National Alcohol Harm Reduction Strategy:
Consultation Document

When the Government's Strategy Unit launched its Consultation it received responses from a wide variety of organisations and individuals. The response by the Institute of Alcohol Studies provides a particularly useful critique of the document:

While we greatly welcome the involvement of the Strategy Unit in developing a harm reduction strategy, we are concerned at the prolonged and disorganised character of a process that is now entering its fifth year. This does not reflect well upon either the Government's willingness to tackle this issue or its competence to do so, and it does not inspire confidence that the final product will be commensurate with the scale and urgency of the need....

...In regard to the role of the alcohol industry, we note that the industry in the form of the Portman Group was given a high profile in the plenary sessions of the Consultation Event held on 22 October, 2002 and that one of the workshops was devoted entirely to the industry's involvement in the national strategy.

The role of the industry is of course an entirely legitimate question for debate, and one discussed at length in our publication on social aspect groups. But we are concerned at the indications that once again the industry may exert undue influence over policy in this area. Only last year, the House of Lords European Union Committee enquiring into drinking and driving noted that the Government's position on the blood alcohol limit for drivers "coincides with that of the alcohol industry but is opposed by local authorities, the police, the British Medical Association, the Automobile Association, the Royal Society for the Prevention of Accidents, the Transport Research Laboratory, and the Parliamentary Advisory Council for Transport Safety".

Lord Brooke of Alverthorpe, the committee's chairman, was reported by The Times as being suprised by the apparent influence of the drinks industry. We hope that there will not be cause for any similar surprise in relation to the national alcohol harm reduction strategy.

It will be remembered that the WHO Declaration on Young People and Alcohol, endorsed by the Ministers of Health of all member countries including the UK in Stockholm 2001 contains the statement: "Public health policies concerning alcohol need to be formulated by public health interests, without interference from commercial interests."

The New Consultation Document

We are particularly dismayed by certain features of the Consultation Document which, in our view, represent a substantial step backwards into a way of thinking about alcohol problems that most people in the field believe was superseded years ago.

In the first place, the Consultation Document ignores the mass of research undertaken, the evidence collected and the many contributions to the development of alcohol policy that have taken place over the last quarter of a century. Contrary to the whole implication of the Consultation Document, we are not starting from scratch and from a position of complete ignorance.

Notable landmarks have included:

• The DHSS Advisory Committee on Alcoholism Reports on Prevention (1977), Services (1978) and Education and Training (1979)

• The Royal College of Psychiatrists Report: Alcohol and Alcoholism (1979)

• Central Policy Review Staff: Alcohol Policies in the United Kingdom (1979)

• DHSS Discussion Document: Drinking Sensibly (1981)

• Royal College of General Practitioners Report: Alcohol: A Balanced View. (1986)

• Royal College of Psychiatrists Report: Alcohol: Our Favourite Drug (1986)

• Preventing Alcohol Problems; A Guide to Local Action. P. Tether and D. Robinson (1986)

• Royal College of Physicians Report: A Great and Growing Evil: the Medical Consequences of Alcohol Abuse (1987)

• First Report of the Ministerial Interdepartmental Group on Alcohol Misuse (1988)

• Alcohol Policies: Responsibilities and Relationships in British Government. P. Tether and L. Harrison. (1988)

• Interdepartmental Circulars on Alcohol Misuse (1989)

• Lord President's Report: Action Against Alcohol Misuse(1991)

• White Paper Health of the Nation. Department of Health (1992)

• Alcohol Policy and the Public Good. G. Edwards et al. (1994)

• Sensible Drinking: the report of an Interdepartmental Working Group. Department of Health (1995)

• Alcohol and Crime: Breaking the Link. All Party Group on Alcohol Misuse (1995)

• Alcohol and the Young: report of a joint working party of the Royal College of Physicians and the British Paediatric Association (1995)

Tackling Alcohol Together: The Evidence Base for a UK Alcohol Policy. D. Raistrick et al. (1999)

• International Handbook of Alcohol Dependence and Problems. N. Heather et al (2001)

The mass of material gathered by the Scottish Executive for the development of the Scottish national alcohol misuse strategy.

