Population approaches to alcohol

I’ve seen some discussion about the total consumption model of alcohol harm in the past few weeks, mostly from Chris Snowdon – both in a blog post for the IEA and on his own blog.  This discussion prompted me to think a bit more about the various ways consumption of alcohol is understood, and the various interventions that might be employed to address it.  I’m not going to add anything particular original here, but maybe point to some issues that sometimes get overlooked – and certainly have done in the recent discussions I’ve seen.

I’ve written before about how public health approaches tend to focus on population-wide problems, and population-level consumption of alcohol might be one of these issues.  Chris Snowdon suggests that the total consumption model is all about targeting heavy drinkers with something of a blunderbuss approach.  The theory, he states, runs that the consumption of the heaviest - and therefore problematic - drinkers moves in step with overall population consumption.  Policies designed to reduce population-wide consumption are in fact aimed at targeting these heaviest drinkers.

As John Holmes has pointed out, this needn’t be in quite the way that Chris Snowdon criticises; the Sheffield MUP modelling isn’t actually based on population averages, but rather targeted groups.

But there’s something more too.  Snowdon’s point is that this is a theory that isn’t held up by evidence, but as he’d probably be the first to point out, evidence and policymaking isn’t as straightforward as all that.  There’s a suggestion that Kettil Bruun, one of the lead advocates of this kind of policy, proposed it on the basis of politics – that a universal policy would be less stigmatising than measures targeted at particular ‘problem’ drinkers.

And also the evidence Snowdon sees as undermining this model is questionable – at least in the way he understands and marshals it.  First, I’m always slightly questioning of hospital episode statistics, and how they have changed over time, as this relates to accuracies of coding.  Second, even if these were accepted as measures of alcohol-related harm, it shouldn’t be surprising if they don’t march in step with current consumption figures.  Apart from the fact that consumption figures themselves can be questioned*, one can expect a lag before the health effects are felt of any increased consumption.

There’s a more important point here, though, about the idea of population level interventions.  One is that such universal interventions don’t have to imply equal effects on all individuals or groups within society, as John Holmes points out.  (Of course, as I’ve pointed out before, in many of the arguments surrounding MUP these apparently targeted effects may be as much a political claim as a genuine aim.)

Another, often overlooked point is that in fact MUP can be understood as a genuinely universal measure that does not rely on the total consumption model as outlined by Snowdon.  I often reference James Morris’ article about MUP on this blog, and unsurprisingly I’m going to do so again here.  The point is: alcohol harm is all about risk.  Not all alcoholics necessarily get liver disease, for example.  Your risk is affected by the amount of alcohol you consume, but it’s hard to predict on an individual basis.  The population model doesn’t face this issue because it’s aggregating so many risks that the broad relationship holds.  That is, if we all reduce our drinking marginally, then the individual change in risk levels is barely noticeable.  However, when all these slight reductions in risk are aggregated at a population level, the difference becomes noticeable in terms of mortality figures.

The important point here is the contrast with Chris Snowdon’s position that alcohol problems are located in a small section of society – ‘those who have a genuine drinking problem’.  It’s certainly true that there are groups of people who have particular alcohol problems, but there’s a whole host of issues relating to alcohol consumption that could be deemed problematic.  It’s the very fact that there are genuine issues relating to the wider population that means I’m concerned about how resources will be targeted in the future to meet public health aims.

And I don’t think this idea that ‘problems’ are confined to a small section of society is helpful.

First, as Alastair Campbell has pointed out this week, the seriousness of someone’s alcohol issues might not be immediately apparent to those around them.  People can be very resourceful in hiding their problems.

Second, people are able to hide such problems from themselves.  I don’t just mean the ‘denial’ of addiction.  We like to think that there are safe (even beneficial) levels of alcohol consumption, but in fact the analogy is more like driving a car: there are safer ways to drive, and it can be beneficial to your mental and physical health as well as quality of life, through many knock-on effect such as sociability, but there are risks in any level of consumption/driving.  The question is about the management of those risks.

Government discussions of alcohol policy haven’t always been helpful in this respect, as concepts such as ‘binge’ and ‘responsible’ are very malleable, and allow people to bend them to fit their own definitions of normal or acceptable – as in this research study which showed that older people tend to define acceptable drinking with reference to ‘propriety’ rather than ‘health’.  I found the same thing in my own research with younger drinkers, where people were perhaps surprisingly able to draw distinctions between themselves and the ‘other’, ‘irresponsible’ drinkers.  This isn’t to say that health should always be the number one priority in someone’s decision whether or not to drink; but it is illuminating to think about how it might be being disregarded.

This doesn’t mean I’m advocating MUP, or other policies that address total consumption across a population.  It simply means that the arguments for these interventions can’t be undermined by a narrow consideration of ideas around total consumption, and it may be unhelpful to characterise alcohol-related ‘problems’ as confined to a small group within society.

*The Mark Bellis et al research I link to is particularly relevant for Chris Snowdon’s point about harm not following consumption across socio-economic groupings.  This research, though not yet concluded, does suggest that there are all sorts of reasons for this pattern – not least that the consumption estimates may be out by differing amounts for different socio-economic groups.