Tuesday 25 November 2014

The paradox of ecigarettes and health

Another day, another strange article about ecigarettes from the health sector.  This time it’s Annabel Ferriman from the BMJ writing about the recent VIP TV advert.

I thought the ad was strange and in poor taste, but I certainly can’t see how, for example, it appeals to children when it’s almost as far from fun cartoon flavours as it’s possible to be – and at other times that’s exactly when ecigs have been said to be targeting kids.

However, I don’t want to go over old ground on this, and there are ecig ads like this E-Lites one that make me uncomfortable too.  The brief point I want to make here is about a paradox in this kind of concern about ecigs.

Ferriman – like me to be honest in the case of the E-Lites print advert – is uncomfortable with the impression that ecig advertising might attract people (back) to smoking.  Now that seems relatively unlikely, especially given the stats the ONS has just released about smoking and ecig use, but at the same time it could be argued that although so far ecigs haven’t attracted non-smokers, and don’t seem to be increasing smoking rates, up to this point that kind of advertising hasn’t been employed, so we should be cautious about its possible effects.

But here’s the paradox.  According to this logic, manufacturers of ecigs should appeal only to existing smokers.  But if they’re going to do this targeting, they’ll need to rely on the one thing that separates smokers from non-smokers: smoking.  And yet as soon as there’s some attempt to link this new product with smoking, some members of the health community seem to cry foul and claim that, in Ferriman’s words, this is ‘thrusting the habit back in my face’.

The whole attraction of ecigs as a harm reduction tool is that they are similar to smoking, given what we know about visual and physical cues being important elements of habit and addiction.

Of course there’s the possibility that ecig manufacturers could somehow attract consumers without making the product attractive, and target smokers without linking ecigs to smoking, but I can’t easily see how.  I just can’t see how any approach to ecigs can be developed that maintains their effectiveness as a safer alternative to smoking while being acceptable to critics like Ferriman.

Thursday 13 November 2014

Should drunkenness be a crime?

This week a report by Alcohol Research UK and the Alcohol Academy has been published, looking at how it might be possible to improve use of the existing law on serving alcohol to people who are drunk.  I think it’s fair to sum it up (extremely briefly) as noting that there aren’t many prosecutions under this law, leading to a discussion of whether this law could be employed more actively to deal with some of the problems Britain might be said to face in relation to alcohol.  It’s well worth a read in full, as an example of clear, careful, open and pragmatic writing on alcohol policy.

Phil Mellows has written clearly and sensibly, as usual, on the practicalities of enforcing the law, and likened drunkenness to love: it’s hard to pin down in scientific terms, but you know it when you see it.  Rob Pryce wrote briefly about the purpose of having a law that effectively bans drunkenness, asking whether we should focus on the actual offences or harms, rather than some proximate causes.  My interest falls somewhere in between the two.

The whole issue, if we’re interested in thinking about whether this law should exist, and how it should be enforced, revolves around a balancing act: do the pleasures and benefits of drunkenness outweigh the risks of people hurting themselves and others.  Don’t imagine this is an easy policy decision.

A useful example is this context is legislation around driving.  We don’t simply have offences of causing harm while driving, or even driving dangerously (even if no-one was actually hurt); we also have an offence of driving while under the influence of alcohol – regardless of any other factors.

However, in this context, counterintuitively, the offence of speeding is a more relevant comparison.  By definition going at a certain speed in particular areas is defined as dangerous.  The point is that we don’t always focus on just the harmful outcomes when creating laws and regulations, and in certain contexts that seems perfectly natural.

[I should acknowledge that the report was talking about the offence that bar staff might commit by serving people who are drunk; that’s not quite the same thing as making it an offence to be drunk, but it makes it offence to make people drunk, which for some purposes is much the same thing – particularly when there’s a dedicated offence of being drunk and disorderly.  The relevant point is that public drunkenness is condemned, as I discuss in a minute.]

Having thought through the issue in this way, I’m much more sympathetic to the law than I was when debating it with the authors of the report and others on Twitter.  Then, I was taking much the same position as Rob Pryce in asking why drunkenness should be an offence in itself.  However, on balance, I think I still oppose it.  I think there are a couple of issues that set it apart from drink driving or dangerous driving.

First, what is the nature of the relationship between alcohol and dangerous driving, health or crime?

