Tackling Alcohol Together

Andrew McNeill writes-

In 1979, the National Council on Alcoholism (NCA), the forerunner of Alcohol Concern, was instructed by Health Minister Sir George Young to become engaged in the prevention as well as the treatment of alcohol problems.

'Prevention', Sir George said, 'does not raise medical issues but political ones, since it presupposes the adjustment of a nation's lifestyle to improve its health... For many of today's problems the answer may not be cure by incision at the operating table but prevention by decision at the Cabinet table.'

This instruction prompted the NCA to set up a prevention committee, and the main idea it discussed was the possibility of helping politicians to make policy by collecting together in one publication all the available evidence on alcohol problems in England and Wales (Scotland has its own national agency) and successful methods of preventing them.

Twenty years later, this publication has finally appeared. It is called `Tackling Alcohol Together: The Evidence Base for a UK Alcohol Policy'. It has been produced by the Society for the Study of Addiction, and an excellent job the Society has made of it. The Society brought together an impressive team of scientists, researchers and practitioners led by Duncan Raistrick, Ray Hodgson and Bruce Ritson and they have succeeded in at last writing the book that people involved in alcohol policy in the UK have needed for little short of a generation.

The book's title is, of course, a reference to `Tackling Drugs to Build a Better Britain', the name given to the Government's strategy against the misuse of illegal drugs. One point being made by the authors is that the drugs problem has been regarded for a number of years as warranting a clear national strategy whereas the alcohol problem has not, even though the harm from alcohol far exceeds that from illegal drugs. Another is that the drugs strategy shows the way in which different sectors can be encouraged to work together to a common purpose, a main theme of this book.

Tackling Alcohol Together is a sister volume to `Alcohol Policy and the Public Good', the book written by Professor Griffith Edwards and his colleagues to provide the scientific evidence underpinning the World Health Organization's Alcohol Action Plan for Europe. As its sub-title indicates, the new book covers much the same ground but specifically with reference to the UK. It should also be seen in conjunction with Alcohol Concern's Proposals for a National Alcohol Strategy, (featured in issue No2. 99).

Tackling Alcohol Together provides a wealth of information and analysis of alcohol consumption and related harm; influences such as price and legal availability of alcohol on drinking behaviour and related problems, and on policy initiatives to reduce alcohol problems. The standard is consistently high and the discussions of alcohol policy issues are in general superior to Alcohol Policy and the Public Good. There are particularly useful discussions of the complex issue of alcohol, crime and violence and the related topic of liquor licensing.

Like its sister volume, Tackling Alcohol Together represents and promotes an evidence-based approach to alcohol policy. There is now a mass of evidence on the causes of alcohol problems and on methods of preventing and treating them and this evidence, so ably presented by the authors, should, they argue, provide the basis of a comprehensive national alcohol policy.

As the summary of recommendations makes clear, a key element of an evidence-based strategy is control of the overall level of alcohol consumption. Because of the strong relationship between per capita consumption and the level of alcohol problems in the whole population, Tackling Alcohol Together advocates reducing per capita alcohol consumption to below 8 litres per annum, a level not seen since the early 1970s. The authors conclude that alcohol taxation provides the principal means of achieving this objective. There are no proposals in regard to alcohol advertising, other than continued enforcement of the advertising code, because there is a lack of evidence to justify stronger measures.

The absence of a recommendation to restrict or ban alcohol advertising will be one of the few features of this book to be welcomed by the alcohol industry. In contrast, the objective of reducing national consumption of alcohol will of course arouse its implacable opposition. All the indications are that the Government's reactions will be similar, and it is in this connection that a worrying degree of naivety is apparent.

The clear hope and belief of the authors is that with the arrival of New Labour, the alcohol policy promised land is in sight. Indeed, they state that, prior to the publication of the Green Paper `Our Healthier Nation' in 1998, no UK Government had ever deemed it necessary even to propose a national alcohol strategy, let alone implement one. This is an odd claim to make, as it means disregarding the whole of the alcohol component of previous Conservative Governments' health strategy. This included targets for reducing the number of heavy drinkers in the population, a commitment to taking public health into account in setting alcohol taxes and the setting up of an interdepartmental ministerial group on alcohol misuse to coordinate activity. It is, of course, true that the Conservatives failed to achieve their own targets, that the Ministerial Group was allowed to fizzle out, and that lots of other things happened or did not happen that worked against reduced levels of alcohol related harm. But to disagree with a policy, or to criticise the ineffective way it is implemented, is quite different from denying that it exists, and to deny the title of `alcohol policy' to the Conservatives' efforts may be thought to be taking political partisanship a bit far.

It may also result in a great deal of disappointment, as there is no obvious reason to believe that the present Government is any more receptive than its predecessors to the proposals contained in Tackling Alcohol Together. Indeed, the indications are that it may turn out to be less receptive.

Tackling Alcohol Together is a considerable achievment. It will or should significantly raise the level of knowledge and debate and it fully deserves to be a landmark publication in relation to the development of national policy. Whether it actually will be depends on people other than the authors.

