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.

Addiction, medicine and local public health

The Chief Medical Officer, Sally Davies, caused a bit of a stir a week or two ago.  On BBC Radio 3’s “Private Passions”, she acknowledged that she had taken cannabis a few times, in cookies.  This excited the Daily Mail, mostly for the apparent scandal of a senior public (health) figure admitting to having taken illegal drugs.  Ears also pricked up in the world of drug and alcohol policy, though, as Davies stated that addiction was a ‘medical’ condition.

I’m not sure I agree.  The term addiction isn’t clear.  For a start, you can distinguish it from physiological dependency, which can wane relatively quickly, while addition persists – that is, if you follow the EMCDDA in defining addiction as the “repeated powerful motivation to engage in an activity with no survival value, acquired through experience with that activity, despite the harm or risk of harm it causes”.  (On addiction, it’s worth listening to the beginning of this Radio 4 programme on addition, or reading this book.)

To an extent this is simply to acknowledge the psychological element of addiction, and that doesn’t in itself mean the phenomenon isn’t medical.  However, I’d argue that this idea that addiction is – or should be treated as – specifically or primarily medical is unhelpful.

We know that people’s health is affected (even determined) by factors that might not be thought of as directly medical: inequality, housing, social networks, the built environment.  And someone’s ability to overcome an addiction is affected by their ‘recovery capital’ – pretty much those exact same factors.

To suggest addiction is purely medical runs the risk of implying that, as a physiological problem, detox or a methadone script should resolve it.  This could detract from the attention that should be paid to secure housing, employment, social networks and all those other factors that influence how likely someone is to recover.

This is one of the reasons to be cheerful about substance misuse treatment now being housed in local authorities as part of public health structures: in theory, this should make it more likely that public health interests will be taken into account across different areas of local policy, from schooling, through transport and planning, to licensing.

In fact, it’s one of the reasons to think that public health is the right place for substance misuse as an agenda generally: public health should be about all these wider factors.

However, as I’ve suggested before, given the way we understand and regulate intoxicants in the UK, health issues aren’t the only ones that relate to substance misuse.  For example, Paul Hayes, former chief exec of the NTA, has noted the importance of the crime agenda in garnering support for drug treatment within government.

As with the definition of ‘addiction’, it isn’t always clear what is meant when people talk about drug-related crime.  Peter Ferentzy is probably right when he asserts that much violence described as ‘drug-related’ would be better described as ‘prohibition-related’, in the same way as we talk about Al Capone’s exploits.  And the Guardian editorial that commented on Davies’ point made a similar claim, but to hint at the advantages in decriminalisation or legalisation.

This is of course one of the underlying aims when people talk about treating addiction as a medical problem: the ‘addict’ shouldn’t by definition be a criminal.  But that’s different to Ferentzy’s argument, where he’s talking about violence/crime relating to the trade in drugs, not the taking of the drugs.  And being addicted to something isn’t a crime in Britain.  What’s criminal is possession of illegal drugs.  In fact, you can access physiological and psychological treatment for addiction on the NHS.  (I should actually say: via your local authority through a range of local or national providers, public, private or charities, but free at the point of use).

When we think of addiction as causing crime, we’re mostly thinking about shoplifting and so forth to fund a habit.  And that is drug-related.  It might be that legalisation could reduce crime – but only if people funded their use without committing crime.  One way that could happen is if legalisation made drugs cheaper*, but this would seem unlikely.

This is one of the reasons I’m cautious about drug treatment budgets being placed within public health: a key benefit of these services – and how these have been justified politically for more than a decade – is their role in reducing crime.**  Crime is only an indirect concern of public health, in that it reflects and reinforces a lack of social capital and security, which can affect health.  It is not included in the Public Health Outcomes Framework (PHOF)***, which is the primary structure according to which public health activities will be driven.

The other reason I’ve been cautious about the substance misuse agenda being housed within public health is that the public health perspective tends to think in terms of population-wide effects and activities.  MUP is (to some extent) a classic case of this, as James Morris has pointed out.  Although it can be presented as a targeted approach, one of its attractions is that although it would only have a marginal effect on each individual’s consumption, when that marginal reduction in risk is aggregated across the whole population, the effect on morbidity/mortality is significant.

