Alcohol Policy in Question

The "sensible drinking" approach to reducing alcohol-related problems is being re-examined by the government in the context of its health strategies for England, Scotland, and Wales.

The government has made it clear that it intends to tackle drinking and driving and alcohol-related violence. Ministers are anxious to distance themselves from the image of their's as the nanny state party, and, in the green papers recently issued, they appear to be undecided as to whether they wish to continue the "sensible limits" approach to alcohol education and to keep in place the health targets based on those limits promulgated by their Conservative predecessors.

However, whilst soliciting views on this issue, Health Ministers have given their backing to the Portman Group's new campaign, "It All Adds Up!", which seems to indicate that the revised "sensible drinking" limits introduced by the previous government will be endorsed. Tessa Jowell, Win Griffiths, and Sam Galbraith, the English, Welsh, and Scottish public health ministers have welcomed "It All Adds Up!" which has been launched with the slogan, "2f3m4", a reference to the two or three unit limit for women and three to four limit for men. Tessa Jowell goes so far as to say, "This campaign is an excellent example of co-operation between the government and the private sector. Everyone needs to know where sensible drinking ends and serious health risks start. Everyone needs to know about when not to drink at all and about how very modest drinking can offer health benefits to certain age groups. The campaign is about spreading sensible information about sensible drinking. That is why I welcome and applaud it."

The danger of the "sensible drinking" approach lies in the way the message is likely to be received. Indeed, when in December 1995 the then Secretary of State for Health, Stephen Dorrell, announced the new limits, which the Portman Group is now advocating, he was condemned in the press for issuing a "boozers' charter". To many the "sensible drinking" message is barely distinguishable from the promotion of drinking and so may have the perverse effect of encouraging the majority of moderate drinkers to consume more rather than persuading the minority of heavy drinkers to consume less. When the "sensible limits" were introduced by the last government, there was a tendency in the media to present them as a medically-approved target rather than as a maximum level and as safe limits rather than the risk thresholds they are intended to be. This problem will be exacerbated by the public health ministers' approbation of what, in terms of the population average, are high levels of alcohol consumption and by the promotion of alcohol as a kind of health food which prolongs life, albeit within severely prescribed limits.

The green paper for England, Our Healthier Nation, presented to the House of Commons by the Secretary of State for Health, Frank Dobson, has only one paragraph on alcohol:

"Many people who drink alcohol enjoy it and cause no harm to themselves or others. Whether people drink sensibly can dramatically affect their physical and mental health and that of others. Drinking too much is an important factor in accidents and domestic violence and can impair people's ability to cope with everyday life. It has been estimated that up to 40,000 deaths could be related to alcohol and in 1996 15 per cent of fatal road accidents involved alcohol. The government is preparing a new strategy on alcohol to set out a practical framework for a responsible approach."

A consultation paper specifically on alcohol is expected in due course. Its possible contents may be guessed at from the more detailed section in the Scottish green paper, Working Together for a Healthier Scotland.

Labour ministers, and Dobson in particular, have been positioning themselves to steal a march on the Tories by portraying the Opposition as the advocates of the nanny state. Concern has been expressed that the tone of the paragraph on alcohol implies a watering-down of the Government's attitude to the problem and the abandonment of the commitments set out in the Conservatives' Health of the Nation, which included:

• health will be one of the factors taken into account by the Chancellor of the Exchequer in deciding alcohol duties.

• the commitment within the framework of the family health services to the promotion of the sensible drinking message will be strengthened.

• an agreed format for the display of customer information on alcohol units at point of sale will be considered jointly with the alcohol trade associations.

• there will be a new initiative to monitor the penetration of the sensible drinking message.

• continued encouragement will be given to employers to introduce workplace alcohol policies and to monitor their impact.

• the expansion and improvement of voluntary sector service provision.

The Health of the Nation also urged continued development of monitoring, screening, and treatment services at local level. The health professions were to be consulted in relation to the possibility of routine hospital admissions procedures including taking detailed drinking histories, and the government stated that it intended to pursue an initiative to heighten the awareness of nurses, midwives, and health visitors on the incidence of alcohol misuse.