Tackling Alcohol Together: The Objectives of the National Alcohol Policy

1 - To increase Public Information and Debate about Alcohol

There are four key proposals to support this objective:

  1. Create a national and local structure to coordinate action on alcohol. The chosen structure needs to be led at ministerial level.

  2. Funding to ensure the availability of statistical information, surveys and research. Research needs to meet the .... requirements of producing definitive answers within planned programmes of investigation

  3. Promulgate a simple safe Iimits message supported by labelling of alcohol content of drinks.

  4. Designated people at national and local levels to develop the skills of media advocacy and build positive media relations

Strategy One - Public Health Promotion Campaigns Linked To Encouragement of Local Action

Agencies such as the Health Education Authority, Health Education Board in Scotland, or Health Promotion Wales would he expected to take a lead role in this strategy, but it would he important to build partnerships that can deliver local action to coincide with centrally coordinated mass media campaigns.

Strategy Two - Working with the media to ensure accurate reporting of alcohol issues and encourage public debate

A central Alcohol Policy Coordinating Unit would probably claim the right to own this strategy, but an independent agency such as Alcohol Concern might be more proactive and adhere more innovatively to the spirit of the strategy. The regional network of Alcohol Concern lends itself to coordinating active public debate.

2 - To Encourage the Drinks and Leisure Industries to Introduce Innovative Schemes to Discourage 'Drunkenness'

There are four key proposals to support this objective:

  1. Extend the role of drug action teams to include alcohol and be responsible for community action.

  2. Evidence-based reform of the Iicensing regulations to harmonise national and local controls. Licensing should include criteria of need and monitoring of untoward incidents associated with licensed premises.

  3. Licensing should require server training and seek to agree a fair system of server liability in the drinks trade.

  4. Set priorities for local enforcement schemes including those based on incident monitoring.

Strategy Three - Innovation to Encourage Safer Drinking Environments

The drinks and leisure industries are well able to develop their business, but what is needed is encouragement and commitment to developments within the intentions of the alcohol strategy, perhaps through formal controls. Providing family areas in pubs or ensuring public transport to service pubs in the late evening are two examples.

Strategy Four - Enforcement of Legislation and Agreements with Automatic Sanctions for Transgressions

Local police action in partnership with licensing magistrates, town planners and representatives of the trade would be one way of leading on this strategy.

3 - To Maximise Community and Domestic Safety

There are four key proposals to support this objective:

  1. Zero tolerance of domestic violence. This requires local schemes that enable the immediate removal of violent drinkers from the home into treatment programmes backed by legal sanctions.

  2. Reduce prescribed limit for drinking and driving to a blood alcohol level of 50 mg%. There should be harmonisation of drink driving laws across Europe. Appraisal of vehicle immobilisers should be undertaken as a medium-term strategy.

  3. Increase the age limit for selected drinking related activities.

  4. Incentives and support for employers to develop workplace policies and employee assistance programmes.

Strategy Five - Take Action to Prevent and Reduce Accidents and Other Untoward Incidents Relating to Drinking

National campaigns would be the backdrop to action which would be mainly local and coordinated through the Drug Action Teams or their alcohol equivalents. Public support against drinking and driving needs to be extended to other behaviours where drinking causes unacceptable risks or nuisance.

Strategy Six - Take Action to Prevent and Reduce Violence or Nuisance Related to Drinking

The national legislation required to implement this strategy is already in place. What is needed is collaboration between local police, social services and probation services backed by a commitment from the Drug Action Teams or their alcohol equivalent to take action. Intolerance of intoxication leading to violence needs to permeate our culture.

4 - To Reduce Alcohol Related Health Problems Below 1990 Indicator Levels
There are four key proposals to support this objective.

  1. Fiscal measures to maintain per capita consumption below 8 litres of absolute alcohol. These measures should be declared in the Chancellor's annual budget statement.

  2. Establish a network of addiction training centres and accredited courses. Training is a prerequisite if services are to match their potential as described - this review of treatment outcome research.

  3. Create incentives for generic services to become effective at delivering minimal interventions. Efforts need to extend beyond primary health care into Social services, probation and others.

  4. Ensure that equal access to specialist NHS units is available in all health authority districts. Specialist services need to be of a standard not only to deliver more complex treatment, but also to to undertake research and contribute to training and policy initiatives.

Strategy Seven - Maintain per capita Consumption at or below 1990 Levels

Once commitment is achieved, implementation of this strategy is ultimately a technical, Treasury exercise. If other measures to contain consumption fail then government can deploy fiscal measures to contain per capita consumption down to predeter!nined levels. Also implied is concurrent public education to create a climate of understanding that would make such measures practical and acceptable.

Strategy Eight - Implement a Comprehensive Health Service Response to Alcohol Problems

It is expected that the Department of Health, which already has mechanisms for influencing and monitoring treatment services, would continue to take the lead role for this strategy. It is important that funding arrangements reflect the broad remit of specialist services within a health district.