There’s been debate in the drugs and alcohol treatment field – notably from Marcus Roberts of DrugScope – about how this perspective might affect treatment services.  The concern is that, actually, a very small proportion of the population are in need of treatment for, say, heroin addiction, and targeting an intervention on a small group is counter to this approach.  (There is anecdotal evidence there’s some grounds for this concern.)  The old NTA arguments, of course, are built around on this very point: that small population of heroin users accounts for up to half of all acquisitive crime.

I’ve been concerned about this, every time I hear discussions about drugs and alcohol drift to the problem of those thousands who are drinking above government guidelines, or the seemingly growing problem of drinking amongst older people.

This is partly a turf war: I think I have a natural tendency to want to defend the areas of work I’ve been involved with.

It is partly from this insular perspective that I’ve recently thought of a reason to be cheerful.  Unfortunately, it undermines the reason to be cheerful about public health moving to local authorities.

It seems to me that there aren’t actually that many population-wide policies that can be implemented at a local authority level.  The most striking population-wide policy – MUP – would require a national policy, despite the hopes of local directors of public health.  Local initiatives – such as this one in Bournemouth – have proved fleeting, and tend to be voluntary.

Or think of putting cigarettes behind screens.  It’s hard to imagine local authorities being able to persuade multi-national operators to introduce this only in one area.

Of course, there are areas where local public health could make a difference – in fact, all those I mentioned above: transport, planning, education…  The difference is that in those areas the aim isn’t to introduce (or spend money on) public health policies; it’s to influence existing policy or activity by adding a public health perspective.

It’s harder to think of population-wide projects that are simultaneously local that public health could spend its considerable budget on.  There could be universal education and information campaigns, but it’s not clear that these have significant effects.  Rather, local public health campaigns are likely to be targeted interventions – those proposals to address older people’s drinking would would be targeted rather than population-wide, for example.  In fact, local public health teams are quite used to targeting particular areas.  For better or worse (and mostly simply for convenience) public health initiatives often focus on ready-made communities – most often working through schools, but also by targeting particular geographical areas.

So my reason to be cheerful is that in fact drug treatment could be justified in these terms; it is the targeting of a specific ‘problem’ group.

What I’m hoping, though, is that Public Health keeps that wider view and manages to have that same influence on other departments and functions of local government.

*My understanding is that there is less acquisitive crime related to alcohol addiction because this is a cheaper habit.  Of course, the flip side of this is that there’s a considerable amount of alcohol-related violent crime related to drunkenness, separate from dependence/addiction, which we might assume would fall if alcohol was less affordable and therefore less was consumed

**Police and Crime Commissioners (PCCs) do have some money that historically went towards substance misuse treatment designed specifically for those with a criminal justice connection (the Drug Interventions Programme – DIP), but this was only a small proportion of the overall spend on these services, and in many cases is unlikely to continue to be put towards treatment.
***Violent crime rates are included in the PHOF.  However, these crimes, if they are related to intoxicants, tend to be linked with alcohol and/or ‘recreational’ drugs used in the night-time economy, rather than the crimes typically associated with addiction specifically.  I should also note that treatment outcomes for opiate users are included, but only defined in terms of the proportion of those in treatment who complete successfully in the past year..  This means that you could scale back the scale of drug treatment and still maintain (even improve) performance on this metric.

My unhappiness with happiness

Relatively recently, happiness seems to have come to prominence in policy discussions.  David Cameron (initially) made it a centrepiece of the Coalition Government agenda, emblematic of the ‘new approaches to government’ promised in the Programme for Government.

This week ‘happiness’ has come my way twice.  (Spoiler Alert – it didn’t make me very happy.)

First, I read Brighton and Hove’s (vaguely) new Public Health annual report.  It’s ostensibly structured around the theme of happiness, with the title “Happiness: the eternal pursuit”.

Second, I read Hannes Schwandt on the LSE Politics and Policy blog.

