Still hoping for a balanced debate

As I never seem to tire of pointing out, there are a myriad of perceived problems related to alcohol, affecting different people, and caused by different combinations of a range of factors.

It shouldn’t be surprising, then, that whenever a policy or evidence discussion occurs – like today’s debate about guidelines for low-risk drinking – it’s almost inevitable a lot of people talk past each other.

(I, of course, would never do that, and if you want to hear me talking to, or with, or at [certainly not past] a BBC interviewer, you can listen here.)

I’ve written before about how the word ‘addiction’ can sometimes confuse as much as it explains, and yesterday dragged some very reasonable and knowledgeable people into an argument about whether there are the same problems with the idea of ‘dependent’ drinking.

So what are these guidelines trying to achieve – because that will help us have a sensible conversation.

I think they do two really positive things.  First, they treat people like adults, giving them some information about risk.  Second, by making the statement that there is no safe level of consumption they help to stop people thinking of alcohol-related problems in terms of ‘alcoholism’, ‘binge’ drinking and liver cirrhosis.  In fact, alcohol consumption at a many levels, although it might not lead to any immediate damage or produce dependence, carries a range of risks in relation to cancer and other illnesses.

That this point isn’t readily accepted is illustrated by today’s Telegraph viewpoint, which suggested government focus on ‘a hard core of [people with] health and social problems’.  We’re very quick to pin problems on other people, namely those at the visible extremes of consumption.

These guidelines are not really for those who have serious dependency or addiction issues – and to say that government should only focus on these groups to miss a large element of the harm related to alcohol in our society.

(I could discuss that Telegraph article at length, but I hope I cover most of my objections through this blog post, so I will limit myself to saying it’s hard for people to gain the sort of experience through drinking that means we “know when they have had ‘one too many’” in relation to cancer risk.)

But even if we can see these guidelines as simply helping people make informed decisions, setting them isn’t simply about science and letting the facts of risk speak for themselves.  They need to be set at a level and explained in way that makes sense to people who are actually doing the drinking.  As Alcohol Research UK point out, there’s a danger that if you set the guideline too low then people just switch off and see it as unrealistic.

But then the ‘realism’ of the guidelines depends on who you’re trying to target.  We should remember that most people drink less than even the revised guidelines (85% of women and 68% of men), so by definition they are a perfectly ‘normal’ recommendation. 

And then there’s evidence that some people change their alcohol consumption if the issue is simply raised as a discussion, without much of a push from a clinician – and the discussion of these guidelines might help with that, particularly as they plant the seed of the idea that alcohol is an inherently risky product.

So we shouldn’t assume they will be ‘ignored’ – and to some extent saying can make it so, as the guidelines depend on their public reputation for their effectiveness.

Also, although I wouldn’t use the word ‘ignored’, it wouldn’t be a failure of the guidelines if lots of people looked at them and continued to drink above those limits.  The guidelines offer information about one element of life: long-term health.  They don’t tell you how to balance up those health risks against the various pleasures you might get from the social elements of drinking, the taste of your favourite drink, or the feeling of being intoxicated.  It’s perfectly reasonable to look at the guidelines and decide to drink above them on the basis that you’re prepared to accept that risk.

But if all that sounds very positive about the guidelines, despite my genuine concern about whether they’ll be ignored, I’ll end with a couple of notes of caution.

First, there is a danger that the guidelines reinforce a policymaking model where managing risk becomes solely the responsibility of the individual, when I would argue government can reasonably play a role in reducing some of the structures that expose people to those risks.

Guidelines shouldn’t be seen as the government’s key policy contribution to reduce alcohol-related harm.  They aren’t aimed at those with the greatest level of problem, and they won’t work as an intervention for everyone.

In that way, they can be attached from both ‘sides’ of the debate.  Just as the Telegraph complains that government should instead be focusing on ‘a hard core of [people with] health and social problems’, so some public health professionals would take the opposite view and suggest that this distracts from more effective population-wide regulation measures to affect price and availability.

From the latter viewpoint, guidelines can be seen as a classic neoliberal response to the issue from government: yes, we admit there’s a problem, but it’s up to you citizens to behave as responsible individuals to sort it out; there’s no need for collective action, just information and autonomy.  The observation can certainly be made that the government benefits financially from alcohol taxes, so why would it seriously look to reduce consumption?

(Thinking of a previous job I had, I can’t help but wonder whether some of those justifying these guidelines as only information to help people make ‘informed choices’ would condemn the document of the same name produced by the Russell Group to improve access to their universities.)

But I’d suggest that although it’s worth keeping an eye on this tendency to ‘responsibilise’ individuals, it’s not an argument against either guidelines in general or these new ones in particular.

I would worry about the guidelines if I felt they let the government off the hook in relation to other elements of alcohol policy, but I’m not sure this is the case.  If we didn’t have these new guidelines, would we have minimum unit pricing?  I very much doubt it.  I can’t believe this is a zero-sum game where MUP has been traded for new guidelines.

My second note of caution is that for many involved in this issue, alcohol consumption means nothing less than a campaign.  This could be said of Gerard Hastings and Ian Gilmore, who sat on the advisory group.  This isn’t to condemn them; we need campaigners, and there’s nothing wrong with having a position, particularly when they’re so open and honest about it.  However, there’s no doubt that if they felt attention was moving away from alcohol consumption and government was becoming complacent, they would be keen to draw attention to the scale of drinking and harm in the UK, and lower limits can help to play a role in that.

But these notes of caution are really, as ever, about how healthy this debate will be in the future, not about the detail of the guidance.

When we consider what happens next, let’s maintain some balance and realism.  The best starting point might be for all those involved in the debate to remember that most people drink within these guidelines, so while there isn’t necessarily a ‘crisis’ they’re not an unrealistic idea either.