Dying for a drink - Alcohol related death rates almost double since 1991
The alcohol-related death rate in the UK increased from 6.9
per 100,000 population in 1991 to 13.0 in 2004, according to data
released by the Office for National Statistics. The number of
alcohol-related deaths has more than doubled from 4,144 in 1991 to 8,380
in 2004.
The figures are an underestimate of the full amount of deaths
as they only relate to deaths caused directly by alcohol. If indirect
causes are taken into account the number of deaths could be 3 or 4 times
higher. However, the new figures still show important and useful
trends.
Speaking for the Royal College of Physicians, Professor Ian
Gilmore, Chair of the College’s Alcohol Committee, said: “These new
figures from the ONS are disturbing, but not surprising as they fit in
closely with other recent figures such as hospital admissions for
alcoholic liver disease and deaths from cirrhosis.
“The increase in deaths is likely to continue unless we can
find some way to reverse the nation’s drinking habits. The College
supports the Government’s Harm Reduction Strategy but if voluntary
partnerships with industry and public education are not proving
effective, the next step is direct intervention on issues such as
availability of alcohol, price increases and restrictions on
advertising.”
Death rates are much higher for males than females and
the gap between the sexes has widened in recent years. In 2004 the male
death rate, at 17.7 deaths per 100,000 population, was twice the rate
for females (8.5 deaths per 100,000), and males accounted for over two
thirds of the total number of deaths.
The figures
For men, the death rates in all age groups increased between
1991 and 2004. Men aged 35 to 54 had the highest death rate in each
year. This rate more than doubled between 1991 and 2004, from 16.9 to
38.3 deaths per 100,000.
The death rates by age group for females were consistently
lower than rates for males, however the trends showed a broadly similar
pattern by age. The death rate for women aged 35 to 54 nearly doubled
between 1991 and 2004, from 9.3 to 17.9 per 100,000 population, a larger
increase than the rate for women in any other age group.
Top of pageRise in alcohol related hospital admissions to record levels
Drink-related hospital admissions in England have reached
record levels according to a new compilation of statistics, published by
The Information Centre for health and social care (The IC), which
presents a broad national picture of alcohol use.1
Numbers admitted to hospital with a diagnosis of alcoholic
liver disease have more than doubled over the past ten years with 35,400
admissions in 2004- 05, up from 14,400 in 1995-96. Twice as many men as
women were admitted with this illness. Death rates linked to alcoholic
liver disease have also risen steadily to just over 4,000 in 2004, a 37
per cent increase in the 5 years since 1999.
In-patient care for people who have mental health or
behavioural disorders resulting from alcohol misuse, has also increased
significantly, rising to126,300 admissions in 2004-05, from 72,500 in
1995-96 (75 per cent over the ten years).
Cases of hospital admissions of patients with alcoholic
poisoning have also increased, 21,700 in 2004-05 compared with 13,600 a
decade earlier. The report highlights that the nation’s thirst for drink
begins at an early age. A national survey in 2005 found that nearly one
in four secondary school children (22 per cent) aged between 11 and 15
said they had drunk alcohol in the week before they were interviewed.
Cider, lager, beer and alcopops are the drinks of choice for this age
group, with the average amount consumed doubling between 1990 and 2000
to 10.4 units per week. Consumption has remained at this level for the
past five years.
A 2004 survey of adult drinking found that three quarters of
the men interviewed (74 per cent) and over half of all women (59 per
cent) had taken a drink in the previous week. Young adults were more
likely to binge drink than any other age group; 33 per cent of men and
24 per cent of women aged from 16-24 drank more than double the
recommended number of units (8 for men, 6 for women) on one day in the
previous week. Older adults (45 to 64) are more likely to drink smaller
amounts regularly, on five or more days of the week.
Although this research shows relatively high levels of alcohol
consumption, the UK occupies a middle position when European Union
countries are ranked according to average alcohol consumption. According
to the World Health Organisation figures for 2001, Luxembourg heads the
consumption table, with its residents drinking a per capita average of
17.54 litres of alcohol a year, compared with the UK’s 10.39 litres.
The survey also confirms that the weekend is the
nation’s favourite time for drinking. Young people (16-25) and adults up
to age44 drink most alcohol on Saturdays,33 per cent and 35 per
cent respectively. Older people (64 plus) say they drink most on Sundays
(30 per cent) and adults in middle age (45-64) consume the most alcohol
on Saturday (24 per cent) and Sunday (26 per cent).
Professor Denise Lievesley, The Information Centre’s Chief
Executive, commented: “This report presents a broad picture of drinking
habits in England. It shows that we cannot underestimate the effect of
alcohol on health. By presenting this data we hope that health
professionals will be better equipped to put their work in context and
to raise awareness of the dangers of alcohol misuse.”
1 Statistics on Alcohol 2006.
Top of pageAlcohol and Health in Wales - A major public health issue
The rise in alcohol-related harm in Wales is documented in a new
report “Alcohol and Health in Wales: a Major Public Health Issue”,
published by the National Public Health Service for Wales. Based on
published evidence, it details the health consequences of alcohol misuse
in Wales.
Alcohol-related deaths have increased more than four-fold
amongst Welsh men and more than three-fold among women in the last 20
years according to the report, which says that some
170 men and 90 women in Wales are likely to die of alcohol-related conditions this year.
As the real price of alcohol has fallen over the last 40
years, the amount consumed has doubled. Heavy drinking among teenagers in
Wales is amongst the worst in Europe. Excessive drinking is causing a
wide range of illness amongst people in Wales.
Cirrhosis of the liver is one of the major causes of death from alcohol misuse. Cancers,mental illness and accidents are others.
The report’s author, Dr Edward Coles, said, "‘Mediterranean-style’ drinking is no panacea. Comparison of
different European countries shows that it is associated with high rates
of cirrhosis. There is a tendency to think of crime and disorder as
being the main cause of illness associated with excessive drinking.
However, cirrhosis of the liver, cancer, mental illness, accidents,
unwanted pregnancies and babies damaged by their mothers’ drinking are
also important.
“Excessive alcohol use is a serious public health problem in
Wales. Health would improve substantially if there was a reduction in
the number of people who drink more than the guidelines.” Guidance
indicates that men should drink less than 21 units a week and women
should have less than 14 units.
Dr Coles said, “There are two mechanisms that have been shown
to produce a substantial reduction in alcohol consumption - increased
price and reduced availability. The National Public Health Service for
Wales believe this is an important message for local licensing
committees throughout Wales.” The report is available from the NPHS web
site
www.nphs.wales.nhs.uk
Top of pagePolice tell drinkers 'wear nice pants'
Police have warned women intent on “getting ratted” to make
sure they have waxed and are “wearing nice pants” in case they collapse.
The advice is contained in a free magazine launched by Suffolk
Police which officers say is aimed at keeping women safe when they go
out drinking and clubbing.
Safe! magazine also contains a picture of a girl in a mini
skirt with the caption “if you’ve got it, don’t flaunt it” and it warns
that alcohol can leave women looking like “wrinkly old prunes”. There
are also mock horoscopes promising disasters of various kinds as a
result of drinking binges.
Officers said they were adopting an editorial style which they hoped would appeal to women in their late teens.
A group which campaigns on women’s safety issues applauded
the police’s efforts but said the style of the magazine was “bizarre”.
Suffolk police explain that the publication forms part of their
‘Nightsafe” crime awareness and reduction campaign and it focuses on the
three main ‘nightsafe' messages:
- Don’t overdo it
- Friends stick together
- Get home safe
“There have been a number of attacks on women who have been
drinking and there is a serious safety message to get across,” a police
spokesman said.
“We’ve written this in a gossipy, tongue-in-cheek style in the
hope that young women will pick it up and read it and take notice.”
“For those of you intent on getting ratted this weekend,
think,” says the article. “If you fall over or pass out, remember your
skirt or dress may ride up.
