assumption that public opinion is more likely to support measures which they are convinced are designed to protect or promote the public good and which are based on evidence rather than pre-judice and the demands of vested interests.
Fortunately, there is now a good deal of evidence available on which to base policy decisions. A recent, comprehensive international review summarised what the research evidence shows to be effective policies for reducing alcohol problems :
Taxation of alcohol
Measures influencing physical access to alcohol
Drink driving countermeasures if vigorously enforced and given a high public profile
Other situationally directed measures such as control of alcohol at sporting events
Treatment of alcohol problems, including simple forms of help given in primary care settings
The review adds that school-based education, public education, warning labels and advertising restrictions can be added to the policy mix, but on the basis of the reasonable hope of long-term pay-off, rather than on evidence of the kind that supports the above group of measures.
The sensible drinking message
As suggested above, the evidence is that public education of this kind has very limited direct effect on actual drinking behaviour. However, it is possible that over a prolonged period such campaigns may effect the general social climate.
We have explained previously our reservations about the `sensible limits' approach to educational programmes aimed at the public at large. We hope that the Government will reconsider this approach, and be alert to the obvious danger of appearing to endorse levels of consumption which are higher than those of the majority of the population.
We do accept that the 'sensible limits' approach may be appropriate in programmes aimed at heavy drinkers and in view of the extensive media pub-licity that these limits receive there is an urgent need to correct the confused and contradictory advice on limits inherited from the previous Government. We hope the Labour Government will emphasise that medical advice is that the daily limits of up to 4 and 3 units for men and women respectively should not result in the old weekly limits of 21 and 14 units being exceeded. In other words, the Government should make it clear that there never was any valid scientific case for raising the drinking limits.
Administrative responsibilities
A feature of the situation that has become very clear over recent years is that statements of good intention and exhortations to do better are not enough. There is a real danger that a national alcohol strategy will founder through a failure to make anyone in particular responsible for its implementation.
We fully support calls for the Interdepartmental Group on Alcohol Misuse to be re-established. We believe that, as before, the Ministerial Group should have the tasks of co-ordinating departmental policies towards the agreed strategic objectives and providing the national leadership required: this includes providing a framework for action for those involved in implementing the strategy at local level.
In regard to local initiatives, we believe that the Government has made a good start with the Crime and Disorder Act by requiring local partnerships to formulate plans to tackle alcohol-related crime. This approach could be further developed.
The Institute of Alcohol Studies' critique of the Government's present attitude highlights the difficulty of establishing a coherent national alcohol strategy when there is a refusal to countenance any reduction of the per capita consumption. The assumption of ministers seems to be that the voting public will not tolerate any measures which limit their opportunity to drink. This is contrary to the evidence of the drink-driving legislation which, over a period of time, won such acceptance that public attitudes are more hard-line than the Government's. The fear of loss of revenue and of restricting a multi-million pound business puts huge power into the hands of the drink industry. Tessa Jowell, the Public Health Minister, is attempting to reconcile the irreconcilable.