Schwandt was writing about how we can understand the commonly noticed dip in self-reported life satisfaction around middle age by looking at the discrepancy between life expectations and reality.  Put in cartoonish terms, we become unhappy in middle age because we realise that all those youthful dreams that kept us going through our teens, twenties and thirties are no longer achievable.  Life ain’t what we’d hoped.  By older age, though, we’ve reconciled ourselves to failure, and even predict worse outcomes than tend to happen – so we’re pleasantly surprised.  It really does pay to lower expectations, it seems.

So why does all this talk of happiness make me unhappy?

Well, there’s a number of reasons.  (Obviously.  I couldn’t be brief.)

First, we could take Hannes Schwandt’s article as meaning that, rationally speaking, we’re not very good at judging what might be thought of as our own objective health or wellbeing.  That is, it’s our expectations of the world around us and our situation that make us ‘happy’ as much as those actual conditions.

If this form of subjective ‘happiness’ is an aim of government, I’m immediately reminded of something else that makes me unhappy: fear of crime.  Community Safety Partnerships and Police forces have as their strategic objectives making people feel safer.  Now, I don’t want to rehearse arguments that other people will understand much better than me, but the point is: PCSOs (to take the example linked to here) seem to exist as much to make people feel safe as to help ensure their safety.  A key role for PCSOs, according to the Met, is ‘closing the gap between the reality and fear of crime’.

I know that an idea of ‘objective’ wellbeing might seem ridiculous, but I think it helps to highlight that this is what government is actually dealing with most of the time: a set of conditions, or proxies (such as health or income), not actual ‘happiness’.

But perhaps, if happiness is the ‘eternal pursuit’, and national wellbeing tells one more about the country than national income, then these conditions and proxies government has some influence on are means to the end of ensuring ‘the greatest happiness of the greatest number’.

In actual fact, Schwandt’s analysis seems to suggest that a more direct manipulation of people’s happiness would be more effective.  He notes that we get used to our situation (e.g. level of income) and our happiness adjusts accordingly.  I’d have thought, therefore, the most reliable way to change our levels of happiness might be through some kind of ‘mindfulness’ programme that encouraged us to live in the moment – changing how we orient ourselves to the conditions we find ourselves in, rather than altering those conditions.

That is, you could say that if subjective happiness is government’s aim, and we know that people are unhappy when their hopes and dreams are dashed, we could make people happier by making them dream smaller.  I find this pretty discomfiting though.

Paul Willis’, Learning to Labour, a classic ethnographic work of young working-class Britons in the 1970s, outlines ways in working-class boys make a virtue of the (apparent) necessity of doing a working-class job.  

As Willis puts it in the opening sentences:

The difficult thing to explain about how middle class kids get middle class jobs is why others let them.  The difficult thing to explain about how working class kids get working class jobs is why they let themselves.

In this case, having some disconnect between one’s aspirations and the most likely reality would be a positive thing, regardless of the ‘unhappiness’ involved.  Perhaps people would be right to be unhappy at doing certain jobs, or facing particular living conditions.  You might even talk about false consciousness.

This has particular implications for public health teams if we take to heart the points in this recently published article, which argues that public health hasn’t taken seriously enough the structural factors behind health inequalities, preferring instead to focus on individual ‘healthy behaviours’.

And this doesn’t need to be about a left-wing conscience.  Those on the entrepreneurial right could embrace this wish for some kind of disconnect; where else does the ‘entrepreneurial’ or ‘aspirational’ spirit so beloved of many on the right come from?  In fact, what else is aspiration but an unhappiness with the status quo?

This discomfort raises the fundamental question: is happiness really, as Brighton and Hove’s public health team tells us, ‘the eternal pursuit’?  Or perhaps more importantly, should it be?

And in turn, this raises the more fundamental question of, well, what do we actually mean by happiness?

On this, I’m a bit torn.  ‘Happiness’ could be defined in a hedonic way, as pleasure, and this would fit with the fact that I’ve always said that I’d rather be a happy pig than an unhappy philosopher, and I think that’s probably still true to an extent.  It’s what lies behind some of my defences of ‘binge’ drinking: I don’t like the idea of ‘higher’ and ‘lower’ pleasures.  (I know that’s not a serious philosophical argument to say I ‘don’t like’ the idea, but it’s one of the levels at which I’m responding.  The other is Bourdieu.)