The Health of the Nation set twenty seven health targets in the five areas of coronary heart disease and strokes, cancer, mental health, HIV/AIDS and sexual health, and accidents. However the trends ran counter to the targets related to drinking, smoking, and obesity. There has been no downward trend in the proportion of men drinking above "sensible limits" and the proportion of women drinking over the levels is increasing. ( See table above)

The Conservative Government's alcohol targets were thrown into question in 1995 when it appeared to raise the "sensible" drinking limits. Although issued by the Department of Health, and although Stephen Dorrell, the Secretary of State at the time, had the opprobrium of the medical profession heaped on him, the work on the changes to the levels was co-ordinated by the Ministry of Agriculture, Fisheries, and Food, which has a responsibility to promote the British drink industry. The limits were raised in defiance of the consensus of scientific opinion and under pressure from the industry's poodle, the Portman Group.

Workers in the field of alcohol policy and treatment will have these, presumably redundant, targets in mind when the Labour Government produces its new strategy. The Department of Health is about to begin the process of consultation, aimed at producing this. It will be interesting to see whether the previous government's inter-departmental ministerial group on alcohol misuse will be revived in some form.

In Our Healthier Nation, Frank Dobson says, "Far too many people are still falling ill and #dying sooner than they should...The Green Paper sets out our proposals for concerted action by the Government as a whole in partnership with local organisations, to improve people's living conditions and health...We put forward specific targets for tackling some of the major killer diseases and proposals for local action."

The green paper lays great stress on the health disadvantages of poverty and the social causes of ill heath. In his statement to the Commons, Mr Dobson said: "There are huge inequalities in our society, and the worst are in health. Poor people are ill more often and die sooner... Successive surveys have shown that over the past 20 years the gap between rich and poor has been growing. As a result, as recent official figures show, the health gap between rich and poor has also been growing." This gap to which the Secretary of State referred is a result of a more rapid growth in good health among the better off. Mr Dobson went on to say, "The previous Government concentrated their attention exclusively on trying to get people to change their personal life styles, which sometimes needs to be done, but they ignored the factors that made people ill but were beyond the control of individuals."

In his reply, John Maples, the Shadow Health Secretary, said that the World Health Organisation had "commended the (Conservative) Government's strategy as 'a model for others to follow.'" He acknowledged the connection between poor housing and bad health. "However, I believe that far more ill health is caused by smoking, the overuse of alcohol, bad diet, and lack of exercise...We must recognise that although some people are ill because they are poor, I suspect that there are many more who are poor because they are ill...getting people to improve their own life style is the key."

Our Healthier Nation proposes targets for four priority areas:

• heart disease and stroke...
  "reduce the death rate from heart disease and stroke and related illnesses amongst people under 65 years by at least a further third (33%)."

• accidents...
  "to reduce the rate of accidents...by at least a fifth (20%)."

• cancer...
  "to reduce the death rate from cancer amongst people aged under 65 years by at least a further fifth (20%)."

• mental health...
  "to reduce the death rate from suicide and undetermined injury by at least a further sixth (17%)."
  

It is suggested that the targets should be reached by 2010, from a baseline at 1996.

The Scottish Office Green Paper, Working Together for a Healthier Scotland, provides greater detail on alcohol policy. It may be an indicator of the direction of government thinking as far as the rest of the United Kingdom is concerned and, as such, the section is worth quoting in full:

"Over 90% of the adult population drink alcohol. It can be a part of a healthy lifestyle if taken in moderation and at the right time and place, and, indeed, there is evidence of physical health benefits of regular moderate alcohol consumption for men over 40 and women after the menopause. Both excessive consumption over long periods and heavy spasmodic drinking cause damage to health, accidents, and anti-social behaviour. The costs of alcohol misuse in personal, social and economic terms are great, and are all too often hidden or unheeded.

"Some 8% of men and 1% of women in Scotland - about 200,000 people - are drinking at levels which are definitely harmful. The 1994 General Household Survey showed alcohol consumption levels in Scotland to be broadly similar to those in other parts of the UK. There has been a greater tendency, however, towards binge drinking in Scotland and this may be the most significant variation in the patterns of alcohol consumption in the UK. Misuse of alcohol is a major risk factor associated with disease, homelessness, unemployment, criminality, mental breakdown, domestic violence and child abuse. Many working days are lost each year due to alcohol misuse. Heavy drinking contributes to high blood pressure, increases the chances of stroke, and is linked to cancer of the throat and mouth. A quarter of the men and a tenth of the women admitted to general hospitals will be problem drinkers. There has been a steady increase in deaths attributable to alcohol.