The reason we ban drink driving is that, regardless of norms or morals, people’s response times fall when they’ve been consuming alcohol, which makes them less safe drivers regardless of their intentions or motivations.  By contrast, I’d suggest the relationship between alcohol and violence or other crimes is not so straightforward – and this is Rob’s point to some extent.  Drunkenness is ‘learned behaviour’, as I never tire of pointing out, and so there’s no inevitable causal link in the same way as alcohol damages reaction times.

The case of health concerns is slightly different.  Drunkenness might be a good proxy for quantity consumed, which reflects likely health harm, and thus someone should perhaps stop drinking for their own good as much as anyone else’s.

But here we face issues of liberalism.  It’s my business if I harm my health through drinking – and the only challenge is if there are shared (NHS) costs associated with that.  But once certain activities are deemed problematic, there’s something of a slippery slope, as so many illnesses have patient decisions at some point in the causal chain and thus could somehow have been ‘avoided’.

The second issue is more fundamental.  It relates to how, with each alcohol policy decision, we’re balancing positives against risks to the drinker and others.  There are huge risks with people driving drunk, and it’s hard to endorse someone taking pleasure in the act of driving specifically while drunk on a public road.  It’s quite a different thing to condemn drunkenness not while being in charge of a car, but while simply being.  There are some definite - and I would argue legitimate - pleasures relating to being in that state, though not everyone will enjoy it and some will draw the line of pleasure at different points.

At the same time, though, just like the risks of driving while intoxicated aren’t just about someone’s own driving, but their ability to respond to other hazards or mistakes, so it could be argued that there are greater or different risks associated with being drunk in a public space with other drinkers than at home.  Hence it’s not illegal for you to pour yourself another G&T, but it is if Wetherspoon’s staff do it for you when you already seem the worse for wear.  It's illegal to drive at 40mph in some areas, but not others.

So where does that all get me in my views on serving people alcohol when they’re already ‘drunk’?  I don’t think I’m quite convinced the law should exist, but equally it’s not as straightforward as I’d initially thought: there is a case that says we ban everyone from doing certain things like driving over 30mph in a built-up area on the basis that there are risks regardless of your abilities as a driver and even if the proportion of accidents would be relatively small if we drove at 40mph instead.

Maybe, given the time I’ve given to sceptical conservatism lately, I should put my money where my mouth is and agree with the pragmatism of what is a clear, measured report looking for ways to use existing laws and regulations to address what most people would agree are problems.  Just don’t trample too hard on the carnivalesque – the fictional experiences of Pentheus and Neil Howie don’t bode well.

Monday 3 November 2014

On the irrationality of drug policy

The reports on drug policy released last week by the UK Government have prompted a raft of interesting responses.  One of the wider interpretations is Desmond Manderson’s piece for The Conversation.

He takes a different perspective from much commentary by going back to basics and asking what prohibitive drugs laws are for, arguing that ‘the legal structure of drug laws is not an attempt to regulate or solve a problem, but on the contrary an attempt to dramatise a worldview’.  That is, prohibition reflects the desire for there to be clear lines between right and wrong and for authority to be able to enforce this.

In such an interpretation, policymakers are seen as being ‘afraid’ of ‘a “permissive” world in which such bright lines cannot be drawn’, making them act ‘like men possessed’.  I’d suggest instead that drug policy is a good case study of how nuanced and complex policymaking can be.

Think of harm reduction measures – and Manderson laments how these are undervalued in drug policy discussions.  Needle exchanges in Britain are a good example of pragmatic policymaking, conflicting with other elements of policy and broader ‘world views’, but somehow working.  Needle exchanges are state-funded facilities that – in one interpretation – facilitate law-breaking.*  But they were established by a Conservative government, and reveal that it is Manderson who is thinking more in terms of ‘bright lines’ than the politicians.

Politicians, in practice, often take a classically conservative view of the world.  That is, they are cautious about fundamentally reshaping policy.  Sometimes this is seen as the result of them being captured by the civil service or focus group findings, and it can lead to the feeling – expressed in relation to Prime Ministers at least from Harold Wilson to David Cameron that they have betrayed their party and the true believers.

Many laws and policies are not followed absolutely.  Whenever anyone (like Peter Hitchens) complains that drugs policies are not enforced, I wonder about driving and the possibility that there might be some people who have not been prosecuted on occasions when they have gone over the speed limit.

The reality of the situation regarding drug laws is not that politicians are ‘possessed’ or even necessarily ill-motivated.  It’s that they would argue – as Paul Hayes does – that drug policy in the UK isn’t disastrous, and there’s huge uncertainty around the potential effects of changing the law.  Yes, the current arrangement is a fudge and a fiction, but that’s the nature of policy and law, and any change is indeed a gamble.