Of course we might mean something more like Aristotle’s ‘eudaimonia’, which I would approximately translate as ‘fulfilment’.  This sort of concept could be compatible with the Millian preference for unhappy philosophising.  It could also come pretty close to the Protestant Ethic, whereby we praise God by working hard to fulfil our potential in the God-given skills we’ve got.

In any case, whether in Aristotle or Mill, there’s an understanding that quite what this means might vary from person to person.  Moreover, there’s various ‘pleasures’ we’d need to balance (the ‘binge’ against the hangover).  So whether we mean pleasure or fulfilment, if ‘happiness’ is going to be the key duty of government, we probably ought to have a think about what goes into the concept.*

However, in the case of the Brighton public health work, we don’t need to have this debate.  It turns out that all the basic form of analysis is the same as previous years, and ‘happiness’ is just a way to structure a discussion of familiar stats on STI incidence, drug-related deaths, numbers of opiate users, prevalence of smoking during pregnancy and so forth.  It just so happens that all these things that public health teams have always cared about fit neatly with ‘happiness’: people who are less promiscuous, drink less, take drugs less often and so forth so that they are publicly healthy are happier (e.g. p.47).

In this way of presenting health as central to happiness, the Brighton report isn’t too far from David Cameron’s point early in the introduction of the ‘happiness index’, when he admitted that he would be concentrating on economic policy, because without money people wouldn’t be able to do the things they enjoy.

Or is it the other way round?  On page 4 of the Brighton report the suggestion is that ‘positive emotions’ make you healthy, and that’s why we should be encouraging ‘happiness’.  By this reasoning, happiness is a means to an end – public health.

Either way, I can’t really see that using the concept of ‘happiness’ helps us understand the issues any better.  Is health a good in itself?  Is community?  Or do we need to explain that people are ‘happier’ with them?  Rather than them enhancing my wellbeing, I think I’d start to find community and religion a bit depressing, actually, if the reason I was participating was to squeeze a few extra years out of my life.  (Now that really would be the instrumentalism in friendship that Winlow and Hall talk about.)

So, bluntly, there’s no clarity around what ‘happiness’ means.  I’d go as far as to suggest that ‘happiness’ is simply a way of obscuring genuine value judgements and balancing of competing claims – and that this sort of use raises more questions than it answers.

In fact, this is precisely what the Director of Public Health says about the report – as a boast.  He claims that readers will be ‘relieved’ (not ‘happy’?) that the report contains more questions than answers.  Personally, I’d like a few more answers.

*I could at this point turn this post into one of my usual complaints about how politics doesn’t focus enough on fundamental values and aims, with debate being conducted at the level of ‘we like good things’, where ‘good’ has been so emptied of content that it’s impossible to really disagree.  Then suddenly we move onto a debate about ‘what works’, as a rhetorical device to present as unquestioned what is actually a value judgement plus a compromise between competing interests, as a policy decision always is.

MUP vs BBCS

So the government has 'shelved' minimum unit pricing (though Public Health England still insists it's under consideration, but won't tell us how - that would be a matter for the Home Office).

This isn't really a surprise, as it was clearly hinted at by Anna Soubry on 2nd July, and then basically confirmed on 12th.  And further back, the government had clearly already cooled on the subject even before the idea was excluded from the Queen's Speech earlier this year.

The government has instead gone back to the idea of a ban on selling alcohol 'below cost' - i.e. below the cost of duty and VAT - originally promised in the Coalition's Programme for Government.  This is despite saying just over a year ago in the Alcohol Strategy: "We do not currently intend to implement a ban on the below cost sale of alcohol (defined as Duty + VAT)."  But then this was also the document that said, unequivocally, "We will introduce a minimum unit price (MUP) for alcohol".  MUP could be said to be the policy centrepiece of the document.

