Tuesday 24 September 2013

Breathalysers and drunk tanks

This morning I saw a story about breathalysers having been used in Norwich city centre to test people entering nightclubs.  I wasn’t excited or outraged by this, just confused.  I couldn’t see how it could be helpful.  However, it’s been bouncing around in my head, and after some helpful Twitter responses, I seem to have come round to thinking that it might be worthwhile after all.

Most of my posts on this blog are somewhat reactive and negative – talking about something that’s annoyed me, whether it’s Brighton’s focus on happiness in their Public Health strategy, the government’s decision to move substance misuse services into local authority Public Health teams, or the tactics of both the alcohol industry and public health campaigners.  The list could go on.  So it’s nice to actually write something vaguely positive for a change – and to feel that I’ve listened and had a think and changed my mind.

In the Norwich example, one of the points that made me initially sceptical was that as far as I could tell (and I watched the video through twice to try to make sure), there was no limit at which people would be turned away.  It seems more likely that bouncers would focus on the usual techniques of judging whether someone is drunk by their behaviour.

This raises all sorts of questions about the adequacy of breath tests.  First, there’s the claim that they are not an accurate indication of pharmacological intoxication.  Then, there’s the issue of whether a test that measures one’s blood alcohol concentration (BAC) gives us an accurate idea of what we might call ‘drunkenness’.  Although some previous research (thanks Matt Hennessey) has found a pretty decent match between BAC readings and subjective judgements of drunkenness, it’s clear from the approach taken here that, as entry will still be based on observed behaviour, there’s something of a PR exercise going on here.

As I’ve been reminded several times, we shouldn’t overstate the rationality or calculated nature of policy.  Sometimes, policymakers are as keen to be seen to be doing something as to actually do something effective.

However, let’s assume that it’s possible there’s something more to this initiative.  Even if it only runs for one weekend, it has still gained some press coverage and might highlight the issue of venues serving intoxicated customers, and the possibility of them being turned away at the front door.  As James Nicholls points out, clubs would have an interest in turning people away not just to please the police but if it changed people’s expectations about how much they could drink before going out while still getting into a club: the clubs will have an interest in initiatives that reduce pre-loading and push people to go out earlier and/or wanting more alcohol to get to their desired level of drunkenness.*

That is, the aim is that people will change their behaviour, seeing that they’re likely to get turned away if they arrive drunk, but I fail to see how this is likely unless there’s a fundamental change in the admission/serving process – which seems unlikely when bouncers are to rely on the same tried and tested observation techniques.

Moreover, drunkenness is seen as desirable by many in the night-time economy.**  That study that showed how observations of how drunk people seemed generally matched BAC figures also noted that for most people knowing their BAC would be irrelevant to their drinking levels over the rest of the night.  Where it would change people’s behaviour, it would be mostly for them to drink more (24.7% of those surveyed), rather than less (just 3.5%).

However, it’s possible that this might reduce drinking levels amongst those going out, as with observational assessments there’s always the feeling that you can beat the bouncers, pretending to be more sober than you are.  People are likely to think it’s more difficult to fool a bouncer who’s liable to breathalyse them.

So by this logic the point of breathalysing people isn’t to actually change their immediate desires for drunkenness; it’s to push them to arrive at the club more sober.

At the same time, this doesn’t undermine the initiative.  We know that interventions that deal with immediate desires can in the end reshape culture as different drinking practices just become normal.  Think of licensing restrictions originating in the First World War that seem to have had a long influence on this country and what forms of drinking were considered normal.  And the current context for policymaking is arguably one in which we’re more likely to accept that people are irrational, and so changing the ‘choice architecture’ that affects their decisions is sensible.

At first sight it would be easier if there were a clear line of BAC that would be unacceptable, as this would reduce the opportunity for just taking a chance with drinking beforehand, assuming that your level won’t be too high, or the bouncer won’t check you, or you’ll be able to explain away a high reading.  However, there are issues with this in practice.  Just to give a couple of examples, the same BAC won’t imply the same effects for all in terms of intoxication, affecting coordination, reasoning and so forth – those things that make it undesirable for a club to let in people who are very drunk.  Second, drunkenness is learned, social behaviour, so even the same level of strictly defined ‘intoxication’ might produce more or less problematic behaviour in different people.