It’s the politicians that are much more comfortable with this idea of inconsistent yet pragmatic compromise than detached academics and commentators.  It’s just possible that an illusion is sometimes better than perfect rationality.  This isn’t to say that we couldn’t improve drugs policy, or improve the debate by being open about the compromises involved, but I’d suggest that the decision-making politicians aren’t possessed – unless it’s by the spirit of Burke or Oakeshott.

*Technically, the offence in relation to drugs is possession rather than use, but the point that there is a conflict with wider world views still holds.

Thursday 30 October 2014

On the merits of blanket bans

This morning there have been two reports released by the Home Office: one on ‘legal highs’ and one on broader ideas of drug regulation.  I was asked to comment on these by Radio Solent, and I thought I’d post some quick thoughts here.  (At the time of writing, the full reports weren't available; only an embargoed press release with some quotes that I'd been sent.)

This isn’t a comprehensive response, but it did get me thinking about drug regulation more generally – a topic I’ve touched on before here and here, for example.  You can listen to one of the interviews in full here (with me starting at 2mins 50secs).

What’s being proposed is some form of blanket ban on ‘legal highs’, as opposed to the reactive banning done at the moment, through Temporary Class Drug Orders, and then adding substances to the list within the Misuse of Drugs Act.

The first advantage of this sort of blanket ban would be consistency with other substances.  At the moment, problems emerge by virtue of the special status unwittingly granted to ‘new’ substances.  People may be tempted to choose these over more established substances, which isn’t a great idea because everyone – from users to medical professionals – knows less about them compared to more established drugs.  Also, and this is something that was put to me by an interviewer yesterday, the apparently ‘legal’ status might be introducing certain people to drug use who wouldn’t otherwise consider it.

This second point isn’t necessarily a problem, unless that drug use is seen as dangerous and/or immoral.  However, that brings us back to the first point, which is that on balance I’d rather people were using cannabis than ‘synthetic’ cannabis, for example.  The advantage of a blanket ban is that, setting aside the detail, it sends the message that these substances aren’t endorsed or legal – and that’s one of the key potential problems with the current inconsistency: even where these substances are now illegal, they’re still marketed of and thought of as ‘legal’, and therefore (I’d suggest) at some level safe and endorsed.

Of course, the reality of the policy may prove problematic: will the government really be able to enforce a ban, and how will that affect research into new drugs and chemicals?  (Although the government has said before that controlling substances doesn’t inhibit research, I’m sure David Nutt would have a different view.)

We can predict pretty confidently that in reality, the government won’t be able to enforce a ban any more than it’s already able to enforce bans on use of heroin, cocaine, cannabis and any other illicit substances – particularly with the emergence of the ‘Dark Net’.

And here’s where the other report comes in.  That’s a review of evidence on how national drug policies relate to levels of use and harm.  That is, whether decriminalising use on the one hand, or introducing harsh penalties on the other, can change a country’s levels of drug use by.  From my sight of the press release scan, it looks like there isn’t really much in it: the harms depend on other factors.  As the report puts it: “We did not in our fact-finding observe any obvious relationship between the toughness of a country’s enforcement against drug possession, and levels of drug use in that country” (p.47).

In some ways, this is an argument for a sort of natural conservatism: why change the regulations, given that they’re irrelevant.  (This is interestingly not the minister’s take.)

I’m actually more interested in what the publication of the report says about the possibility of mature policy debate in this country.  Drugs policy is an area where thinking is not clear – or at least not generally conveyed clearly in public debates.  The report itself falls into this trap, solemnly declaring that we should have policy based on ‘evidence’ and talking in favourable terms of treating drug misuse as a health problem rather than a criminal one.

But these sorts of statements are close to meaningless in themselves.  As long as these drugs remain illegal, drug policy will always be a criminal as well as a health matter – and much of the criminal issues relating to substance wouldn’t be affected by decriminalising possession: if you still need to steal to feed your habit, I can’t see how that’s going to change by decriminalising the act of possession.

And evidence – as I’ve said before – doesn’t tell you what policy to implement.  That’s based on moral and political principles, and will be the result of a trade-off.

The advantage of this report, and the debate today in Parliament, is that they might actually open up some genuine debate about those aims and principles.  When Norman Baker says that policy should be based on evidence, this isn’t quite the right phrase – but there is definitely wrong with policy debates around drugs.  I think ‘legal highs’ (and e-cigarettes) could be the most important and interesting things to come along in recent years to promote an open debate that really gets to the root of what government should be interested in when it comes to psychoactive substances.