“You could show off more than you intended - for all our
sakes, please make sure you’re wearing nice pants and that you’ve
recently had a wax. “Better still, eat before you go out, think about
how much you’re drinking, pace yourself and drink plenty of water in
between bevvies or better still, don’t get in this sorry state - it’s
not nice.”
A spokeswoman for the Suzy Lamplugh Trust said: “The language
is bizarre. I’ve never seen anything like it before from the police. But
they have a point. It’s no good simply telling young women not to
drink. You have to get their attention. You have to applaud the police
for trying.”
Top of pageReaders' survey
Alcohol Alert Magazine has been edited and published by the Institute
of Alcohol Studies, in its present format, for over ten years.
The magazine aims to provide a broad range of information for
all readers with a personal or professional interest in issues relating
to alcohol. The magazine typically features discussions of alcohol
research findings, analysis and evaluation of alcohol policy and
legislation, insights and commentaries from experts in the alcohol
field, and occasionally, book reviews.
We are currently carrying out a readers’ survey with a view to
improving the magazine. We would like to know what the readers think of
Alert’s current format and content. All information collected will be
used to update the magazine and meet the needs of our readers.
We would be very grateful if you could take time to complete the questionnaire and email it to Emilie Rapley, Research and Public Affairs Officer.
We thank you in advance for taking part in our survey, and look forward to reading your comments and suggestions.
The Staff at the Institute of Alcohol Studies
Top of pageWouldn't it be nice...
With the new Licensing Act 6 months into operation, John
Tierney suggests that it is unlikely to achieve one of its main
objectives.
The Department for Culture, Media and Sport has a dream: that
the 2003 Licensing Act (which came into force in November 2005) will
provide the basis for a transformation in the nature of the night-time
economy in England and Wales. In the dream, town and city centres will
no longer be dominated by concentrations of high-volume pubs, bars and
clubs oriented primarily towards the business of encouraging young
people to drink large amounts of alcohol. No longer will these
‘entertainment quarters’ be shunned by older (and some younger) people
because of concerns about crime and disorderly behaviour, and a
jaundiced view of the attractions on offer. In the dream, couples with
children, the middle-aged and the elderly will cheerfully rub shoulders
with young revellers as they too enjoy the delights of a night on the
town.Some, as the fancy takes them,may drink alcohol, others may opt for
a citron pressé or a milky latte, and the streets will bethronged with a
mélange of well-behaved promenaders. Exactly how the 2003 Licensing Act
will facilitate this transformation is, though, somewhat hazy.
None the less, it is a dream shared by many people, and the
reference point is, of course, continental Europe. “We want to be more
European”, said the then minister for Culture, Media and Sport, Richard
Caborn, a couple of years ago, when arguing in favour of the new
Licensing Act. At about the same time, a councillor from Greater
Manchester – whose city centre night-time economy has been particularly
successful (at least in economic terms) put it like this: “I spent time
in Berlin over Christmas and was struck by the mixed age groups that
used the city centre. Theirs is very much a café-and-cake culture, and
we definitely see that as part of the Manchester vision.”
Also drawing on an image of continental café culture, the
Department of Environment has, for over a decade, been arguing that the
‘animation’ and ‘crowding out’ resulting from a broader mix of
participants will reduce problems of crime and disorder in town and city
centres. What has not been considered is that an intermingling of
different groups (including, for example, older people and children),
within the context of an already established drinking culture, could
lead to an increase in these problems.
Among central government and local authority policymakers
striving to realise such a vision, ‘diversity’ has emerged as a key
concept. It is acknowledged that making the night-time economy of
England and Wales ‘more European’, will require achieving a diverse mix
of participants enjoying a diverse range of leisure activities. Town and
city centres during the evening, especially on Fridays and Saturdays,
are often described as no-go areas for older people and couples with
children. However, whilst it is not uncommon for local authorities to
label these negative perceptions or concerns as exaggerated (a similar
response occurs with respect to the ‘fear of crime’), the central issue
is not the degree to which public perceptions correspond with ‘reality’;
rather, it is the tolerance threshold associated with different
publics. In other words, even if no criminal or serious disorderly
behaviour was occurring, the fact that large numbers of inebriated young
people are milling around engaging in (normal) boisterous behaviour is
likely to act as a disincentive to participation. Community safety
initiatives and effective policing (and the police have extra powers
under the 2003 Act) can address such things as violent crime, criminal
damage and urinating in the street, but they are more or less irrelevant
when people are simply having a ‘good time’ and not harming anyone. For
this reason alone, attracting current non-participants into town and
city centres during the evening will continue to be a major challenge.
If we look at the community safety initiatives that have been introduced
around the country in recent years, it is clear that, where successful,
they have generally made town and city centres safer for ‘typical’
participants in the night-time economy (welcome as that is), rather than
acting as an incentive for current non-participants to join in.
Clearly, there also needs to be diversity in terms of what is
on offer if these non-participants are to be enticed into the nighttime
economy. Restaurants, theatres and cinemas, for instance, could make an
important contribution, though as things stand, their impact will be
linked to how near they are to heavy drinking areas within a town or
city centre, particularly at the weekend. The fundamental stumbling
block to the creation of diversity in terms of what is on offer,
however, is the market and the way in which it is structured. High
street businesses that are not based upon the consumption of alcohol
have found it increasingly difficult to compete with those that are -
witness the cinemas and retail outlets that have transmogrified into
large capacity licensed premises over recent years.
As far as the future is concerned, unless they are remarkably
philanthropic, entrepreneurs, in the shape of corporations or
individuals, will only alter existing leisure attractions or develop new
ones if it is judged to be commercially viable. There may, for example,
be local people who would like to see a town centre club providing
jazz, country music or late night cabaret, but how realistic is it to
expect the development of these sorts of attractions, outside of major
conurbations with large reservoirs of guaranteed customers? In terms of
profitability, events of this nature cannot begin to compare with a one
thousand capacity, themed vertical drinking bar.
Given the nature of the market, the power of the drinks
industry, patterns of drinking in this country, and the powers available
to Licensing Authorities, one would have to be immensely optimistic to
believe that the 2003 Act constitutes the basis for the creation of
diverse, multicultural, sophisticated and hassle-free leisure zones, at
least in the foreseeable future. The reality is that the night-time
economy, as it is presently constituted, is an economic sector dependent
upon alcohol and, increasingly, one that caters for young customers who
themselves are becoming dependent upon alcohol.
John Tierney is Lecturer in Criminology at the School of Applied Social Sciences, Durham University
Top of pageDrinkaware Trust launched
Industry joins Government to promote ‘sensible drinking’ A
new independent charitable Trust aimed at “positively changing the UK’s
drinking culture and tackling alcohol-related harms” has been launched
by Government Ministers Caroline Flint and Vernon Coaker, the alcohol
industry and key stakeholders.
The ‘Drinkaware Trust’, voluntarily funded by the alcohol
industry and to be up and running later this year, is described as a
unique initiative born from the Government’s ‘Choosing Health’ White
Paper and Alcohol Harm Reduction Strategy.
The new initiative is a further development of a Trust
established in September 2002 as the charitable arm of the alcohol
industry’s Portman Group, and originally known as The Portman Group
Trust. In 2005 the Trust awarded a total of £100,000 to 55 projects
around the UK.
The new Trust will bring together industry, charities, lobby
groups, medical professionals and experts in the field to address
‘alcohol misuse’ and promote ‘sensible drinking’ across the UK.
Work by the Trust includes educational campaigns to promote
‘sensible drinking’ among the general public, project aid for local and
national initiatives, and the running and evaluation of pilot programmes
to tackle alcohol related harm.
Public Health Minister Caroline Flint said: “This is an
international first. The new Drinkaware Trust is a model of how
industry, stakeholders and Government can work together to achieve a
shared goal. Alcohol misuse can blight the lives of communities across
the country - not only harming the health of individuals but fuelling
late night violence and causing a nuisance to society.
“The success of the Trust will depend on securing the support
of a broad range of stakeholders across the UK - and that’s what we’ve
done.
