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?


  1. Most people will ignore the guidelines. The people least likely to ignore the guidelines will be people in public health who will now have a much greater pool of 'problem drinkers' now that the guidelines have been lowered. This will then lead to the inevitable call for more taxes and restrictions to be placed on people to combat the increase in 'problem drinking'.

    Maybe that's why people get upset, cause we know from experience how public health operate.

    1. To some extent I think you're right about the guidelines, though I don't think people will exactly 'ignore' them so much as be unaware of them or their own levels of drinking.

      I've written about the danger of classifying more people as problematic drinkers, and I appreciate that, but that's not an argument against having guidelines in general and if these were to be challenged it would have to be on the actual methodology - though I still think it's interesting that the consultation isn't about the level. I wouldn't want to challenge the modelling, particularly, but I don't see why we shouldn't be thinking about what is an 'acceptable' level of risk, and what's the level that will communicate with people most powerfully.

  2. >>There’s careful discussion of this in the Sheffield model

    No, there's ill-informed and/or just biased consideration of this in the Sheffield work. But then again, they have form.

    1. I'd be interested in a careful rebuttal of the approach to risk functions used by the Sheffield group, for example the paragraph on Ischaemic heart disease p.27 of the Sheffield report. I'm not sure how they're biased - but if you can identify this from flaws in their risk modelling I'd happily be persuaded.

    2. There is such a huge volume of epidemiology around alcohol that activist/researchers can pick out tons in supporting any conclusion they wish to end up making.

      And you can object to my term 'activist/researchers' but in my several years of experience, 95% of researchers who come into the field don't see any good reason for alcohol, and most of their work is designed for advocacy, not revealing new scientific knowledge.

    3. I wouldn't deny that people bring their own baggage to the agenda; that's why I mentioned my own position on alcohol, and I think that's always clear in my writing. However, these guidelines are (and can only be) about the medical risks associated with alcohol. It's up to the individual to balance those against their likely pleasures. I don't think the researchers are advocating or misrepresenting, but I'd agree that they're presenting just one element of the picture that a consumer might need. I'm sure the discussion will develop as well through the consultation and further discussions around the exact number and risk levels applied.

  3. Sally Davies and her no safe level/old wives' tale rhetoric is indefensible. Even the RSS has written a letter condemning the evidence-free manner in which she and the DH went about their media operation. But badly behaved though she was, it's difficult to argue that people would be any better informed if they read the Sheffield report. I'll assume it's because you're a nice guy that you've omitted to mention that the rinky-dink J Curve in the Sheffield report - based on yet another theoretical model from the city of steel - bears no relationship to any J Curve based on observational studies, ie. what actually happens to people. When reality clashes so obviously with theory, it's better to side with reality.

    As for describing Sheffield's cherry-picking hatchet job on the health benefits of moderate drinking as a 'careful discussion', I think you need to have a lie down.

    I thought Winkler made a fair point about lowering the guidelines for alcohol, sugar etc. Aside from middle class hypochondriacs, people WILL ignore them. What he fails to appreciate - perhaps because he comes from an era when there was still an element of truth seeking in public health research - is that the guidelines are not designed for people to follow but for problem inflation. In this instance, to recruit another two million men into the dwindling ranks of 'hazardous drinkers'.

    1. I have to say I think this debate isn't so much about the science as the principle of guidelines. Most people attacking this would be challenging the guidelines regardless of the methodology or the precise number. I'd prefer it if they were up-front about that and could explain why giving a guideline is actually a bad idea.

      Winkler misses the point by talking about targets. There's plenty of problems with targets in managing organisations' performance, but these guidelines aren't targets to measure or drive Public Health or population 'performance'; there are already metrics for that on hospital admissions, treatment outcomes etc.

      Yes, I'd worry that this sort of guidance is only followed by those who need it least (and I've written about this already), but guidelines shouldn't be seen as the only intervention available and they contribute to a broader environment that helps shape discussions around alcohol.

      Personally, from my research I'd say government messages on alcohol (particularly 'binge' drinking) have been counterproductive because they give other drinkers a 'get-out' clause to con themselves about the risks of their own drinking. As I make very clear in this post, I don't have any problems with people drinking at higher levels than medical advice would recommend, but they shouldn't do so thinking that they're doing themselves good.

      On the J-curve issue, the risk functions are taken from existing research and show various shapes (see p.26 of the Sheffield report). But my whole point is that people are challenging the evidence when (a) they're not qualified to do this, having not read the material that's out there; and more fundamentally (b) this isn't actually why they object to the guidelines.

      What I'd like to see is some honesty and openness about why they're opposed (and Chris Hackley has given this, for example) - and some reason for me to agree with them. At the moment, I still can't see why guidance is a bad thing.

    2. "..I still can't see why guidance is a bad thing"
      But as Sally Casswell and others have pointed out, drinking guidelines don't change drinking behavior.
      Modern guidelines created along public health thinking serve two purposes: a)governments feel some advice should be provided by them - looks uncaring otherwise; and b) the advice becomes re-interpreted by alcohol regulators (Police, licensing, NHS, etc) as limits, above which people are endangering themselves and so should be restricted in all sorts of ways, usually involving taxes, availability and marketing.

    3. I don't disagree with this. Certainly public education campaigns relating to drinking are often more about showing voters that government is 'doing something' rather than actually changing behaviour. And I don't doubt that some people will apply the risk guidelines in the way you're describing. But that's partly because thinking about risk isn't something that's straightforward and we tend to distort or simplify the arguments. I'd prefer to advocate for a clear, open debate than say we can't use reasonable words and analysis because someone might misrepresent them. That just feels like giving up.

  4. It was Griffith Edwards who realised that the numbers of the UK's alcoholics did not matter politically speaking, so he created dependent drinkers. That was the start of 'problem inflation' of drinking.
    The next wave is Harm to Others.

    1. Again, this is really difficult, because one person's 'problem inflation' is another person's effective lobbying. You could say the same thing about the NTA painting drug users as criminals (but getting huge increases in funding thanks to New Labour's 'tough on the causes of crime') or universities boasting about 'employability' and 'transferable skills' in order to prove their worth to the economy (but meanwhile undermining other arguments for education). There's a lot going on when people distinguish between alcoholism and dependency or even heavy sustained use (see my post on addiction from October). And harm to others is absolutely genuine; just ask the child, parent or partner of someone with substance use issues - and those issues don't have to be something that's neatly labelled 'alcoholism' or 'addiction'. But yes, I take your point about the difficulty of expanding the perceived problem. I'd yet again appeal for a grown up debate - and that means that people need to stop claiming that risks from alcohol are only confined to those at the very top end of the spectrum of consumption. There's no doubt I'm putting myself at (some) risk from my own consumption, for example, but equally that risk isn't certainty of health harm.

  5. A grown up debate would look very different from the one we have now.
    But it will never happen. Far too much self-interest and too many careers to protect, and being an absolutist crusader for any cause is a wonderful boost to the self-esteem. There is immense ego appeal in trying to protect The People.

    This alcohol debate is really about differing values and visions of perfect society. Always has been, always will be. Debates about MUP or drinking guidelines are just skirmishes in a longer war.