As Virginia Berridge points out, there are bound to be historical accidents and anomalies that shape approaches to different substances, but at the same time it would be nice to feel that there is conscious deliberation going on and to have some open debate about what makes alcohol, tobacco, coffee and all the rest different from ketamine, marijuana, heroin and all those other substances that the government has declared to be unacceptable.

So far, the conversation has only been about decriminalisation, and that’s where advocates of a more liberal policy would have to make a choice: is this a sensible first step in the right direction, or does it endorse what is fundamentally an unjust and unworkable system?  (You can see Steve Rolles and Julian Buchanan go over this ground pretty much every day on Twitter.)

Of course, one thing we often forget in these debates – and I haven’t touched on yet here – is how harms from drugs don’t only relate to users, but also producers and distributors of drugs.  That is, one of the biggest problems of making the drugs trade illegal is not the users in the UK, so much as the lives of those in producing countries, where crime undermines the state (think Mexico or Afghanistan), or those involved in production in the UK, who are often victims of trafficking.  It’s a great shame when this is ignored in favour of a somewhat parochial debate about UK heroin or cocaine users.

However, it’s not often I feel optimistic about policy – but today I’d rather focus on the positive (if only to distract from my tiredness at having got up stupidly early).  If a government can raise these issues shortly before an election, then surely there is hope that we can have that grown up debate, which would be a good thing regardless of your views on drug use.

Friday 3 October 2014

Medication and Recovery - Magic Pills and Methadone

This week there’s been a lot of media fanfare around the ‘magic pill’ that’s going to save thousands of ‘mild alcoholics’.  I’m not usually in favour of putting things in quotation marks, but in this case it’s almost obligatory because the fanfare is quite clearly over the top.

I don’t particularly want to write about the weaknesses of this approach; that’s been done very well by Niamh Fitzgerald and Matt Field here.  Also, although it’s tempting, I don’t want to analyse all the misunderstandings behind articles such as this by Hugh Muir in the Guardian.

What I am interested in is what the fervour says about how public debate around alcohol and drug use is able to sustain apparent contradictions in understanding different substances.

For the past few years – at least five – the field of drug treatment in the UK has been grappling with the issues of ‘medication’ and ‘recovery’.  What does it mean to ‘recover’ from a ‘substance misuse disorder’ (and what is one of these anyway?) and what role can and should medications like methadone play in that process?

This is the point of the much referenced Strang Report, called, in fact, ‘Medications in Recovery’.  (Though as I said to someone who sat on the panel – though I didn’t know at the time – that was all a bit of a fudge anyway, since although we can all agree that ‘recovery’ is a good thing, the word itself only begs all the crucial questions that still need answers.)

Anyway, the upshot of this great debate is an increased emphasis on the importance of psychosocial interventions – or ‘talking therapies’ as they’re more commonly known – in fostering recovery, and a concern that long-term medication doesn’t really amount to ‘full recovery’.

To add to this feeling of moving away from medication, the trends in drug use – and therefore need for treatment – suggest that fewer people are using opiates like heroin, and there’s an increase the relative importance of drugs like ‘legal highs’ (or ‘new psychoactive substances’) that don’t fit a model of substitute prescribing in the model of methadone for heroin – in fact they often don’t fit any model of prescribing at all.

I’m not saying the shift in emphasis away from methadone maintenance is right or wrong – or that the way this has played out is the same everywhere – but the key point is there’s been a crucial shift in emphasis in public policy debate.

This shift actually ties in quite neatly with broader trends in medical policy so emphasise ‘social prescribing’ rather than imagining medicines can sort everything.  Of course this opens up a can of worms as to whether it’s fair to characterise GPs as ‘pill pushers’, but this is a definite direction of travel in primary care policy discussions, only amplified by current concerns around antibiotic resistance.

You might even make links to broader public policy trends.  Methadone maintenance works on the principle that if you get rid of physical cravings for a drug, someone won’t need it, and therefore should be well-placed to stop using it.  But behavioural economics – which underpins the popular ‘nudge’ theory of public policy – reminds us that we don’t necessarily act on the basis of what we ‘need’ or what’s ‘good’ for us.

It’s in the context of this mood of public debate that Luncbeck has emerged with Nalmefene – or Selincro, as it’s marketed.