“There is nothing wrong with drinking in moderation. Alcohol
is a normal part of society and we’re not trying to stop that. What we
are saying is that people need to be sensible and not drink excess
amounts that can lead to serious conditions such as liver cirrhosis or
result in disorderly behaviour.
“Everyone has worked really hard to make this work and I am confident the new Drinkaware Trust will help in achieving this goal.”
The New Trust marks a significant milestone and underlines
both the industry’s commitment to share responsibility for positively
changing public behaviour, tackling and preventing alcohol misuse and
the Government’s role to work in partnership with the industry and key
stakeholders to achieve this.
It also forms part of the Prime Minister’s ‘small change, big
difference’ initiative to draw together the power of businesses, the
voluntary sector and local communities to tackle specific health
problems by making it easier for people to change the way they live
their lives.
Government has been working in partnership with the alcoholic
drinks industry for some time to promote more sensible drinking. And the
launch of the Drinkaware Trust marks another move in the right
direction. Government is also working with the industry to implement
their social responsibility standards, which will address irresponsible
promotions, underage sales and includes putting sensible drinking
messages on alcoholic drinks labels.
Vernon Coaker, Home Office Minister, said: “The Home Office
has put in place tough measures to deal with alcohol related disorder. I
have made it clear that we will not tolerate the minority of people who
drink to excess and cause fear and intimidation in our towns and
cities.in the UK. The Trust has set itself challenging goals. By working
together, the drinks industry and organisations tackling alcohol harm
will make these all the more achievable.”
Chris Searle, Chairman of The Portman Group, said: “We are
delighted that we have been able to provide the practical means to take
the implementation of the alcohol harm reduction strategy forward on the
education and campaigning front. This approach demonstrates the
benefits of the industry, government and other stakeholders working in
partnership around a shared agenda.”
An interim chief executive will be appointed very shortly and
the Drinkaware Trust will be seeking a chair, a permanent chief
executive and 13 independent trustees to run it. Trustees will come from
a broad base including alcohol experts from the health, education and
voluntary sectors as well as the drinks industry. There will also be two
lay trustees. Once they are appointed, it is the aim that the Trust
will be fully operational by the end of the year.
The alcohol industry has pledged £12 million to the charity
over the next three years to fund the Trust’s activities, including
promoting the charity’s consumer information website www.drinkaware.co.uk in advertising, at point of sale and on product labels.
The new Trust also has the support of the Scottish Executive,
the Welsh Assembly and the Northern Ireland Office who have all signed
the Memorandum.
Top of pageNHS 'hypocrites' invest in Diageo
The controversy about whether it is right or sensible for
public health bodies to form partnerships with the alcohol industry took
a particular turn in Scotland when NHS chiefs were branded
“irresponsible hypocrites” for investing charitable donations totalling
£250,000 in Diageo, the world’s leading premium drinks business, owning
such brands as Smirnoff vodka, Guinness, Gordon’s , Bailey’s and Johnnie
Walker whisky.
Brian Adam, the SNP MSP for Aberdeen North, said: “It’s
inappropriate and irresponsible for the health service to be bolstering
the drinks industry. Having shares in a company like Diageo is
hypocritical. There are plenty of other areas which can guarantee a
reasonable financial return without damaging society’s health.”
NHS Grampian has an endowment fund which consists of money
donated to the trust and left in wills. Cash from it has allowed the
trust to buy almost £30 million worth of shares in a host of firms,
including Shell and Vodafone.
News of the investment in Diageo coincided with reports of a
65 per cent rise in alcoholrelated liver disease in Grampian during the
past five years. The Scottish Executive is trying to curb the
binge-drinking culture as hospitals struggle to cope.
Alayne Jones, of the Alcohol Advisory and Counselling Service
in Aberdeen, also criticised the Diageo investment. “It is hypocritical.
But the problem can only be sorted by the government and Scottish
Executive,” she said. “When they stop raking in huge profits from
alcohol firms then other organisations might follow suit.”
NHS Grampian said the companies invested in by the endowment
fund were carefully selected. “We don’t see the investment as a conflict
of interests,” a spokeswoman said. “We have financial advisers who tell
us where to invest the money. But we will not invest in arms companies
or tobacco firms. But no-one has said that drinking responsibly is bad
for you. However, these investments are reviewed all the time so in the
future we may think differently about having money in Diageo.”
Tom Wood, who chairs the Scottish Association of Alcohol and
Drug Action teams, defended the investment decision. “We’re not
anti-alcohol per se,” he said. “We have got no issue with Diageo or
other drinks companies, although I might sometimes be critical of the
way they promote their drinks.”
Top of pageEvidence base for EU strategy released
‘Alcohol in Europe: a public health perspective’ sets out our
habits, harms and hopes over 400 pages, but how much will be included
in the strategy?
By Ben Baumberg, co-author of the report and Policy and Research Officer at the Institute of Alcohol Studies
Five years ago, the leaders of the countries that then made up
the EU signed a resolution on alcohol and young people, setting in
train a process that will ultimately give us the first EU strategy on
alcohol. We are not there yet – the strategy itself is due out this
autumn – but May 2006 saw at least one staging post along the way, with
the release of the evidence base on which the strategy will be based.
Entitled ‘Alcohol in Europe: a public health perspective’, the report
spells out the effects of alcohol in the 25 countries of Europe, and
what we can do to change these effects.
While the report has 10 (lengthy) chapters within its 400-plus
pages, there are two main themes running through it which have crucial
importance for the EU’s strategy – (1) what alcohol in Europe looks like
now, and (2) how we can make it look better in the years to come.
Where we are now
While alcoholic drinks have been around for millennia, alcohol
was only rarely seen as a social problem before medieval Europe. Aside
from more recent medical developments showing the health consequences of
drinking, the biggest change was a series of associated parts of
‘modernization’ – industrialization, improved communication links –
combined with the spread of knowledge about how to distil alcohol into
stronger spirits. The increase in drinking and drunkenness these allowed
was met by large ‘temperance’ movements across much of Europe in the
nineteenth and early twentieth centuries, campaigning against the ‘evils
of spirits’ before sometimes moving on to an opposition to all
alcoholic drinks.
While these temperance movements have today faded to
insignificance in most (but not all) EU countries, the modern era of
strong, available alcohol is still with us. The EU is the heaviest
drinking region in the world, drinking 11 litres of pure alcohol per
adult per year, although a minority of 55 million adults (15%) do
abstain. An estimated 23 million Europeans are dependent on alcohol (5%
men, 1% women), while 100 million (1 in 3) are estimated to
‘binge-drink’1 at least monthly in the 15 ‘old’ EU countries alone, and 1 in 6 adolescents aged 15-16 bingedrink1
at least three-times per month. Drinking levels and patterns differ
between different groups within the EU population, with lower
socioeconomic groups and particularly men more likely to be drunk or be
dependent on alcohol.
While changes in recent years are not as dramatic as those of
medieval times, the picture is still noticeably different in 2006 from
what it was in 1966 – or even in 1996. The ‘spirits drinking’ countries
of northern Europe now drink more beer than spirits, while the high
consuming ‘wine-drinking’ countries of southern Europe drink much less
wine and indeed, much less overall than they used to. While there is
still a clear north-to-south gradient in some aspects of drinking
behaviour (such as frequency of drinking), the differences are much less
than many still believe; Greece, for example, drinks more of its
alcohol in spirits than Norway, while recent data also suggests that
Spaniards drink more beer than wine. Adolescents and young adults have
moved even faster, with the cliché of French and British drinking belied
by UK young adults drinking more often with meals than their French
counterparts.
The down sides of this level of drinking are there for all of
us to see. The crime caused by alcohol leads to 33 billion Euros worth
of costs – partly in police time, but also in criminal damage and
needless security guards – while 17bn Euros is spent on alcohol-caused
health care across the EU, and 60bn Euros worth of potential economic
contributions are lost. This is aside from the lowered quality of life
for addicts, and the associated pain and suffering of family members
(which itself can be valued at 68bn Euros), let alone the pain and
suffering of the victims of alcohol attributable crime (valued at 9-
37bn Euros).