Yesterday, David Cameron said the new (or should I say old) proposal was 'effectively a minimum price'.  Indeed, Jeremy Browne's statement is careful to frame the measure in these terms: "It will no longer be legal to sell a can of ordinary strength lager for less than about 40 pence."

Now, setting aside the point I would make in an academic setting (that it says something about the views of this government that they chose lager as the illustration), this sparked me thinking about what is different between the two proposals: MUP vs below cost pricing.

MUP has been rejected because the government does "not yet have enough concrete evidence that its introduction would be effective in reducing harms associated with problem drinking, without penalising people who drink responsibly".  However, if there's insufficient evidence about MUP, surely there's also insufficient evidence about setting what's 'effectively' MUP?

In fact, if we take at face value the statement from the Home Secretary that the measures are to 'curb excessive drinking', it seems clear that there's less evidence that a below cost ban will 'work'.  Today, the Sheffield Alcohol Research Group that did the modelling on MUP that's often cited have published a clear comparison of MUP and the below cost ban.  The evidence of the model* is that public health benefits of BBCS, as they call it (Ban on Below Cost Selling), would be tiny compared to MUP at 45p.

It's for this reason that the decision has been branded 'disgraceful', for example.

There's obviously something else going on here.

MUP is generally understood by public health campaigners as in line with a population model (explained by James Morris here).  That is, reduce everyone's consumption by a tiny average amount, and the difference to any specific individual in terms of risk might be almost negligible, but when you add all this up across a population, you get a noticeable fall in the total harm.

However, this is not how the government has portrayed MUP.  Generally, it has been presented as a targeted policy.  The 2012 Alcohol Strategy was very clearly presented as dealing with 'binge' drinkers, with the Prime Minister's foreword beginning and ending with a reference to them.  It is in this context that the promise of MUP was introduced, with an explicit reference to problems caused by 'pre-loading' (drinking alcohol bought from a supermarket/off-licence before you head out to a pub or club).  David Cameron on another occasion explained that MUP was a way of stopping families with a 'reasonable drinking habit' subsidising 'binge' drinkers.

I don't really know what this difference in understanding of MUP is caused by.  It could just be a way to 'sell' the policy to a wider public, using 'binge' drinkers almost as a cover.  It could be a genuine belief that this is how the policy could or should work.  It might, perhaps most plausibly, represent genuine confusion.  Or maybe it reflects the kind of wishful thinking that seems to dominate alcohol policy discussions: that despite the fact that there's a myriad of 'problems' associated with the substance, somewhere out there is a single policy or initiative that can deal with them all.  The debate around MUP seems to have taken this form, with it being seen as the solution to all ills.

I don't think this representation of MUP is any kind of cover.  I would suggest that the government genuinely believes that alcohol-related issues are caused by an 'irresponsible minority', and that those with a 'reasonable drinking habit' should be largely left alone.  The idea of a 'reasonable drinking habit' as something that should be seen sympathetically would certainly grate with a public health view of the world.

If this is true, then the government's ideal policy would not be population wide but something that's targeted.  And duty on alcohol is targeted (if in a slightly bizarre way), varying by drink type.  A key example of this is white cider, which is considered to be a particular problem by the government - so much so that legislation was introduced in 2010 in order to define it as a separate drink.  If my calculations are right, the below cost ban would make 3 litres of Frosty Jack's £7.65, compared to £2.75 in 2010, according to the Daily Mail.  Meanwhile, a bottle of wine will still be able to be as low as something like £2.20.^†  This is precisely the sort of targeting that I can imagine the government being in favour of.

UPDATE 18-07-13
John Holmes of the Sheffield team has informed me that in fact Frosty Jack's isn't taxed at the spirits rate.  That makes me confused about what exactly the 2010 duty change can possibly be doing.  I'm trying to find out what on earth its point is now by the questionable mechanism of Twitter.

In light of its shelving of standardised packaging for tobacco as well as MUP, the government is currently being characterised as in hock to big tobacco and alcohol, symbolised by Lynton Crosby's lobbying connections.  Just like with the Labour debates around union funding, I think it's a lot more complicated than that.