It’s worth noting at this point that Nalmefene is actually an opioid antagonist, similar to Naltrexone, which is used to treat heroin users.  That is, it blocks the receptors that give opiates like heroin their pleasurable effects on the body.  It’s precisely this sort of intervention that opiate treatment in Britain is (arguably) moving away from.

One explanation for the fanfare, then, is simple business logic: pharmaceutical companies see an opportunity in the public concern about (non-dependent) drinkers, and so manufacture a relevant product, which fits particularly well with the fact that the UK market for opioid agonists and antagonists is likely to shrink in the coming years.  A ‘pill’ that’s similar to what’s been used for opiate treatment can now be used for alcohol treatment, just at the point when the general feeling is that alcohol treatment services need to be expanded (probably at the expense of drug services designed for heroin users).

I think there’s something more to it than that, though.  This isn’t just about Lundbeck putting out a press release and there being a slow news day.  Nalmefene is genuinely more likely to find favour than similar drugs designed for people with issues with substances other than alcohol.

I think the fact we’re so interested in this ‘magic pill’ at the same time as think tanks as varied as Demos and the Centre for Social Justice talk about the importance of ‘character’ and how drug users ‘have a responsibility to work towards their own recovery’ to take ‘responsibility’ for their own recovery, and the Conservative Party announces the idea of ‘benefits cards’ for those with substance misuse issues, points to a distinction made between alcohol and other drugs.

This distinction is also infused with a notion of class – as the idea of benefit cards makes clear.  It might be worth asking whether – if the aim of these cards is to protect families from the impact of parents diverting resources ‘to feed their destructive habits’ – the same protection should be afforded those in families not receiving benefits.

Regardless of this policy question, though, there is a difference in who is expected to show self-reliance and not be medicated by the state, and who we think might benefit from the ‘magic pill’.  The latter are drinking half a bottle of wine a night, apparently – and the very choice of drink to illustrate the problem says something about the way it is understood.

If we think back to the idea that the shift away from methadone maintenance might dovetail with the principles of behavioural economics, in fact the opposite could be true: you could argue that a pill to deal with cravings fits perfectly with the idea that we’re weak-willed, irrational beings – we can’t be trusted to moderate our drinking simply through reason and self-control, so we need a pill to do it for us.

The question is: who gets a magic pill and who has to demonstrate self-reliance?  I’m not sure the answer doesn’t depend on the substance being used and the status of the user.

Friday 19 September 2014

Drinking within limits with Drinkaware

Last week, Drinkaware published a report called ‘Drunken Nights Out’.  It’s definitely worth reading, and the analysis of drinking practices and beliefs underlying it is surprisingly nuanced and thought-through.  Perhaps that’s testimony not only to the researchers but to those who sat on advisory panels.  If you don’t have time to look through even just the executive summary, then I can recommend a summary provided by Alcohol Policy UK.

The report carefully assesses people’s beliefs, behaviours, activities, fears and motivations.  For example, it’s noted how (certain forms of) drunkenness are considered normal, that many people’s early experiences of drinking enforced an instrumental approach to alcohol (drinking to get drunk), but that even such determined drunkenness (as Measham and Brain would call it) is ‘within limits’.

It’s this last point that’s particularly interesting, because it’s noted that these ‘limits’ aren’t like the limits government refers to, and in fact are framed in completely different terms.

However, the report falls down, in my opinion, when it moves to solutions to the perceived problems.  This is partly due to the restrictions applied to the scope of the report, but it’s also due to certain assumptions applied.

First, the report sets its terms of reference by stating that it’s only concerned with what’s in Drinkaware’s remit.  In the eyes of some public health professionals, this will immediately limit its usefulness, as the key factors of price and availability are not within Drinkaware’s gift.  Moreover, it’s stated that the report takes a harm reduction approach, meaning that it’s not aiming to reduce the number of ‘drunken nights out’ so much as reduce the harms associated with them.

This statement leaves me in a slightly uncomfortable place.  I agree that the focus shouldn’t particularly be on reducing the number of drunken nights out per se.  If people want to spend their evenings (and money) on this, I can’t immediately see why it’s any more execrable than partaking in state-subsidised opera, or skiing (so long as they know what they’re getting into).  Both of those alternatives often (or always in the case of certain opera companies) involve the state paying for the choices of individuals, which is the only real downfall of ‘drunken nights out’ as identified by Drinkaware.