Most importantly of all, alcohol is responsible for 195,000
deaths each year. However, this also takes us into the tricky territory
of the epidemiology of old age, given the 160,000 deaths delayed, which
can be easily misinterpreted: It does not make sense to say that “the
full toll of alcohol is 40,000 deaths,” by setting the deaths delayed
against the deaths caused. Most of the deaths delayed occur in a
different age group (the very old) from most of the deaths caused (youth
and middle-age), and for different types of drinkers (frequent light
drinkers rather than heavy and binge-drinkers).
The number of deaths delayed is very likely to be an
over-estimate, given three substantial errors in the current estimates.
Firstly, the epidemiological studies on alcohol often bundle former
drinkers in with consistent abstainers, as Kaye Fillmore has recently
shown. Secondly, the studies forget that people’s drinking changes over
time – a recent British Regional Heart Study paper shows that this error
was the difference between drinkers having a lower risk of death than
abstainers with the error vs. a higher risk when it was taken out.
Finally, heart disease deaths at older ages are highly over-estimated,
with many coroners using ‘heart disease’ as a code for both uncertainty
or general organ failures.
It is probably more sensible, then, to focus on the more
accurate estimate of 115,000 deaths caused up to the age of 70, and the
more robust estimate that alcohol is the third most important cause of
premature death and disability in the EU – ahead of factors such as
illegal drugs, obesity/overweight and lack of fresh fruit and
vegetables.
The EU’s political engagement with alcohol has been focused on
young people, and it is they that are the group that is most at risk.
Alcohol isthe single biggest cause of premature death in young adults –
responsible for 1 in 10 premature female deaths at this age, and an
appaling 1 in 4 male deaths. What is more, the trend in slightly younger
adolescents since the mid-1990s has been for increased
binge-drinking,and while this has stabilised more recently, this
suggests that the future toll is even greater than the current one.
Alcohol is not a simple substance, and we must get used to its
nuances and complexities –causing deaths while saving lives, inflicting
pain while producing pleasure. Yet the overwhelming image from a health
perspective is the damage that alcohol causes in the EU, touching on
nearly every aspect of human life. The complexities, and the need for
action, raise challenges as to the best future action on alcohol in
Europe, which takes us into the rest of the report.
Reducing harm in Europe
At its simplest, there are three things that we need to know
before deciding on a European alcohol strategy. The first is what the
law allows us to do. The second is which policies work in reducing harm.
And for each policy that works, the third is considering the costs of
that policy compared to its benefits.While the second area is the one
most people think of when they hear the siren call of ‘evidence based
policy’, the policy debate can benefit from the research contribution in
all three areas.
An interest in international law is not what makes most people
passionate about alcohol and addiction issues. It only becomes
important when it stops health policy makers adopting effective policies
– which it does, but not as often as is sometimes insinuated. The world
trade law of the WTO sets certain conditions for health policies, for
example, but the WTO have also demonstrated that they will prioritise
health over trade when these conditions are met. Similarly, the European
Court of Justice has upheld trade-distorting alcohol advertising
restrictions, because “it is in fact undeniable that advertising acts as
an encouragement to consumption” (in their words) and that Member
States can decide on how much they want to protect human health.
More importantly, the treaties signed by nationally elected
leaders – which make up ‘EU law’ – do not give the EU the powers to make
policies for health unless they are a by product of creating an
efficient EU market. While this means that an EU strategy can only ever
encourage certain policies (such as sensible licensing restrictions),
there are other areas where EU legislation can help the smooth runnings
of the market, such as for drinks health warnings or advertising.
While not the only essential information, reviewing what works
in reducing alcoholrelated harm is perhaps the most important basis for
action –otherwise all our goodwill and efforts will be wasted. This is
sensitive, however, as finding that a policy ‘does not work’ suggests
that those of us working in that area have been wasting our time…which
is why we must be clear that school-based education is neither an
effective single policy nor a futile effort. Reviews of educational
programmes show that the overall effect is either small or zero – but
given that education on alcohol is both a human right and potentially
lays the ground for other interventions, we have no excuse for not
trying to make that small effect as large as possible (see page 257 of
the report for a guide to improving alcohol education).
Other policies that generally work well include unrestricted
breat testing, lowered blood alcohol concentration levels for drivers
(and even lower ones for young drivers), regulating the market (e.g.
licences, taxes) and brief advice to heavy drinkers (e.g. by GPs).
Policies that generally don’t work well include designated driver
campaigns and advertising self regulation. Some policies have research
suggesting that they will have some effect, even if the evidence isn’t
conclusive – such as for advertising restrictions. And finally, we must
remember that policies are not ‘magic buttons’ to be pressed and
forgotten about… their effectiveness depends on what happens around
them – mass media campaigns work well if they support specific
interventions, for example, while raising the minimum age for buying
alcohol will not work if it is not properly enforced.
No researcher should fool themself that policy makers will
simply adopt the most effective policies – and nor should they, given
the number of considerations that matter for making and implementing any
policy in a democracy. But each of these other considerations can be
better understood from the research, including the economic costs of
public health policies. Alcohol is clearly an important economic
commodity, with the EU playing a central role in the global alcohol
market, and several hundred thousand jobs linked to it at the very
least. However, most discussions of this miss an obvious point – if
people spend less money on alcohol, they have more money to spend on
other goods. This means that for every job lost producing or selling
alcohol – and the evidence suggests the link with consumption levels may
not be as strong as might be thought – others will be generated
elsewhere in the economy. More sophisticated modelling in the tobacco
field suggests that public health policies could even lead to an
increased number of jobs, depending on exactly how people spend the
money they save from less alcohol. In otherwords, public health policies
on alcohol are unlikely to have any significant impact on the European
economy – and may even slightly help it, given the reduction in the
considerable social costs of alcohol.
So what happens now?
Put in the starkest possible terms, the report shows that
alcohol is a major public health problem, but that we know what to do to
reduce this level of harm. This in itself is unlikely to be surprising
to most readers of Alcohol Alert; but for the process of making policy
in the EU it is a crucial basis from which to proceed. What is now left
to do is the messy business of policy debate – which is less a matter of
evidence than one of argument, persuasion and passion. We are now at a
stage rich in potential; what remains to be seen is whether we look back
at this moment with regret at how much difference we failed to make,
or whether we look back with pride that the first EU strategy on alcohol
genuinely changed Europe for the better.
Reference
1 Defined as 5+ ‘standard drinks’ on a single occasion.
The problems of defining binge-drinking are discussed further in
chapters 1 and 4 of the report.
Top of page'Beer crazy' World Cup
Before the start of the World Cup in June, there was
widespread anxiety that the tournament could risk resulting in a ‘binge
drinking own goal’. Previous football events such as Euro 1996, and the
1998 World Cup, saw many episodes of violence and rioting, as a result
of mass confrontations of inebriated fans, and it was feared that a
possible upsurge in alcohol related crime and disorder was likely to
occur as a result of the 2006 World Cup, especially as the timing of the
matches coincided with usual drinking hours – contrary to the previous
World Cup held in Japan in 2002.
The timing of the tournament was thus seen as potentially
problematic. On the six month anniversary of the implementation of the
legislation, shadow secretary of state for Culture, Media and Sport,
Hugo Swire said: “It is too early to judge the full impact of the of the
extended opening hours, but the summer, and particularly the World Cup,
will be the real test of what effect the changes will have”
How big a test of the new licensing regime and its longer
trading hours the World Cup would provide was, however, unclear, as the
matches were all scheduled to be played at times when the pubs would
have been open in any case under the old regime.
Impact of Licensing Act 2003
Independently of the World Cup, the impact of the new Licensing
Act is uncertain. For one thing, the effects of the nationwide police
enforcement campaigns coinciding with the introduction of the Act have
complicated the picture. This has not prevented the Government and the
licensed trade from claiming that early crime figures show the new Act
is succeeding as there does not appear to have been the upsurge in crime
that some in the media predicted.