This could be linked to broader ideas of neoliberalism, and I think this helps understand where the government is coming from.  The targeting of individuals comes from the same place: the fundamental approach to government is that market forces should be allowed to roam free, and undesirable outcomes that arise are the fault of flawed individuals, rather than flawed structures.

I've said before that there's a reason big tobacco gives to think tanks like the Adam Smith Insitute: it's not so much that they'll be easily swayed by the cash; it's more that they're already inclined to agree with the idea that the tobacco industry (like almost all others) should be free to operate in a largely unregulated market.

Similarly, at the moment both Coalition parties are led by individuals with a fundamental belief free market principles, and I'd suggest that the idea of banning below cost selling fits more neatly with a free-market worldview than a minimum price (above this level).  Of course in other contexts loss-leading is considered a legitimate tactic within the market.  But then maybe this could be justified by saying that alcohol is no ordinary commodity.  (The distinction here seems to be more one of an impression rather than substance, as the practical difference between the two interventions seems marginal.)

So my conclusion is that MUP has been shelved because the government simply doesn't have a public health philosophy (in terms of defining either the problem or the solution) and it is ideologically defaulted to protecting the free market and targeting apparently problematic individuals.

(As with the issue of the industry funding think tanks, we probably get closer to the heart of the Lynton Crosby issue if we start with the fact that Cameron is the sort of person who would hire a person like Lynton Crosby, who has all these sorts of alcohol and tobacco industry links.)

For public health campaigners this might seem like an unfortunate blow.  However, I want to end on a positive note, so I'll make two points.

First, public health concerns aren't the only issue in alcohol policy, as I've said before, and so we shouldn't expect them to trump everything else - and we should remember that MUP wouldn't have been a panacea for all alcohol-related issues in any case.

Second, and somewhat flippantly, it's nice to know that the population-wide model doesn't always win out at the expense of targeting.  One of my roles is in commissioning drug treatment, and the general approach of this - targeting a few thousand individuals in an area, rather than a few hundred thousand - sits somewhat at odds with the public health population-wide model.  Targeting can sometimes be helpful.  Unfortunately, it can also be stigmatising - but that's something for my next post.

*Some representatives of the alcohol industry would want me to point out that this isn't really 'evidence' according to their definition, as it doesn't look at something that's actually happened - it's 'only' modelling.

^†This is based on the figures on p.7 of the Sheffield report, which give spirit duty+VAT as 33.9p per unit, and wine as 24.5ppu, assuming 9 units in a bottle of wine and 22.56 units in a 3l bottle of Frosty Jack's.

E-cigarettes and a new culture of intoxication?

I've talked about e-cigarettes before, and they still fascinate me as a case study in intoxication, whether it's the comparison with alcohol and the idea that there might be a 'complex', 'premium' aspect to the product beyond the nicotine, or the comparison with medicines.

One of the ongoing issues with e-cigarettes is the possible 'gateway effect'.  That is: if they're not properly regulated, young people will be able to easily get their hands on them, and then they might develop a nicotine addiction and graduate to the hard (harmful) stuff, 'real' tobacco.

Clive Bates has challenged this idea on his blog, and I'm inclined to agree with much of what he says.  However, it led to an exchange on Twitter with Andrew Brown, who pointed out this brand of e-cigarettes, which particularly plays on the connection with 'real' cigarettes.  The packs look like cigarette packets, even down to mimicry of the paper seal you sometimes get, and the e-cigs themselves look almost exactly like 'real' cigarettes, with a 'filter' and a white main section.  The tastes and strengths are described by direct comparisons with certain brands of cigarettes, the word 'smoke' is used right across the website and branding, and the advertising slogan appears to be it's "OK [to] enjoy smoking again".[1]

Andrew has posted very promptly on this, following another Twitter exchange today.  Because he's sensible, thoughtful, and expresses himself clearly, he's careful to note that he's not actually sure what the right action might be.  I'm going to have a go at pinning down what I think, as the next step in what could hopefully be a helpful debate, but as a result this has been dashed off quite quickly, so apologies if it's not as neat and clear as it might be.