Secondly, the Consultation Document fails to mention international alcohol harm reduction initiatives in which the United Kingdom is already a participant. These are the World Health Organisation's Alcohol Action Plan for Europe and the EC Council of Ministers' Recommendation on the Drinking of Alcohol by Children and Adolescents.

As the British Government was actively involved in these initiatives and indeed has officially endorsed both of them, it is already committed to a range of actions designed to reduce the harm associated with alcohol products.

To produce a Consultation Document after four years of effort which omits any reference to these initiatives, both of which were extant during these four years, and which, additionally, appears to be oblivious to the mass of evidence that exists on the harms associated with alcohol products, is an achievement of a sort but one more likely to reduce than enhance the credibility and coherence of the final product.

This is evident right at the beginning where the opening sentence of the Minister's Foreword repeats the mantra of the alcohol industry that the majority of people are sensible drinkers who drink without causing or experiencing any harm whatever, alcohol problems being restricted to a small minority of 'alcohol misusers'. Even a very limited familiarity with the scientific literature would enable the Minister to understand why this assumption is exactly the wrong starting point for a strategy to reduce the harm associated with alcohol products.

There are not two entirely separate populations of drinkers, a large population of 'sensible drinkers' on the one hand and a far smaller one of 'alcohol misusers' on the other. There is the one population, amongst which alcohol problems are widely distributed. The harm associated with alcohol products is a reflection of the prevailing drinking culture. In particular:

1 Much, and in relation to some kinds of problems, most of the harm associated with alcohol products is generated not by a small minority of 'alcohol misusers' but by the mass of ordinary consumers who sometimes drink excessively or inappropriately.

2 While normally risk is proportionate to dose, for some conditions there is no clear threshold of consumption below which problems never occur. The concept of completely risk-free drinking is a fantasy. In relation to these conditions, all drinkers are at increased risk compared with non-drinkers.This is clearly the case in relation to accident risk. Recent research suggests it is also true of the risk of female breast cancer, and is particularly true also of social problems related to alcohol consumption.

3 In the United Kingdom, much of the harm associated with alcohol is the result of acute rather than chronic intoxication. Drinking to get drunk is now a central element of socialising for a substantial proportion of young people. The Government's own figures show that the majority of 20-24 year old men, and over 40 per cent of women of that age, have a hazardous pattern of alcohol consumption: Prevalence of hazardous drinking in the past year by age and sex (Source: Psychiatric Morbidity among Adults living in Private Households, 2000).

4 There is a strong association between the average or overall level of consumption of a population and the level of harm associated with alcohol products: as a rule, societies with higher levels of consumption have higher levels of harm.

In regard to reducing the harm associated with alcohol products, the evidence is clear that the most effective strategies are those which combine measures designed to affect the overall level of consumption with measures targeted at specific groups and problem areas, and affect features of the drinking environment rather than relying on attempts to persuade individuals not to drink too much.

Where we go from here?

We agree strongly with Dr Martin Plant that the whole area of cost benefit analysis stands out as needing further development. We would not however agree that the development of a harm reduction strategy must await this or any other area of research being carried out. We already have enough scientific knowledge to begin to embark on the strategy: the wheel does not have to be reinvented. We hope that despite the omission of any reference to them in the Consultation Document, the Strategy Unit is familiarising itself with the available scientific literature such as the works listed above.

At this stage, we believe that the Government and the Strategy Unit needs to explore four specific areas of enquiry in addition to those already identified above and in our original submission:

• If it is not already happening, steps should be taken to lay the groundwork for monitoring the future impact of the strategy and the Licensing Bill now in Parliament, not only in relation to alcohol-related crime and disorder but also in relation to drinking patterns and levels of consumption, the health service and other kinds of alcohol problem such as family disturbances.

• A system needs to be established for monitoring public opinion on issues relevant to alcohol policy.

• Specific proposals should be put forward and a consultation undertaken in regard to the education and training needs of those who will be involved in putting the strategy into practice.

• Specific proposals should be put forward and a consultation undertaken in regard to how the harm reduction strategy should be administered and implemented. Particular attention needs to be paid to central coordination, local coordination and local representation, and quality assurance.