One body clearly unconvinced by the Government’s presentation
of the crime figures was the Association of Chief Police Officers. Chris
Allison, ACPO lead on Licensing and Commander in the Metropolitan
Police Service, said: “ACPO has consistently welcomed much of the new
Licensing Act and the Police Service is already making use of the new
powers that are available to it. We fully agree with the Minister that
is far too early to say whether the extension to the licensing hours has
had a positive or negative impact on crime and disorder.”
The figures quoted are not comparing like with like and do not
take account of the fact that the Home Office gave £2.5 million in
additional funding for Police and Local Authority enforcement activity
during the period 14th November 2005 through to the 24th December 2006.
ACPO has consistently said that it will be at least a year before we can
measure the true impact of the act and we remain firmly of that view.
ACPO is working closely with the Government and other key
partners on the review of the Guidance in an attempt to deal with areas
of concern that have become apparent since implementation of the Act.
Beer Bonanza
With an estimated 815 million pints of beer sold during the
World Cup, which represents an increase in sales of 60 million pints
compared with the same period last year, the licensed trade have
unquestionably come out as the true winners of the tournament. The
British Beer and Pub Association (BBPA) reported that “the feel good
factor as well as convenient kick off times helped many pubs boost sales
and attract a large clientele”. Before the start of the event, the
British Retail Consortium predicted that for every week England remained
in the tournament, an extra £124 million would be spent on food and
drink, a figure mostly comprising beer, but also wines and spirits,
snacks and confectionery. Evidently, opportunities to maximise profits
during this time were welcomed by retailers beyond the licensed trade,
and sales of football paraphernalia – ranging from inflatable hands to
large screen televisions – soared.
Benefits for the alcohol beverage industry have spanned beyond
the UK, however, as Anheuser-Busch, the brewer of Budweiser, and
official sponsor of the 2006 FIFA World Cup, has just announced that it
will retain its sponsor position until 2014. A spokesperson for the
brand claimed: “In every corner of the World, football fans share a
passion for their favourite teams and players, and they enjoy watching
the games with a cold beer”.
This recent announcement has merely sparked up the heated
debate surrounding the sponsorship of sports events by alcoholic brands,
a marketing strategy believed to be particularly effective amongst
young people. The US based Centre for Science in the Public Interest has
circulated a “Global Resolution to End Alcohol Promotion in World Cup
Events”, seeking the endorsement of concerned organisations and
government officials.
It is hoped that this will represent a first step towards
diminishing the influence of the alcohol beverage industry, whose
interests, certainly in the UK, continue to be, to a large extent,
protected by the Government. Indeed, this ambiguous ‘entente’ has been
well documented by the Institute of Alcohol Studies and others and the
implementation of the Licensing Act 2003 merely served to reinforce the
drinks industry’s position as the key stakeholder.
Before the World Cup, the BBPA consented to an ‘action plan’
with Government Ministers, in an effort to encourage corporate social
responsibility. The proposed aim of this was to “target sales to under
18s, continue to improve drinks retailing standards and deliver
responsible trading practices over the World Cupand summer period” (BBPA
Press Release 16 May 2006). However, this pledge appears to be at odds
with a comment made by a BBPA spokesman, who claimed: “ If we make it to
the final the whole country will go beer crazy in celebration” (The
Publican 8 June 2006). He also suggested further measures would be
implemented within licensed premises in order to create a safe
environment for the fans, including ‘enhanced security on the doors
where needed, entertainment after the matches so people don’t all leave
at once, calming music played, and food promotions to make sure
customers are eating as well as drinking’.
In the aftermath of the tournament, Mark Hastings from BBPA
applauded licensees for the successful management of the event: “Pubs
once again proved they are the home of responsible drinking and the
ideal place to experience the roller coaster ride that is the inevitable
part of following England in the World Cup”.
The national team’s opening match against Paraguay could
perhaps be best described as such, given the violent fights that broke
out during the match, resulting in outdoor television screens being
banned in London and Liverpool. Although no exact figures of arrests for
alcohol related offences during this period have been released in the
UK, a recent poll conducted in five European countries suggests that
England is widely considered as having the worst behaved and most
troublesome fans,predominantly as a result of excessive alcohol
consumption. However, it was also reported that of the 9000 fans
arrested in Germany, 810 cases involved England fans, most of which were
in fact ‘preventive arrests’; the cooperation between police forces in
Germany has been highly praised, and the British Police successfully
managed to keep at bay the 3500 known hooligans prevented from entering
the country.
Nonetheless, the impact of the tournament in terms of alcohol
related crime and disorder still remains unclear, as the results of the
4th Alcohol Misuse Enforcement Campaign (AMEC), which ran one month
prior to the event are still unknown. Indeed, the £2.5 million
nationwide campaign,launched by the Government and the Association of
Chief Police Officers (ACPO), involved all 43 police forces in England
and Wales, and was expected to set standards of ‘acceptable behaviour’
across British town and city centres. The campaign was the second to run
since the implementation of the Licensing Act 2003, in November 2005;
the legislation granted the police additional powers of enforcement to
combat alcohol related crime and disorder, by enabling them to take firm
action against shops, stores, pubs and clubs selling alcohol to under
18’s, as well as bars and clubs that actively promote excessive
drinking. Despite these additional powers of enforcement, it is
unlikely that the majority of licensed premises will have been suddenly
transformed into safe havens of relaxed entertainment.
Information or data concerning local police enforcement
initiatives remain dispersed and largely anecdotal. Recently published
Home Office Statistics from the 2006 Crime Survey for England and Wales,
allegedly show that there has been ‘no indication of a rise in the
overall level of offence or a shift in the timing of offences as a
result in the changes in opening hours of licensed premises’. These
figures have already been embraced by the recently appointed Licensing
Minister, Shaun Woodward, who echoed this view by claiming that the new
regime had led to ‘no discernable increase in alcohol related crime and
disorder since November’. It is yet too early to draw conclusions on the
impact of the World Cup during this transitional period; as expressed
before, the effects of the legislation are likely to be cumulative, and
any objective evaluation should account for the exceptional
circumstances that are the combination of major police enforcement
campaigns alongside an international football tournament.
Emilie Rapley
Policy and Research Officer
at the Institute of Alcohol Studies
Top of pageDiscriminating against the former drinker
By Jonathan Goodliffe
Does this kind of discrimination exist?
People who have a history of problem drinking usually
will not want to tell prospective employers about it. If they still have
the problem they may want to cover it up. If they have a reasonable
record of sobriety they may also want to cover it up in case they might
be the victim of ignorant prejudice. There is no legal duty to make an
unsolicited disclosure of these matters, although it is sometimes best
to do so.
Some professions, such as the law and medicine, have had
special difficulties facing up to problem drinking among their
membership. On the one hand people may be reluctant to take effective
action to help a colleague when his drinking is causing serious
problems. On the other hand, after he has had appropriate treatment and
got sober he may find it difficult to re-establish his career because of
the profession’s reluctance to trust him with a responsible job. It
may, of course, be justified. It takes time to rebuild professional
confidence and competence after long term addiction.
Medical screening
Nowadays an employer may ask a prospective employee to complete a
questionnaire to establish whether he is medically fit to carry out his
job. If it discloses problematic conditions a medical report may be
asked for. Sometimes the applicant will be referred straight to a doctor
or organisation providing a screening service.
Any information provided by the candidate in answer to the
questionnaire and the contents of the doctor’s report will usually
qualify as “sensitive personal data” under the Data Protection Act 1998
and must be “fairly processed”. Practical guidance as to how employers
should handle this data is given on the web site of the Information
Commissioner.