The issue here, placing ourselves in the position of all-powerful regulator, is working out what we might want e-cigarettes to do - and what we might not want to see.  So, one of the advantages to making e-cigarettes look like 'real' cigarettes is that they might be more attractive to current smokers, hopefully shifting them to what is generally understood to be a less harmful pastime.  However, the flipside of this is the fear about the 'gateway': if they're so similar, what stops someone (generally understood to be younger) shifting the other way?  And, regardless of age, there's concern from organisations like the BMA that e-cigs, particularly if 'vaped' indoors and in public, will re-normalise smoking, unravelling the apparent effect of the smoking ban that has made smoking seem abnormal.  I can see how this could be the danger with a poster that might seem to say it's OK to smoke again.

You'll probably have noticed by now that I keep referring to 'real' cigarettes, when I could have used a word like 'conventional' or 'traditional'.  This is deliberate.  If e-cigs are seen as a replacement, then the possibility is that they're forever be understood as an imitation, an echo, a shadow of the 'real' thing.

Attending the Under Control conference last weekend got me thinking about the pleasures of drug-taking.  (Well I did drink some ether and plenty of beer.)  So did reading this book chapter by Steve Wakeman about novel psychoactive compounds (NPCs) or as they're more commonly know, legal highs.  The point is, there's pleasure potentially associated with lot of aspects of taking what's seen as an intoxicating substance: the social aspect; something approaching a 'pure' intoxication; conversely an ability not to feel intoxicated; perhaps the frisson of doing something illicit, or frowned upon, or dangerous.

Few people will find the final of these thrills as important as Wakeman's participants, one of whom decided that there wasn't much of a buzz in highs that were legal, and so decided to snort them off his dashboard while driving (though he waited till he was stopped at traffic lights - safety first, kids!).  However, as I've said before, there can be something of a frisson in smoking, knowing that it might kill you.  This could be particularly powerful when combined with the sense of invincibility of youth that means you don't really believe it'll kill you.

This idea of cigarettes as attractive in part because they're dangerous would, I'd suggest, only be strengthened by the view that they are the 'real' thing, in contrast to bowdlerised e-cigs.  Of course, if e-cigs are a nicotine replacement therapy, as the UK Government seems to think, then this is precisely the view that must be taken.  According to this view, and following Ingrid Walker's presentation at Under Control[2], the medicine (e-cigs) is likely to be presented as involving choice and health, compared to the destruction and failure of the tobacco.  (We're going back to Sarah Wollaston's strange claim that tobacco only brings bad breath, disease and death.)

I'd suggest that this perspective - whereby e-cigs are simply there to wean people off smoking - is one that governments can feel comfortable with.  This gives a reason for having an intoxicant on the market - it's there to divert people from another.  However, if we're serious about getting people to move away from tobacco, I'd suggest this dynamic of real/fake isn't helpful.  To some extent, OK-cigs know this, and that's (paradoxically) why they've gone out of their way to mimic traditional cigarettes: they want people to feel that their product is somehow real.

But my point would be that the mimicry can only go so far.  I think it would be more powerful to be able to say:

"Here's something - not a cigarette - that does the same thing, but better.  It gives a high, but without so much danger - and also with more choice of what the device looks like and what the vapour tastes like.  There's much more choice, and less danger."

OK, you lose some of the James Dean frisson, but you can present e-cigs as positive and something worth doing in their own right, rather than a healthy, diet, responsible version of smoking.  You'd also cut down the dangers of re-normalising smoking or offering a gateway to cigarettes.  It is clear that this is in the minds of some people who are currently selling e-cigs, with the shop in Camden quoted in this article sounding like it's trying to carve out a particular niche for the market.

This approach would also have positives in terms of resolving the Wetherspoon's issue.  At the moment, regulating indoor 'vaping' is difficult.  If device manufacturers stepped away from conventional mouldings (maybe branching out into something like these) then that would make it easier.  Perhaps there could be special categories for different types of e-cigs: if you wanted to go down the medicine route, fine, you could make the device look like a traditional cigarette; if you wanted to market it as a new nicotine product, then you have to deliberately move away from mimicry.  Of course, there'd be difficulties in setting down guidelines like this clearly, but there'd be some merit - and it does happen in the field of BB guns, which can't look too much like 'real' guns.