"According to the Office for National Statistics, there has been a small increase in the 1990s in the proportion of children in Scotland aged 12-15 who drink alcohol at all (from 59% in 1990 to 64% in 1996). However, there has been a more marked increase in the amount consumed by those who drink. The average number of units a week drunk by children of this age has more than doubled - from 0.8 units in 1990 to 1.9 units in 1996. Alcopops, which were first introduced into the market in 1995, accounted for about 18% of all alcohol consumed by this age group in 1996. Consumption by women has increased in the last two decades. Their smaller average physical size means that a given amount of alcohol may cause more damage to women than men.

"The target set for alcohol consumption was to reduce the 1986 figures for men drinking more than 21 units per week and for women drinking more than 14 units per week by 20% by the year 2000. The heavier the drinking above this level, the greater the hazard to physical and mental health. Findings from the Scottish Health Survey are that 33% of men and 13% of women drank more than these recommended levels. This indicates an increase compared with the 1986 levels of 24% and 7% respectively. To be effective, preventative policies have to focus on the moderately heavy drinkers as well as those at the extreme end of the range.

"The Government are fully committed to tackling alcohol misuse on a broad front. Alcohol development officers have been appointed throughout Scotland, co-ordinating action at local level. The licensing framework in Scotland works well and can react to particular problems, for example, licensing boards are required to refuse late night extensions unless satisfied of their community benefit. Regulation has recently been strengthened. Local authorities can now have recourse to byelaws prohibiting the consumption of alcohol in designated public areas. Under Scots law, it is already an offence for adults to buy alcohol for supply to children and recent legislation allows the police to confiscate alcohol from under 18s who are drinking in public.

"The Government have made clear that, if their current measures to bolster the action taken by the drinks industry towards better self-regulation do not bear fruit, they will take further action which could include legislation in areas which have traditionally been left to self-regulation. The Government have also made very clear their determination to tackle alcohol misuse by young people - which can lead not only to crime but also to under-achievement, poor health and poor employment prospects.

"A high proportion of adult fatalities from fire in dwellings (where the cause of fire was carelessness with smokers' materials, pans left on cookers, or misuse of electrical apparatus, for example) has been linked with excessive intake of alcohol.

"In 1991, Health Education in Scotland: A National Policy Statement, set a national target of achieving a reduction of 20% by the year 2000 in the number of Scots drinking above the recommended sensible levels of 21 units a week for men and 14 for women.

"This target of 19% for men and 6% for women has not been reached and is unlikely to be by the year 2000. The Scottish Health Survey shows that a substantial proportion of the population -33% of men and 13% of women - is drinking in excess of the target limits, and the proportion doing so has increased sharply among both men and women since 1986. Given the large increase in excessive drinking in recent years and the widespread pattern of excessive drinking across social classes and across different regions within Scotland, the potential for reducing excessive alcohol consumption may be limited. This conclusion is supported by HEBS health survey findings, published in 1996, which show a motivation indicator (those drinkers aged 16-74 who want to or intend to cut down on their drinking) of only 6% for men and 4% for women. The main motivational barrier cited to moderating drinking was finding it difficult to cut down or stop when friends were drinking. The same survey showed that only 22% of heavy drinkers were taking action to change their behaviour: 49% were not even considering taking such action.

"The Government would welcome views on whether the current target for alcohol should be maintained and, if not, specific suggestions for alternative population indicators for alcohol misuse.

"The most recent guidance on alcohol consumption emphasised daily rather than weekly drinking levels. The recommendations are that regular drinking of 4 or more units a day for men, and 3 or more units a day for women is likely to result in increasing health risk.

"The Government would welcome views on this latest guidance, against the background of the previous weekly levels.

"Underage drinking is being viewed as a significant problem in its own right. The inclusion in future of young people's alcohol consumption in the Scottish Health Survey will be of considerable benefit in this regard.

"Views would be welcome on setting a new target or indicator for underage drinking."

The purpose of a Green Paper is to invite consultation. Our Healthier Nation and Working Together for a Healthier Scotland are obtainable from The Stationery Office Bookshops and priced £10.30p and £7.50p respectively. Responses should reach the Department of Health or the Scottish Office by 30th April.