Medical screening can, however, sometimes be unpleasant,
intrusive and disproportionate. The questionnaire may require the
applicant to give information concerning medical conditions for the
whole of his life time, making compliance particularly onerous for
people in the later stages of their careers. The applicant may also be
asked questions about the health history of his family, whether living or
dead. Sometimes a medical screening may last several hours and amount
to a full medical examination. It is questionable whether practices such
as these amount to the fair and lawful processing of sensitive personal
data as required by the 1998 Act. They may also affect the usefulness
of test results for specific functions such as blood pressure.
The medical approach
Bissell & Haberman commented (‘Alcoholism in the
Professions’ (1984)) that “alcoholism is the most common, serious
illness likely to affect a professional in the first fifteen years after
completing graduate education”. Yet aspiring doctors receive very
little training on the health effects of alcohol (in contrast to, for
instance, more respectable common conditions such as hypertension and
depression). They may acquire the necessary know-how as they go along in
their careers, but often they do not.
The 1998 Act defines “processing of data” as including
“retrieval, consultation or use of the information or data”. Arguably
only someone with appropriate qualifications and training can “fairly
process” medical data in order to express an informed view on whether
the applicant’s past drinking is likely to cause problems in the future.
A qualification as a general medical practitioner on its own may be
insufficient. Some prospective employers will make an initial review of
the answers to the questionnaire and then, if a problematical medical
condition is revealed, refer to an appropriate specialist. This seems
the most sensible practice.
A right not to be discriminated against?
Once the prospective employer has received the medical report
and complied with its duties under the 1998 Act, there is nothing in law
preventing it from discriminating against people with a record of
addiction, whether or not they are still drinking or using. So in theory
the employer can apply the concept of alcoholism as an incurable
disease to its logical conclusion by refusing to employ someone who has,
for instance, been clean and sober for 5 years.
This contrasts with the position under the Americans with
Disabilities Act, where addiction counts as a disability. The US Supreme
Court has, however, construed the duty not to discriminate narrowly. In
Raytheon v Hernandez (2003) an employee had a drug test at work, tested
positive for cocaine and was dismissed. He subsequently got successful
treatment for his alcohol and drug addiction, and applied to be
re-employed. The Court held that the employer was entitled to turn him
down in reliance on its policy of not reemploying staff who had been
guilty of workplace misconduct.
In the UK where the prospective employee’s health record
includes, for instance, a history of depression as well as addiction
(the two conditions are often co-morbid) the depression may count as a
“disability” and trigger rights under the Disability Discrimination Act
1995. The Employment Appeal Tribunal has ruled that this applies even
where the depression is caused by the drinking or drug taking.
Article 26 of the International Covenant on Civil and
Political Rights requires that “the law shall prohibit any
discrimination and guarantee to all persons equal and effective
protection against discrimination on any ground such as race, colour,
sex, language, religion, political opinion, national or social origin,
property, birth or other status”. “Other status” might include a record
of medical conditions. International instruments such as the Covenant,
which do not have direct legal effect, may nonetheless influence the
development of domestic law.
Discrimination on the ground of the applicant’s opinions
A sub-species of discrimination is sometimes applied against
professionals in the addictions field. Within that field widely
differing opinions on the cause and nature of alcohol and drug problems
are held. Many people who have had addiction problems regard themselves
as still suffering from an incurable illness years after they have
become clean and sober.
The disease concept of alcoholism is, however, a minority view
in the field of the addictions, particularly in the UK. So if, for
instance, a “recovering alcoholic” applies for a job with an
organisation which follows alternative theories, his belief as to the
nature of his condition may be regarded as inconsistent with the
approach to treatment adopted by that organisation. Alternatively his
approach may be regarded as too strongly influenced by his personal
experience and thus lacking in scientific rigour.
Sometimes this may operate in reverse, when someone who does
not believe in the disease concept applies for a job in a treatment
centre applying the “Minnesota Model” of treatment, which endorses that
disease concept. He too may be rejected on the grounds of his beliefs.
If a person applying for a job in the field of addictions is
doctrinaire in his beliefs and entirely rejects the value of alternative
theories and approaches, he may well be unsuitable. Sometimes, on the
other hand, it is the employer’s attitude which is problematical and
doctrinaire. But is there anything necessarily inconsistent, for
instance, between a belief in the disease concept of alcoholism and a
recognition of the value of behavioural therapies? Theories of addiction,
moreover, have much common ground as well as areas of disagreement.
Discrimination in this form may, when carried out by a“core”
public authority, such as an NHS trust or a local authority, contravene
the Human Rights Act 1998. Article 10 of the European Convention on
Human Rights, to which the 1998 gives limited effect, provides: “Everyone
has the right to freedom of expression.This right shall include freedom
to hold opinions and to receive and impart information and ideas without
interference by public authority”.
After employment has begun
When the employee has been taken on with knowledge of his
medical record further issues arise. Should the data remain within the
personnel department or should it be communicated to the employee’s line
manager? In most cases the line manager will not need to know, but in
some cases it may be desirable and appropriate that he should. The fair
processing of this data will, however, surely require that the employee
should be consulted at every stage where the data is communicated or
used in any way, so that only those who need to know get to know and the
data is not used unfairly behind the employee’s back.
If the line manager does get to know of the employee’s health
record then any subsequent use of it will amount to “processing”. The
1998 Act requires that the processing must be fair. If, for instance,
the data influences decisions as to whether the employee should be
promoted, given additional or different responsibilities, or made
redundant, the employee must generally be consulted. Moreover the data
protection principles require that data should be kept up to date,
sousing the outcome of a pre-employment screening several years after the
employment has started is likely to be problematical.
Information about a person’s drinking history and
the application of the label “alcoholic” to him is sensitive for a number
of reasons. First, the label is often particularly damaging in career
terms. Secondly, many people are uncomfortable discussing the subject.
If they have a concern about an employee’s drinking past this may
influence their decision-making without their being able or willing to
articulate those concerns to the employee. Thirdly, because the
opportunities for discussing this “unmentionable” subject are limited,
mistakes and snap judgments are more likely to be arrived at than in
relation to other management issues and medical conditions.
At the same time there is a danger of the employee himself
imagining discrimination and unfair treatment when the reality may be
otherwise. Indeed his own depressive tendencies may suggest that he is
being treated unfairly when that is not the case. On other occasions his
concerns may have a real foundation but be difficult to prove. They may
provoke denial and righteous indignation if raised with the employer.
Data not caught by the 1998 Act
Sometimes, of course, the employer’s knowledge of the
applicant’s problematic drinking derives not from the medical screening
but from being tipped off over the telephone when taking up references
or otherwise by word of mouth (particularly within close-knit
professions or specialities). Another possibility may be that the
applicant himself makes a full disclosure informally at interview. The
disclosure may not be recorded in writing but will be remembered by
those to whom it is made.
A recent decision by the Court of Appeal suggests that data in
this form may not be caught by the 1998 Act and thus may not be subject
to the fair processing requirement, unless, perhaps, it is used in
conjunction with data which is caught by the Act.
Enforcement
Damages or compensation can be claimed for breaches of rights
under the Human Rights Act 1998, the Disability Discrimination Act 1995
and the Data Protection Act 1998. So, for instance, a job applicant
might be subjected to a poorly conducted medical screening involving
unfair processing of his sensitive personal data. It might result in his
being refused the job on medical grounds. In that event he might be in a
position to claim substantial compensation against the employer under
section 13(1) of the 1998 Act. It would be a defence, however, to show
that even if the screening had been properly conducted the result would
have been the same. And if he is offered the job and his only damage,
therefore, is the distress arising from the handling of the screening he
cannot sue (section 13(2)).
Suppose he starts the job and years later does not get a
promotion because of concerns about his addiction record. Those concerns
are not addressed in conformity with the 1998 Act. If he can prove
this he should recover substantial compensation.
He may also want, at that point, to walk out of the job. Can
he say that the same behaviour resulting in the contravention of the
1998 Act also amounts to a sufficient breach of his employment contract
as to justify him treating the contract of employment as at an end and
claiming damages for unfair dismissal? This proposition does not yet
seem to have arisen in the courts. If it does arise the outcome is
likely to depend at least partly on the wording of his contract.