So, having begun the day thinking this was a pointless PR exercise, I’m wondering if there might be some mileage in it after all.

Thinking in this way about an idea that initially seemed unhelpful prompted me to look again at drunk tanks.  (This was also of course so I could end the post on a typically negative note.)

‘Drunk tanks’ as I refer to them here are distinct from triage style units that take the heat off emergency departments because, according to the ACPO proposal, the individual drinker pays for their confinement.

Such a scheme can have two possible aims (which may be connected).  First, to recoup the costs associated with drunkenness.  In this sense, as I discussed in my previous post, the responsibility for drunkenness lies almost entirely with the individual.  This shouldn’t be taken for granted, particularly if we are in this new policymaking world of understanding individuals as inherently irrational.

In this sense, the drunk tanks would work perfectly well if run efficiently.  However, ideas such as a late-night levy, or (in order to capture the off-trade’s role in this issue) simply funding these initiatives through taxation on alcoholic drinks would seem perfectly reasonable.  Such approaches would acknowledge the role of availability of wider structures in shaping culture and desires.

One concern of mine is the involvement of private companies, implying the addition of a profit incentive.  Even if one accepts that an individual should pay for the cost of their care, it’s another step to suggest that they should generate profit.  Of course the argument would run that the private company could provide the care and the profit at a cheaper rate than the existing state institutions, but I’d be baffled as to why that couldn’t already be done within the current system***, or why a third sector provider wouldn’t be able to provide the same or a cheaper service than the private sector.

However, there’s a second possible aim of the drunk tank, and that’s to re-shape behaviour.  It’s here that I think other approaches are likely to be more effective.

The drunk tank as deterrent relies on people reacting to the spectre of having to pay for their care by being more careful about their behaviour.  However, such attempts to re-shape people’s decision-making are not always effective.  Women in particular are frequently reminded of the importance of safekeeping strategies.  You might think of articles like this or campaigns like this, this or this.  However, research (not just mine) suggests that often what is the more likely consequence is ‘safety talk’.  One example in my research was a young woman who took a fixed amount of cash out with her, and no debit or credit card, so she couldn’t drink more than she felt was good for her.  She also took out an extra tenner, hidden in a ‘secret pocket’ so that if she lost her bag, or drank the full amount she had with her, she’d still have the money for a cab home.  Only, in practice, she knew that money was there and her drunken self would end up spending it on alcohol and deciding to walk home.  Regularly.

This highlights Harry Sumnall’s issue with the idea of the participants in the research cited above who said they’d drink more if they were given a BAC reading: “at time of interview subjects had drunk 10-16 units. I dont trust their answers”.  It’s a good point: we are different when we’ve had 10 units or so.

And that’s why I’m not sure about drunk tanks changing behaviour.  They might, as a spectre, but we’re also very capable of explaining away our drinking and underestimating our risk when we’re thinking of things we like.  Moreover, it’s unlikely to seem such a frightening prospect when we’re getting out that ‘secret tenner’.  At this point, we maybe do need some ‘nudging’ rather than an appeal to our rational, better natures.

If we’re serious about changing behaviour, I’d be interested in more structural solutions – and that could include initiatives like the Late Night Levy, even – or perhaps especially – if the costs are passed on to the consumer.  Certainly there are problems with how this would apply if it only affects the premises that are open late at night, ignoring the role of the off-trade; that’s one of the reasons MUP is attractive.  At the moment, though, I remain fascinated by the Gothenburg model of alcohol retail, largely removing the profit motive from the trade.

*This doesn’t necessarily mean they’d be keen on a strict definition of who they should be letting in and serving and agree with the police.  In a 2008 study, only around 60% of staff surveyed knew it was illegal to serve drunk people alcohol, and even of those who did know, over 8% of those still felt it was part of their job.

