Tuesday 9 July 2019

Why secondhand drinking isn't like secondhand smoke

This week the Guardian have published a piece highlighting the indirect harms that can arise from drinking.  This is important stuff that should be more prominent in alcohol policy debates.  Too often, issues around alcohol policy drift into the classic libertarian territory of saying that it’s simply someone’s individual choice what they put into their body.

This position neglects two key points.  First, decisions are made in specific contexts that have been designed, consciously or not, by policy.

Second, our decisions have impacts on other people; no man is an island.  The classical liberal debates about alcohol aren’t simply about whether alcohol enslaves the individual drinker, as JS Mill put it, but also in terms of his ‘harm principle’: do your actions harm those around you?

The article in the Guardian lays out quite clearly some potential harms from other people’s drinking: violence, drink driving, neglect, abuse, and so on.  And Ian Gilmore makes what seems an obvious comparison with passive smoking.  Indeed it’s referred to as ‘secondhand smoke’, and the title of the article refers to secondhand drinking.  We’ve been here before.  In 2009 Liam Donaldson referred to ‘passive drinking’, though the concept didn’t get much traction.

I should be clear that I think discussing these very real and serious harms is important, and can – indeed should – reshape our debates about alcohol policy.  However, this analogy worries me, for all the usual reasons I write about on this blog.  We need clarity and honesty from messengers on this issue for two reasons.  First, you want to protect your reputation as a messenger for being open and truthful.  Second, and much more importantly, you actually want to generate the best policy solutions, which means being clear about what exactly the problem is.

For ‘passive’ or ‘secondhand’ drinking, the problem is qualitatively different from ‘passive’ or ‘secondhand’ smoke.  If we base our solutions for alcohol simply on analogy with tobacco, we’ll make some serious mistakes, as they’re quite different drugs, perceived quite differently, that play different roles in our society.

Crucially, the danger with passive smoking is in the substance itself: someone else is exposed to the toxins in the smoke.  This is the key justification for the smoking ban: you physically need to separate non-smokers from smoke to reduce their risk of developing certain health issues.

For alcohol, this does not happen.  A child might access a parent’s alcohol, for example, but this is not ‘passive drinking’; it’s actual drinking.  The harm comes not directly from the substance, but indirectly through the person using it.

As the Guardian piece points out, there are all sorts of harms that are related to alcohol.  However, these are quite different to those related to tobacco.  People in smoking areas tend not to start fights after they’ve had just a few cigarettes.  People tend not to fail to get the children to school because they’ve been busy smoking too many cigars the night before.  You don’t have a few pipes of tobacco and become incapable of driving safely.

To be fair, I think Ian Gilmore knows this.  He explains that the smoking ban, which he sees as a positive policy intervention, was only possible as a result of increasing awareness amongst policymakers and the public that secondhand smoke is bad for your health.  But he then recommends a completely different policy solution for ‘secondhand drinking’: increasing duty, and therefore the price.  This is genuinely analogous to tobacco – but analogous to an intervention introduced to reduce harm to the smoker, not those around them.  The idea is that higher taxes both reduce consumption and enable society to pay for the treatment of health conditions of those who do continue to smoke (though the cost-benefit analysis of the latter point is much debated).

What Gilmore is really doing is being disingenuous, or more generously being a pragmatic lobbyist.  He states: “Secondhand smoking [as a concept] really changed public opinion and paved the way for legislation to make bars and public places smoke-free.”  Here he is stating his lobbying approach.  He wants to establish secondhand drinking as a concept in public opinion so that different policy solutions are contemplated.

And this is fine by me.  If we define the problem differently (it’s not just about harm to the individual drinker, but the people around them too) then it’s reasonable we should consider different policies to address this.

The problem is that tobacco is a poor comparison because of what causes problems and what it’s place in society is.  And in pragmatic terms this is important not just because we want to have accurate descriptions of reality, but because lobbyists want to use the right tactics.

But for the moment let’s just focus on the reality.  Most of the problems with tobacco are about tobacco.  If you replace the tobacco smoke with other ways of getting the actual drug – nicotine – then suddenly much of the harm (to others as well as the person using) disperses too.  When we’re talking about bans on e-cigs, we’re in the slightly trickier territory of JS Mill’s use of the word ‘nuisance’ rather than his clearer idea of ‘harm’.