Jonathan Goodliffe is a solicitor who writes from time to time
on alcohol and the law. A fuller version of this article is available
on his web site at www.articles.jgoodliffe.co.uk/ articles/discr.htm
Discrimination against people with alcohol problems
Evidence that people with alcohol dependence often face
discrimination from individuals and institutions was found by a German
survey of public attitudes. It appeared that public attitudes and
beliefs about alcohol dependence are more negative than those about
diseases such as schizophrenia, depression, Alzheimer’s disease,
rheumatism, diabetes, AIDS, myocardial infarction, and cancer. These
attitudes affected public preferences for resource allocation.
In the survey:
- Most (85%) thought alcohol dependence, more than any of the other diseases, was self-inflicted.
- More respondents (78%) said they would ‘distance’
themselves from people with alcohol dependence more than from people
with other diseases.
- A little over half believed that alcohol dependence was severe, but only 30% felt it could be treated effectively.
- Just 4% thought they personally were at risk for alcohol dependence.
- Only 7% of respondents said they would spare alcohol treatment from budget cuts if resources were scarce.
Reference:
Schomerus G, Matschinger H, Angermeyer MC. Alcoholism:
illness beliefs and resource allocation preferences of the public. Drug
Alcohol Depend. 2006;82(3):204–210
Leading charities call for urgent Government action for UK’s 1.3million children affected by parental alcohol problems
A coalition of eleven prominent charities and
academics led by Turning Point has called for urgent action to address
the misery faced by one in eleven children in the UK who live with
parents with alcohol problems. Turning Point’s ‘Bottling it Up’
campaign, launched earlier this year, found that 1.3m children in the UK
are affected by parental alcohol problems.
In a letter which was delivered to the Children’s minister,
Beverley Hughes MP, the coalition called on the Government to launch a
national inquiry to examine the impact of parental alcohol problems and
to develop new services for children and parents and start rebuilding
the lives of those affected.
The letter was signed by Turning Point, Adfam, Alcohol
Concern, Children's Society, Barnardos, NACOA (National Association for
Children of Alcoholics), Bath University, Brunel University, Stella
Project, Princess Royal Trust for Carers and Drugscope.
Turning Point’s ‘Bottling it Up’ report, which was
published in May 2006, reveals the devastating impact of alcohol on
children and their families:
- Children suffer from behavioural, emotional and
school-related problems. They worry about the harm to their parent’s
health, find it difficult to make friends and often have to take on the
burden of looking after siblings, parents and the home. They are also
more likely to express anger through anti-social behaviour and develop
alcohol problems themselves.
- Parents who misuse alcohol struggle to show their
children enough affection and care. They can be emotionally distant from
them and caring responsibilities may be left unattended.
- Overall, the whole of family life is disrupted and
chaotic, they become isolated from other family members and the
community and conflict and violence are more common.
Turning Point’s Chief Executive, Lord Victor Adebowale, said:
“The Government cannot ignore the children and families
affected by alcohol misuse any longer. We are dealing with a major
social and public health challenge which devastates hundreds of
thousands of lives. The strength of support from other leading
organisations and from the general public is giving the profile of this
issue a great boost. We hope to see imminent commitment from the
Government to assess the scale of the impact of parental alcohol misuse
and begin to work with agencies to find new ways to support families.”
Top of pageA theology of the use and misuse of alcohol
Debates about measures to tackle alcohol problems usually
touch sooner or later on questions of rights and responsibilities. Are
people who get drunk exercising their legitimate rights or behaving
irresponsibly? What of those who become dependent on alcohol? Can they
be held to account for what they do, or do not do, while they are under
the influence?
Here Professor Christopher Cook introduces the themes
explored in his new book ‘Alcohol, Addiction & Christian Ethics’.
Professor Cook, as well as being a psychiatrist with a special interest
in alcohol problems and a scientific advisor to the Institute of Alcohol
Studies, is also an ordained minister of the Church of England.
“Do you not know that wrongdoers will not inherit the
kingdom of God? Do not be deceived! Fornicators, idolaters, adulterers,
male prostitutes, sodomites, thieves, the greedy, drunkards, revellers,
robbers— none of these will inherit the kingdom of God.”1
St Paul seemed pretty clear that some things were simply
wrong. The lists of vices which he employed in his letters were probably
intended to be uncontroversial and so to elicit immediate agreement
from his readers. However, times change and some items in his lists now
appear much more debatable than they were two millennia ago. They are
now interpreted differently, and some attract more public moral
opprobrium than others. It is, of course, those statements that are now
controversial which attract much public debate. However, having now
spent 20 years working with people with alcohol and other drug problems,
it is St Paul’s inclusion of drunkenness in a number of these lists2 which has increasingly interested me over recent years.
Moderate alcohol consumption is seen as a normal part of
contemporary western lifestyle. But even amongst those who do consider
themselves to be Christians, the matter is not at all straightforward.
Jesus was apparently accused by his opponents of being a drunkard (see
eg Luke 7:34) and on this basis I have heard it suggested in a Sunday
sermon that Jesus must himself have been drunk at times – a suggestion
which attracted great controversy after the service!
Of course, drunkenness is not the only matter of concern.
Whilst alcohol is associated with violence, family disharmony and other
forms of antisocial behaviour, alcohol causes or is associated with a
wide and diverse range of problems – social, psychological and
biological – which may or may not be associated with overt drunkenness.
Whilst the misuse of alcohol is recognised as a matter for social
concern, our enjoyment of alcohol makes us ambivalent about these
associated problems.
When it comes to drunkenness, we might still expect the
majority of those who read Paul’s letters today to express disapproval.
Amongst those who read the New Testament rarely or not at all, there
might be much greater debate. While many still disapprove of
drunkenness, it is seen by many others as being another way of having
fun, of relaxing, and of getting away from the stresses and problems of
today’s world.
It might well be that there is greater agreement about the
ethics of drinking very large amounts of alcohol, or about the morality
of very serious alcohol related problems. Slight intoxication at home
with friends is one thing, but causing a death by drunken driving is
quite another. But even amongst those who do consider themselves to be
Christians, the matter is not at all straight forward.
Whilst there is much truth in this, it does not answer
questions about how much is “too much” or about how likely and how
serious problems have to be before they become ethically unacceptable
consequences of drinking alcohol. Furthermore, it does not get to the
heart of an important way in which our view of the whole subject has
changed dramatically since the time of St Paul.
Whatever controversies about drinking and drunkenness there
might have been, things changed most significantly in the 19th Century
as the concept of “chronic inebriety” was medicalised and increasingly
subjected to scientific scrutiny. Prior to this time, it is probably
fair to say that drunkenness was not seen very differently from any of
the other kinds of vice in St Paul’s lists. Christendom knew that
drunkenness, like adultery and theft, was wrong. People shouldn’t do
these things – but they did. All people were sinful and all needed
forgiveness. All were called to amend their lives. Drunkenness was one
thing amongst many for which people needed to repent. But the increasing
medicalisation of the problem, concurrent with the much wider effects
of the enlightenment on public discourse, changed this forever.
Drunkenness, and other alcohol-related problems, came to be viewed not
so much as primarily ethical issues, and certainly not as theological
matters but rather as concerns of public health, public policy and
public order.
Whilst the majority of people who get drunk are not in any
commonly accepted sense “alcoholics”, perceptions of drunkenness have
also been influenced by the development of the concept of “addiction”.
This concept, extended to the use of a variety of other drugs and also
to various behaviours in which no extrinsic chemical substance is
involved at all, has been notoriously elusive of a universally agreed
definition. However, it is now scientifically encapsulated in the
concept of the dependence syndrome. The alcohol dependent person is
understood as suffering from a bio-psycho-social disorder which
importantly changes and constrains the usual experience of freedom of
choice about drinking behaviour. The alcohol dependent person
experiences withdrawal symptoms when they stop drinking and they
experience a subjective “compulsion” to continue drinking. Because we
usually do not consider people to be morally responsible for acts about
which they have no freedom of volition, the concept of addiction
or dependence introduces an important change in the way that drunkenness –
or at least chronic drunkenness or “alcoholism” – is commonly viewed.