**There’s loads of stuff on this, but as well as my work, these two articles are particularly useful.

***For example, if it’s expensive because the police/ambulance staff are overqualified for the role they’re performing, a solution like the Cardiff triage centre solves precisely this problem by employing people and resources to fit the precise issue.

Drunk tanks, free school meals and universalism

In the past week, a couple of stories caught my eye, as they sparked considerable media attention.  Nick Clegg promised free school meals for all children in their first three years of primary school, and the Association of Chief Police Officers (ACPO) proposed ‘drunk tanks’ for those who were so drunk they were ‘incapable of looking after themselves’.

At first sight, you might think there’s little to connect the two policies, but I’d suggest they’re two sides of the same argument, regarding universalism.  This sparked me thinking about the ideas I'll ramble about in this post.

Daniel Sage has talked about this (relatively) recently over at his blog Knowledge is Porridge.  His argument was that Labour seemed to be moving away from the idea of universal benefits, and suggested that it’s universal services that command support and engage people – think of the NHS, most obviously, but also schools and public transport (especially for pensioners).

Nick Clegg’s free school meals, and Labour’s recent announcement on childcare, can be understood in this light: providing universal services to all children.

However, there’s immediately a potential problem with this initiative being classified as ‘universal’: if we take the unit of analysis as an adult (rather than all children) then it could be argued that the service only immediately benefits those who have children.

I have heard this same argument advanced in all sorts of contexts.  For example, people sometimes complain that their union does nothing for them – which can often be seen as a positive thing if this is because they’ve never had cause to draw on legal support, other funds or the helplines provided.

The idea in the back of people’s minds when they say this is that people should pay for what they use – and this is not the principle behind the NHS or union services.

Examples of this idea in practice might include the suggestion that those who consume particular amounts of alcohol or fatty foods should pay for their own medical treatment, rather than relying on the NHS, because they have caused their own illness.  This is what distinguishes ACPO’s proposed ‘drunk tanks’ from triage models already in place in town and city centres which mean that drinkers aren’t admitted to hospital emergency departments at great cost: the drinkers themselves would face fines to pay for the service they have received.

However, it’s hard to draw the line as to where someone is at fault for their illness.  Thinking of alcohol-related issues specifically, alcohol is understood to distort reasoning through its effects as both an intoxicant and an addictive substance.  For centuries the British legal system has struggled with the issue of how alcohol affects a person’s responsibility, and we still don’t have an entirely satisfactory answer.*

One response to this issue, particularly for those on the left, is to argue that, yes, people are rational and they should take some responsibility for their actions, but they don’t start from equal positions in the game of life.  This can mean in practice an emphasis on cultural or wider structural factors that affect people’s propensity to behave in certain ways.  ‘Lifestyle’ might be a class issue.

This doesn’t in itself undermine the agency or rationality of those who do behave in ways that might be deemed damaging to their health.  The link above about addiction and rationality points to an interview with Carl Hart from Colombia University (I’d also recommend the Q&A on his own website).  His train of thought isn’t to say that crack addicts, being rational, therefore have themselves to blame because they could theoretically make different decisions.  Rather, he suggests: “If you’re living in a poor neighborhood deprived of options, there’s a certain rationality to keep taking a drug that will give you some temporary pleasure”.  The whole point is that his experimental work presented crack users with genuine choices – which meant that they often chose something other than crack.

However, these arguments are unlikely to persuade those who have a worldview that emphasises personal autonomy and responsibility – precisely those who are most likely to be opposed to the idea of universalism in the first place.**  Such a worldview, with an emphasis on the market, tends to take something of a moral or natural selection view of life: people sink or swim, win or lose, live or die by their own merits and luck.

And indeed, those on the right may be as tempted as those on the left to argue that ‘lifestyle’ is a class issue – class (or more accurately groupings of people, say chavs, the underclass, the mass) can be mobilised as a negative concept, as much condemning as explaining.