On the other hand, that limiting of the scope of the report doesn’t actually follow from the initial statement that it will only look at interventions that are in the gift of Drinkaware.  In fact, given the strong links between drinking, drunkenness and the carnivalesque (or simply outrageous behaviour) in the way we think about alcohol in today’s Britain, it could be argued that educative approaches would be more likely to persuade people to go out on such nights less often, than to completely change their understanding of alcohol.

This brings me back to my old frustration with the alcohol industry (though I shouldn’t lump a whole range of interests together like that).  I often agree with them, but sometimes for completely different reasons, but other times find myself hugely disappointed by their cynical, self-interested approach – and I can’t help feeling this report is too constrained by a particular way of thinking about what is appropriate for Drinkaware to do.  I don’t think in this case these limitations are due to the same calculating cynical approach I’ve seen from the WSTA and Portman Group, but rather just accepting what they already do as inevitable restrictions.

But back to the practical recommendations of the report.  First, there’s one suggestion that people with a public health perspective should be applauding.  The report notes that education initiatives should challenge the assumption that if you ‘get away with it’ on the night, there’s no long-term problem.  Once the hangover is gone, you might feel fine on each occasion, but you could be doing long-term damage to your health.  I don’t expect to see a magical intervention that can successfully defeat this assumption, given that a belief in one’s immortality is something we cling to despite mountains of evidence – but this is an appropriate target for intervention.

After this, though, my academic perspective saw a couple of key flaws in the approach.  First off, methodologically, there are problems with simply asking people what they think or do regarding drinking.  We’re actually concerned with what they do, which doesn’t always correspond exactly with what they say – particularly regarding drinking within limits or having safekeeping strategies.  Most people know that some of the best laid plans for a night out can often fall apart in reality.  You have just one more drink, and raid the money you’ve saved for the taxi home to do this, but you might well still talk about knowing your limits and setting boundaries when you describe your drinking to other people.

This then leads into the broader point around limits.  Although the report is refreshingly clear about people having limits around their drinking, it doesn’t pay enough attention to its own acknowledgement that these are founded on completely different principles to the limits the government espouses, or indeed those placed on the same individuals’ behaviour at other times in the week.

I never seem to stop citing MacAndrew and Edgerton on drunkenness and limits, and here’s another opportunity.  Basically, they compared how drunk people behaved (and were treated) in different societies, and argued that drunkenness is set of norms and is ‘learned’ as much as everyday behaviour.  To give a simple example, in some societies people became fired up when drunk, whereas in others they chilled out.

And the ‘limits’ were different too.  Even when apparently blind drunk and on a drunken rampage, a reveller in one society found time to apologise to a researcher – acknowledging that his actions were ritualised and the outrage shouldn’t apply to a visitor.

These sorts of limits aren’t what Drinkaware is talking about in the report; they’re wider and more fundamental.  They are not about whether you set yourself the limit of four drinks or five on a works night out, but instead whether murder, drink driving or domestic violence when drunk is acceptable.

These sort of limits aren’t just individual; they’re influenced by broader issues like the legal framework surrounding alcohol.  That doesn’t mean Drinkaware can’t do anything about them, though.  And more importantly it has serious implications for the solutions proposed in this report.

The report makes the same mistake as the ‘Would You?’ campaign, which I’ve written and spoken about a number of times at conferences and in academic articles: it suggests that education campaigns should remind people that ‘they would not accept such behaviour outside the context of drunken nights out’ (p.10).

This is irrelevant.  The whole point of ‘drunken nights out’ is that these evenings operate under different norms to the everyday.  To tell someone they wouldn’t accept this behaviour outside of a drunken night out is just to remind them that’s why they go on these nights out in the first place.

I’d suggest that a more appropriate response is to stress certain absolute lines.  Looking at the work of MacAndrew and Edgerton, or indeed our experience in recent decades in the UK, we can see that certain things can be branded unacceptable regardless of drunkenness.  The claim shouldn’t be that you wouldn’t do something sober, making the comparison between the two scenarios; it should be simply to state that certain behaviours are unacceptable regardless of context.  We’re perfectly capable of holding onto certain norms when drunk, and there’s no reason to think this approach shouldn’t be considered within the scope of Drinkaware.

This might seem like a semantic distinction, but I think it’s crucial, and does reflect a genuine misunderstanding on the part of the report’s authors.  It’s not just that such strategies wouldn’t be effective; it’s also that it would be sad to apply everyday norms to all aspects of human life, and that’s what the general philosophy of ‘you wouldn’t do this sober’ suggests.  There are some benefits and pleasures in drunkenness and carnival.