To the extent that the alcohol dependent person is the subject of this
“compulsion” they are not free moral agents, and their responsibility
may be understood as diminished or removed.
Paradoxically, and perhaps partly because the individual is
seen as responsible for their plight, the concept of addiction has not
always led to moral sympathy for the addict. Perhaps this is partly
because the individual is seen as responsible for their plight. If they
hadn’t drunk too much (or perhaps if they hadn’t drunk at all) they
would never have become alcohol dependent. However, I think that this
lack of sympathy also concerns the emphasis that is placed upon the
difference that is perceived between the addict or alcoholic and other
people. Instead of being sinful as we are all sinful, the addict comes
to be viewed as sinful in a different kind of way, or to a greater
degree. In fact, the so called “moral model” has become the subject of
much criticism in scientific and medical circles. The more enlightened
view is to understand the addict as sick rather than sinful. I would
suggest that this view owes more to the enlightenment than to Christian
tradition. It is a morality which singles out the other person as
different from self, rather than one which understands all human beings
as sinful, including oneself. It is a morality which ignores or
overlooks one’s own failings and draws attention to those of someone
else.
Unfortunately, scientific and theological debate no longer
take place in the same forum. Matters of religion are largely relegated
by secular society to the private domain. As areas of academic discourse
theology and science are discussed in completely different journals,
conferences and common rooms, as though they had little to do with each
other. The implication is clearly that theology is no longer considered
necessary to a proper understanding of matters such as addiction and
drunkenness. And yet, spirituality – largely as a result of the work of
Alcoholics Anonymous and its sister organisations – is increasingly
considered to be vital to provision of holistic treatment, and addictive
disorders are viewed by many as being a spiritual problem. Theology has
thus been replaced by science, and religion by spirituality. Does
Christianity (or any of the world’s other major faith traditions) any
longer have anything important to contribute to the debate?
It is my contention that Christian theology does have an
important contribution to make to an understanding of addictive
disorders – and particularly to an understanding of the ethics of
alcohol use and misuse.
However, this contribution is best appreciated not by a narrow
focus on scriptural texts making explicit reference to drunkenness, but
rather by broader theological reflection on the phenomenon of alcohol
dependence and addiction. In my book, Alcohol, Addiction and Christian
Ethics, I have taken two Christian texts for detailed study, on the
basis that they appear to reflect a phenomenologically similar experience
to that of the subjective compulsion of alcohol dependence. The first
of these is St Paul’s discussion of the divided self in Romans 7, and
the second is Book 8 of the Confessions of St Augustine of Hippo, both
texts which reflect an understanding of the ways in which individuals
can struggle within themselves in respect of behaviour to which they
aspire.
In Romans 7 (vv15-19), for example, St Paul writes:
“I do not understand my own actions. For I do not do what I
want, but I do the very thing I hate. Now if I do what I do not want, I
agree that the law is good. But in fact it is no longer I that do it,
but sin that dwells within me. For I know that nothing good dwells
within me, that is, in my flesh. …….I can will what is right, but I
cannot do it. For I do not do the good I want, but the evil I do not
want is what I do.”
And compare this with the experience of an alcohol dependent
woman, married to an alcohol dependent husband, whose story was included
in the “Big book” of Alcoholics
Anonymous:
“George tried many times to go on the wagon. If I had been
sincere in what I thought I wanted more than anything else in life – a
sober husband and a happy, contented home – I would have gone on the
wagon with him. I did try, for a day or two, but something always would
come up that would throw me.
“It would be a little thing; the rugs being crooked, or
any silly little thing that I’d think was wrong, and off I’d go,
drinking…… I reached a stage where I couldn’t go into my apartment
without a drink. It didn’t bother me anymore whether George was
drinking or not. I had to have liquor. Sometimes I would lie on the
bathroom floor, deathly sick, praying I would die, and praying to God as
I always had prayed to Him when I was drinking: “Dear God, get me out
of this one and I’ll never do it again.” And then I’d say, “God, don’t
pay any attention to me. You know I’ll do it tomorrow, the very same
thing.””3
If we are honest, I think that we all have these kinds of
experiences. It may not be quite as dramatic, and the implications might
not be quite as serious, but we all find ourselves doing things that we
know we shouldn’t do and then regretting it. We struggle to stop
destructive patterns of behaviour and find ourselves doing the very
things that we have decided in our own minds we will not do. We eat more
than we know we need; even to the point of prejudicing our own health.
We find ourselves sucked back in to particular arguments, or destructive
relationships, when we have promised ourselves that we wont go there
again. We spend time watching television when we know that work or
family commitments require urgent attention. We spend money on things
that we know we can’t afford. And so the examples go on – often known
only to ourselves or to those closest to us – but all representing the
same internal struggle to be the kinds of people that we desperately
want ourselves to be.
Looked at in this way, it might be argued that we all have a
subjective compulsion to do things that we don’t want to do. Perhaps it
is even a characteristically human experience to have such internal
struggles and to be aware of having them. It certainly is not unique to
the experience of the addict or alcoholic. And even if the atheist or
humanist might wish to choose a different language, these struggles have
been the concern of theology for many centuries before they came to be a
topic of scientific interest. For St Paul, the solution was clear:
“Wretched man that I am! Who will rescue me from this body of death? Thanks be to God through Jesus Christ our Lord!”4
He understood the grace of God in Jesus Christ as being the
only way to become free from this struggle – and Augustine of Hippo went
on to write in similar vein about the necessity of this grace to set us
free from the struggle set up by the division of the human will against
itself. A post-modern culture is much less happy to
accept the particularity of this solution, but Alcoholics
Anonymous adopted a not dissimilar, albeit not so Christocentric,
understanding in the 2nd of its 12 Steps:
“We…. came to believe that a
Power greater than ourselves could
restore us to sanity.”
The necessity of a “Higher Power”, whatever it might be, as a
component of a spiritual recovery from alcoholism was to become
fundamental to the philosophy of Alcoholics Anonymous, as detailed in
the second of its 12 Steps:
“We…..came to believe that a Power greater than ourselves could restore us to sanity.”
For St Paul and St Augustine, faith in Christ was the only pathway to freedom from the divided self.
Many men and women have found freedom from addiction through
spiritual and religious experiences – but many continue to struggle
despite their faith. On the other hand, secular programmes of treatment
with no spiritual or religious component at all continue to benefit
many. We must, therefore, be wary of proposing simple solutions such as
those that require Christian faith, or exclude such faith, as a means of
recovery from addiction. However, in one form or another, it would
appear that grace is an important component of recovery, and grace is a
theological concept. To separate theology and science in discussion
about such matters is, therefore, I would argue, at least a highly
impoverishing approach to a proper understanding of the nature of
addiction.
To return to the broader problems in society of alcohol use
and misuse, I would propose that theology still has important things to
say. To imagine that the man or woman with a drinking problem is either
the victim of their environment or the agent of their own catastrophe is
equally simplistic. We are all both agents and victims, and Western
culture fosters various kinds of dependence in various ways. Whilst we
need to analyse such systems as matters of public health and public
policy, theological models of these systems need to be formulated and
articulated in the course of secular debate. Not to do so is to collude
with the implicit assumption that such phenomena can be adequately
understood within an essentially atheistic framework of understanding.
* A version of this article first appeared in ‘Borderlands’ – produced by St. John’s College, Durham
References
1 Corinthians 6:9-10, NRSV
2 See also Romans 13:13, 1 Corinthians 5:10-11,
Galatians 5:19-21
3 Alcoholics Anonymous, Alcoholics Anonymous World Services Inc, New York, 3rd Edition, 1976, pp324-325
4 Romans 7:24-25.
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