As I wrote last week, many of the problems related to alcohol are not neatly about alcohol.  We can take the substance away and still not resolve the underlying issues.  A reductive focus simply on price and availability will not serve those who still end up drinking – and those around them.  When we discuss the harm of ‘secondhand drinking’ we need to be thinking about treatment, culture, education, social support, wider resources.  I worry that the analogy with tobacco leads people to a narrow set of ‘solutions’.  Gilmore states: “[With cigarettes] we have relentlessly pushed the price up.  Quietly, but relentlessly.  And that’s made a huge impact.  The UK is the leading European country in reducing smoking rates.”  The analogy remains and the conversation comes back to price.

‘Passive drinking’ never caught on as a concept.  Maybe ‘secondhand drinking’ will, but it needs to mean something more than an analogy with smoking, otherwise the public and policymakers will, quite rightly, see through it.  We can do better than this.  Let’s be open and honest about this issue (as most of the Guardian piece is), and work from that to realistic, sensible policy interventions.

Wednesday 3 July 2019

There but for the grace of God

Over the past few weeks, and in my previous blog post, I’ve been debating how we can best think about the support our sector tries to offer.  Sometimes this is about structures of oversight and how different services are divided up, but I’m frequently reminded of the possibly trickier issues of funding and stigma.  In this post I want to suggest they’re all potentially linked.

As I say, I’ve been thinking about targeted support and stigma a lot recently.  It’s the old issue of how you can offer targeted support to those who need it most, without creating a perception of them somehow being less than ‘normal’ people – a perception that will quite possibly make people less likely to seek out that support, as doing so would identify them as ‘in need’ or ‘at risk’.

This is a standard social policy issue, applied to school meals, university fees, child benefit, and so on.  In general terms, the argument would be that since the 1980s we have seen a move away from these approaches to something more targeted.

While there are potentially issues with this ‘targeting’ approach, the logic makes sense, and to a certain extent it’s unavoidable.  If we have limited resources, we have to ask how we can prioritise different issues or individuals.  This might seem to have become more severe during a period of austerity, but it’s not an issue that goes away: if we get an increase in funding, there will always be more worthy causes and good ideas than it can support.

But I’ve been conflating two ideas here: targeting issues and targeting people.

We will always have to balance up different initiatives or issues.  For example, are we more concerned about TB or measles as infectious diseases at the moment?

Think of this as comparable to when you move house.  You might well debate whether to redo the bathroom or kitchen first – or perhaps at the time it’s more of a priority to repaint a few other rooms.  Most of us don’t have the time or money to do everything at once.

That happens in all departments and policy areas.  We live in a finite world.

So why am I worried about stigma?

Well, targeting issues is not the same as targeting people.  (And even targeting issues can cause stigma if we see those issues as only relating to certain people.)

Let’s compare the attitude to prevention for measles and cervical cancer.  Both are prevented through vaccination, and there have been issues with ensuring coverage of both – but for quite different reasons, I would suggest.  The MMR scare has been well-documented.  The issue there is seen as being in the vaccination itself.  Some people perceive it as risky.

The issue with the HPV vaccine (though it doesn’t seem to be talked about much anymore) was that this was a sexually transmitted virus and so there was some concern that admitting to needing it was an acknowledgement that you, or perhaps more accurately your daughters, were likely to have unprotected sex.

The framing of this as a population issue helped get us over this: the vaccination is just something that health professionals recommend for everyone, to reduce our risk at a population level.  This is framed as leading to ‘community immunity’ as some people call it (to avoid thinking of people as a ‘herd’).

So what’s this got to do with alcohol?  Well this is again that old issue of whether ‘the problem’ resides in the substance (alcohol is ‘no ordinary commodity’ – a carcinogen, a toxin or a poison) or the person (‘I am an alcoholic’).  I’ve written about this before, and my usual get-out is that there are as many problems related to alcohol as there are individuals experiencing them.  We therefore shouldn’t search for a single diagnosis or solution.

But this doesn’t really help policymaking in lots of contexts.  Saying ‘it’s complicated’ (or more likely in policymaking circles ‘complex’, ‘multifactorial’ or ‘wicked’) doesn’t get us very far.  What are we going to actually do about that complexity?  (Actions speak louder than words.  You talk, we die.)

This is particularly acute when we know that, even controlling for the total amount of alcohol consumed, different groups of people experience different levels of harm.  This is partly due to certain protective factors and differences in patterns of consumption, but it’s also because risks don’t seem to just add together, they multiply.  Drinking and smoking and low levels of physical activity combine to make a particularly toxic combination for a range of health risks.

