Tuesday 19 January 2016

In defence of alcohol guidelines

The last week or so has seen some pretty strong debate around the proposed alcohol guidelines published by the Chief Medical Officer.  I’d sort of assumed that, like many news events, this debate would be replaced by another issue after a day or so, but in fact a letters debate was still being printed in The Guardian on Thursday 14th January – almost a week after the guidelines came out.

This debate, as I predicted when the guidelines were released, seems to have involved people talking past each other, often from ill-informed or inconsistent positions.  The letters to The Guardian are a case in point, so I want to spend some time here talking their criticisms through.

I should start by acknowledging my personal position in this, as I think this is important in how we react to guidelines.  I drink between 20 and 30 units most weeks – about 3 pints on each of Friday, Saturday, Sunday and Monday.  (For those of you who are wine drinkers, this works out at more than 2 or 3 bottles a week.)  I drank more than the ‘old’ guidelines, and I certainly drink more than the ‘new’ guidelines, as the threshold for men has been lowered.

I often feel torn on alcohol issues.  Thinking of a similar discussion about older people’s drinking, you could say I took a different position, challenging Jackie Ballard on her assertion that older people’s health would inevitably be damaged by increased levels of alcohol consumption.  The evidence we’d just been presented with flatly contradicted this point (which is a complete misunderstanding of the nature of risk and uncertainty).  There’s also a danger that if you tell people a certain level of consumption will definitely cause health damage they’ll switch as off, because they’ll probably know someone who drinks at that level and hasn’t suffered any harm.  That’s the nature of risk.

Equally, though, I’ve been quite supportive of the guidelines released this week, which have had exactly the same objections thrown at them.  I value having them even while I’m not exactly in step with their model of low-risk behaviour.

But I think this feeling of being unsure is appropriate – alcohol can be both pleasure and poison, even at the same time.  If we’re comfortable with a simple, coherent position, we’re probably missing something.

More than this, though, there is a difference between telling people what to do and giving them information.  It’s exactly why I welcome the advice, but don’t stick to the low-risk limits.

Jackie Ballard was wanting older people to drink less, and wanting to tell them so, based on what I saw as a misreading of the evidence.  This is exactly what the Chief Medical Officer and related researchers have been accused of in the past week or so, but in fact I’d suggest they’re doing something quite different.  They’re trying to offer information about risk to guide individual decisions.  (And this information only related to medical risk – so you may wish to balance it against the physical or social pleasures of drinking.)

14 units a week or less would be a good level for everyone to drink at from a public health perspective, considering overall population health outcomes like hospital admission rates, but it’s up to each individual to judge whether that sort of health improvement is of any interest to them.

There seems to be a school of thought that thinks because giving advice is difficult, we shouldn’t do it at all.  That is, each person has different genetic and environmental factors that will influence their level of risk, and so it’s impossible to give a single risk figure for all people in the population, making any single figure misleading.

But my response to this is that we use these single approaches in all sorts of elements of life.  We set a single age of criminal responsibility (apart from in exceptional cases), even though we know people’s maturity and powers of reasoning vary considerably.  We set a single speed limit even though different cars and drivers have different stopping distances.  In terms of health and lifestyles, we give single figures for recommended exercise or fruit and veg consumption.  I’m not saying these are all the right way to approach these issues, but the idea of a single target or recommendation is not unique to alcohol guidelines, or even unusual.  It’s a standard approach to advising and governing behaviour.

I would argue that if we’re making decisions that affect our health, it’s helpful to know the best information possible about how that might happen. 

This is why I think the letter written by Jack Winkler, Emeritus professor of nutrition policy, London Metropolitan University, is wrong when it complains that we need a more complex response, ‘not just admonitions’.

In fact, it could be seen as dishonest to provide medical professionals with tools by which to screen people for problematic alcohol consumption, and then not give drinkers themselves access to the same information.

One main argument – put forward by Sally Caswell previously and Chris Hackley more recently – seems to be that giving out limits puts the onus on the individual to manage their own risk, and distracts from lobbying from more effective controls on price, availability and so on.

As I’ve noted before – and did when these guidelines came out – there is a genuine concern that recent trends in government policy focus too much on individual decision-making, neglecting the wider context that shapes these decisions.  (This is what is generally meant by neo-liberalism in a social policy context.)  So I’m sympathetic to the idea that guidelines could distract from other elements of the alcohol policy picture.

However, I’d draw attention to Nick Heather’s response to this.  The simple answer is that if alcohol is legal and available in any form, individuals will be making decisions about how much to consume and in what format, pattern and setting.  These decisions unquestionably affect a person’s risk of health harm.  And there is, unavoidably, a certain sense of responsibility.  This is not simply ‘victim blaming’, but an awareness that we make our own decisions, though not always in circumstances of our own choosing (to badly paraphrase Marx).

But these letters to The Guardian show that even making the research available alongside the guidelines doesn’t mean it will be read and understood.

David Lewis from York writes that “The guidelines conveniently ignore the evidence around the cardioprotective and neuroprotective effects of moderate alcohol consumption.”  They absolutely don’t.  There’s careful discussion of this in the Sheffield model, and that’s part of why the guideline isn’t set at zero despite the fact that for many conditions there is no ‘safe’ level of consumption.

Dr John J Birtill from Guisborough in North Yorkshire states that the guidelines “tell us nothing about how much longer the non-drinkers will live on average, the range of this extra life expectancy, the quality of life during the extra years, or the likely alternative causes of death. The lifetime benefit of abstention might be rather small compared to the lifetime pleasure of moderate alcohol consumption.”

In themselves, perhaps they don’t; they’re just low-risk guidelines.  And any condensing leads to interpretation.  But the report they’re written into does talk about precisely these issues, and the Sheffield report gives even more detail.  These things aren’t being hidden; they’re part of the discussion.

And the whole point of Millian liberalism is that the individual is best placed to decide about their own ‘pleasure’ in various activities, so it would be odd if the state stepped in and said this is where the perfect equilibrium lies.  This correspondent seems to be objecting the fact that the state hasn’t done this, at the same time as complaining that effectively it has.  I’m confused.

Some of those writing in are clearly highly motivated to find out about this issue, and highly qualified, seeing as they’re listed as doctors and professors.  And yet they’ve failed to read (let alone understand) what’s already available and clearly signposted.  So what hope would the rest of us (most of whom aren’t actually that interested in the detail) have of finding out and understanding without providing these simple guidelines?

So I still can’t see what harm having guidelines does.  And if we’re having them, what’s so wrong about something that gives the level at which you’re taking the same risk as the average car driver?

Sure, they don’t deal with all the myriad problems alcohol can cause.  And they won’t be effective for everyone.  And they aren’t the only policy tool available.

But while alcohol is legal, isn’t guidance on risk something a consumer should reasonably expect to be given?  In fact, we even give this kind of guidance about ‘safer’ consumption levels/patterns/settings with illegal drugs: always use with other people; never share or re-use injecting equipment; smoke rather than injecting; reduce your dosage after a period of abstinence; and so on.  Maybe alcohol users deserve the same courtesy we grant users of other substances?

Friday 8 January 2016

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.)

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.