What I want to suggest here is an alternative way of addressing this criticism of universalism.***

In the end, we come back to some ideas from my previous post about risk and population health.

A focus on personal responsibility tends also to mean an opposition to population-wide measures, as these are seen as hurting the ‘responsible majority’.  A targeted approach, according to this ‘consequentialist’ view, seems much fairer.  We should be left to get on with our own decision-making, with the attention directed at those whose actions produce negative outcomes – the doughnut eaters who end up with diabetes.

However, it’s revealing that a standard alternative offered to universal health care is an insurance-based system.  Such an approach highlights the importance of the concept of ‘risk’ in understanding alcohol harm.  Just like those union dues, we pay insurance because we don’t know how likely we are to suffer some form of misfortune.  And in fact, at our individual level, neither does the insurance company – rather, it aggregates the risk in the same way that a government would do in formulating a total consumption model of alcohol harm.

This idea of risk is generally accepted by liberals/libertarians – note Chris Snowdon’s comment on my last post: the government shouldn’t be intervening because the risks are ‘trivial’ at an individual level for the levels of consumption we’re talking about.

But inherent in risk is a lack of certainty.  And such a lack of certainty is hard to manage if you’re a rational actor.  This would be fine if you could be given probabilities of your actions: you pays you money, you takes your choice.  But we’re also told that the advice offered by medical practitioners regarding alcohol consumption is unreliable, with recommended daily consumption guidelines having been ‘plucked out of the air’.  That is, there are no reliable estimates at an individual level for the risks associated with drinking.  It’s precisely this point – that we’re not really able to assess our own level of individual risk – that lies behind population-wide interventions.

Of course one instant response is to say that such theoretical nuances don’t really apply to the reality of serious ‘lifestyle’ related illnesses – the alcoholic or the doughnut eater.  But thinking again of alcohol it’s not that easy to say that there are clear-cut cases.  Not all heavy drinkers suffer from alcohol-related liver disease, for example, – and certainly not cirrhosis – and on the other hand genetic or other compounding factors can increase your risk.  Moreover, there might be no outward warning signs until the liver has been extensively damaged.

That makes rational decision-making about one’s alcohol consumption pretty tough – especially if we are to disregard government recommended limits – which makes it harder to place the responsibility for an individual’s alcohol-related illness entirely at their door.  The alternative, I’d have thought, would be to accept some idea of reasonable risk metrics – and that’s something the temperance movement could perhaps help us with.  Though I’m not sure that would go down too well those opposed to universalism and population-wide alcohol control.

(This argument might apply more to the longer-term health effects of alcohol rather than the immediate ending up in a triage unit at 1am on a Saturday morning, but I’d like to think it’s still worth thinking about in alcohol policy discussions.)

*There are great chapters covering this issue here: http://www.palgrave.com/products/title.aspx?pid=550243

**Notably, the articles I link to above that mention people paying for care related to ‘lifestyle’ decisions are based on comments from individuals associated with Policy Exchange and the IEA, both of which advocate free market solutions to public policy issues – i.e. have considerable faith in models based on an individual rational actor.

***It should also be noted that rational-choice models can acknowledge the importance of context, just like Carl Hart’s model of crack users.  Iain Duncan Smith sees it as his mission to make work pay., his model could be understood as suggesting that people are simply taking rational advantage of an apparently warped system.

Saturday 14 September 2013

What are we arguing about?

Up to this point, I haven't used this blog for short, sweet pieces that simply point people to other articles, but there's always a first time.

This article in The Guardian outlines how we can end up talking at cross purposes when we haven't actually agreed the terms of the debate - or what we're arguing about.  (Reminding me of the social science injunction to 'define your terms'.)

In policy discussions this happens all the time, and is exactly what I try to use this blog to address - most recently in my exchange with Chris Snowdon about the utility of the total consumption model of alcohol-related or harm.  (Or were we talking about population level policy interventions?)

I can't think of a better short, sweet link to leave on a blog called 'Thinking to Some Purpose'.

Friday 13 September 2013

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.