I say ‘different’ groups of people.  I mean class.  People from more deprived areas face higher levels of alcohol-related health harm even though, on average, they’re drinking less.

What can we do about this?  And what can we do about the fact that dependent drinkers are not a particularly popular group, and people find it hard to say ‘there but for the grace of God go I’?  Is this difficulty in identifying with ‘alcoholics’ partly due to the Alcoholics Anonymous approach of defining ‘alcoholics’ as a distinct, tightly defined group of people?  If we want public support for treatment or prevention, we need people to identify with those facing issues – unless we want to resort to the ‘mad, bad and dangerous to know’ approach that justified funding drug treatment in the 2000s.

Kettil Bruun and others solved this by suggesting that interventions should address a whole population (the HPV and measles approach), whereas Michael Marmot, thinking about wider public health issues, proposed something called ‘proportionate universalism’ in an attempt to square the circle: support is universally available, but targeted and made accessible for those most in need or traditionally least likely to make use of it.  Both represent a response based on the understanding that we live in a class society, which shapes both material resources and status.

So what does this mean for us today?  What are the burning issues in alcohol policy where this is relevant?

Well I’ve been thinking recently about two popular ideas.  One is labelling of alcoholic drinks, and the other is their idea of improving funding for alcohol treatment – perhaps through a ‘treatment levy’ as Alcohol Change have suggested: a specific addition to alcohol duty that is ringfenced to support alcohol treatment in the UK, which is still in some senses the ‘poor relation’ of drug treatment, which is not exactly affluent itself.

I think these two approaches (albeit slightly tweaked) have much in common, and can provide the best of the Marmot and Bruun approaches – which in themselves are attempts to get round that knowledge that, yes, alcohol is a potentially problematic substance for all, but perhaps we’re not all equally at risk.

Labelling is not simply about individual level decision-making on a specific occasion.  If we model it in that way, there’s a danger that (thinking about calories, for example) someone might choose to have a few vodkas rather than just one glass of wine, and end up drinking more alcohol.  For me, the point is more to create that general perception that for everyone alcohol is no ordinary commodity, and has risks attached.  That can then shape decision-making and culture in the longer term, both at an individual and population level.

I don’t want to overstate the potential of this.  More fundamentally you could ask the question why this information is displayed on other drinks but not ones containing alcohol.  But there is a neat dovetailing with the need for funding for alcohol treatment.

This levy is designed to specifically improve alcohol treatment, which supports people with the most serious problems but perhaps doesn’t do as much as we might hope.  In England, treatment services engage more than 50% of all people estimated to be using heroin, whereas they manage about 15% of people drinking dependently, which itself is a narrow definition of having a problem.

Specialist treatment, then, is focused on those most in need.  And here we return to the example of HPV.  If we think of the treatment of cervical (or other) cancers, debate tends not to focus on the fact that many of them are linked to ‘lifestyle’ factors such as smoking, drinking, diet, exercise, sexual behaviour (in terms of virus transmission).  Cancer is seen as a lottery and people should be treated.  Alcohol dependency is not viewed in the same way.  As in the HPV example specifically, it was seen as being linked to individual personal choices.

And this is where the idea of an alcohol levy, though logical, has some challenges.  It is an addition to alcohol duty, designed to support services that only serve a minority of the population.  I think that, rather than a levy, a more achievable idea is a broader ‘rationalisation’ of alcohol duty.  There is some appetite for this – and from organisations like the IFS, not just alcohol specialists.  From a political perspective, as I’ve noted elsewhere, there’s an opportunity to frame this kind of change as a positive of Brexit; something that I imagine politicians will be keen on (if this ever goes ahead).

The other advantage of this framing is that it feels less like a targeted tax all drinkers pay for people who have problems they don’t.  Of course this is the basic principle behind taxation and public services, but that doesn’t mean it’s an easy sell when this discussion is only about a particularly challenging issue.  If this allocation is contained within broader alcohol taxation (and I still support the idea of a hypothecated tax to produce a ringfenced budget) then that debate about the principle of ‘who pays’ is less at the forefront.  This is potentially a virtuous (or vicious) circle.  If we believe general taxation is for issues that affect us all, and alcohol treatment is funded in this way, then perhaps we might start to see alcohol treatment less as something that is for a special category of people.

And this links with the idea of labelling, which presents alcohol as a substance that comes with certain risks.

Crucially, though, this is different from the total consumption / whole population model of alcohol harm.  It acknowledges that alcohol is not all about risks adding up and leading to harmful health conditions, or even the slightly more subtle point that if we all drink more at a population level there will be more dependent drinkers.

The point is that there is, to some extent, a special category of people who are facing bigger challenges than the rest of us.  Their issues aren’t simply hangovers, ‘presenteeism’ at work and failing to fulfil some imagined potential.  But also, as with most other health or social issues, we can’t perfectly predict who they will be.  The point is to generate not just sympathy but empathy for those who need treatment.  ‘There but for the grace of God…’

Monday 1 July 2019

Local substance misuse services or national everything services

Whether it’s in relation to alcohol or opioid treatment, I’ve been thinking a lot recently about how people might need support specifically in relation to certain substances (as opposed to ‘substance use disorders’ or wider issues related to health or social care).  That sounds a bit cryptic, so let me try to explain.

As usual with this blog, it’s not an original or mind-blowing insight, but something that keeps occurring to me that I think we should remind ourselves of more often.

When we discuss treatment or policy, we often do this by substance.  So there’s been discussions of alcohol labelling recently, and a growth in personal testimonies of how giving up alcohol makes people fitter, happier and more productive (recently Megan Montague’s Sober Story caught my eye).  And there’s discussions locally and nationally of how we can specifically improve opioid substitution treatment (OST).

But as we know, if ‘addiction’ is anything, it’s about more than a substance.  It’s about all those things we label ‘recovery capital’ – health, housing, employment, relationships, etc – whether for good or bad.  To a certain extent, substance use becomes a ‘substance use disorder’ when it starts to have negative effects on other aspects of a person’s life.

And so it’s unsurprising that people find it hardest to change their patterns of substance use when the challenges they’re facing – and their reasons for using – are not just about the substance.  It’s people with the least severe issues for whom the substance is the primary problem, and it’s these people who are best served by interventions that focus on the substance itself – like alcohol brief interventions.

And yet when we talk about treatment services, we’re generally thinking of things that are designed for those most in need of support.  We know that most people ‘spontaneously recover’ without formal support, as a result of their own thinking and support from friends, family and the wider community.

And yet the services we provide – which should be replicating those supporting factors like employment, housing, family, community – are typically labelled ‘drug’ and/or ‘alcohol’ treatment services.  In fact it’s not just that they’re labelled in this way; we commission and provide them separately from housing, employment, and other health and social care services.

This doesn’t make sense to me.  And in conversations and meetings over the past few months and years I’m encouraged by the fact it doesn’t seem to make sense to anyone.  I’ve written before about how substance misuse treatment can feel neither part of the ‘health family’ or social care and other related services, and given the cross-cutting nature of these issues there’s no point in searching for the ideal institutional ‘home’ for this agenda.  But equally, it’s inefficient (and exhausting) for local areas to be reinventing the wheel, and I think there are some structural and policy changes that could make this easier.

This doesn’t just mean devolution of budgets, though that might make collaborative work easier.  I still don’t think there’s a magical solution, and the key is to get relevant people to work together better at a local level – not just on the frontline, but in linking policies and planning.

This isn’t an endorsement of localism, though.  Without some form of external prompt, when we’re under pressure we often have a default of ‘tending our own garden’.  It can seem not just comforting but a priority to focus on what we can control ourselves and JFDI if we want to make a genuine difference.

The problem is that this isn’t the most efficient way to deliver support to the people we’re most concerned about.  There is a role for national organisations like PHE to be that voice reminding us to look up and think about the bigger picture.  Actually, it needs more than just a voice.  Recommendations are often disregarded, or considered to be stating the obvious – even if they’re equally obviously unachievable.  Requirements, from an agency with teeth, can drive these conversations, particularly in the areas where collaboration is most challenging.

In searching back through this blog to see when I’ve written about this before, I notice a striking, brief piece from several years ago.  Nothing has changed as yet, but the sheer weight of reports and recommendations from organisations like the ACMD do genuinely seem to be making a difference.  More and more people seem to be agreeing with the idea that strengthening national guidance and oversight (even commissioning at a national level) would be a step forward, and I get the feeling that key people with influence at a national level are taking this on board.  Here’s hoping.