Of course the reason the Government wouldn't feel comfortable with this is that it would be licensing something that could be labelled a new intoxicant.  Although I can't go into it here, I see a general reluctance to countenance the pleasure of intoxication in itself by government, and in this case there's also the additional factor that the drug (nicotine itself, not found in tobacco) cannot be dressed up as 'natural'.  However, in the context of 'legal highs', which governments around the world have struggled to regulate for, there's the possibility that these sorts of debates will be forced to move to new ground.  E-cigarettes are a much easier target than Benzo Fury or the latest NPC, but it's hard not to see the inconsistency in the situation.

Caffeinated drinks offer an interesting comparison.  Coffee or tea might be constructed as 'natural', but Red Bull and Relentless are not.  They are presented in the 'hit' or 'kick' formula that's familiar from the alcohol industry's response to rave culture.  I have heard youth workers and those involved in drug treatment express concern that these could be the next major issue for the substance misuse sector.[3]  And yet they are legal.

There are all sorts of other issues involved in this debate, which I don't have time to discuss here.  Most notably: first, the involvement of 'big tobacco', which I think could actually potentially be a positive thing (imagine if those interests were shifted to selling something less harmful); and second, the nature of addiction and free choice within a market.  However, I'm happy to leave this post with this question: why shouldn't e-cigarettes operate a little like energy drinks, carving out a market niche distinct from their traditional (natural) forebears?  There's plenty of possible challenges to this position - perhaps most powerfully something thinking about addiction - but I'd suggest it's an interesting alternative starting point for thinking about the issue, rather than seeing e-cigs as re-packaged nicotine inhalers.

[1]Alasdair Forsyth has made the interesting point that this approach might be in breach of a code or law, as the e-cigs don't actually produce any smoke...

[2]I should say that I might be mis-representing this as I'm getting it second-hand - I couldn't go as I felt I ought to think of the day-job and go to presentations (which were themselves fascinating) about methadone maintenance and safe injecting rooms.

[3]I think this is somewhat overstating the case, with there still being plenty of heroin use across the country, not to mention ketamine and mephedrone.

Public health realpolitik

I've written two posts recently about the role of the industry in alcohol and tobacco policy.  The principle behind these was that, following a particular model of how policymaking could or should be done, there's a role for both industries - so long as it's at the right stage of the process: defining what's a problem about tobacco or alcohol, and what sort of government actions are legitimate.  There's less of a role for the industry (if any) in assessing the validity of research evidence.

I started to think about this issue again recently when the Daily Express, amongst others, ran a story noting that the risk of cancer increased with the consumption of just two drinks in a year.  Some responded to this idea by suggesting that the public health lobby was in danger of becoming a 'lunatic fringe', and comparing it to the temperance movement.

This critique is based on the idea that such a small level of risk is largely irrelevant to people who don't live their lives as risk minimisers.  There's also the additional concern around 'crying wolf' that I've noted before with reference to 'binge' drinking social marketing: if you tell people a couple of drinks a year (or even a month) is seriously bad for you, then they might not listen when you're telling them that more than 21 units a week is genuinely risky (if that's a more important message to get across).

There are some fundamental arguments here about the nature of alcohol and the role of public health professionals and researchers.  One of the key distinctions between smoking and drinking in terms of public health ambitions and tactics, apart from the issue of passive smoking, is that there is generally considered to be a 'safe' limit of alcohol consumption.  Indeed, sometimes certain amounts of alcohol are understood to be beneficial.  This impression is only strengthened by 'responsible' or 'sensible' consumption levels, which then offer a concept on which to hang a narrative that constructs your own drinking as unproblematic.*

The presentation of this sort of finding that two beers a year might harm your health could be seen as attempt to change this impression.  If just two beers a year can increase risk levels, then the message seems to be that there's no safe level of consumption.  This is certainly what Stephen McGowan thought on Twitter, and to some extent it seems to be the motivation of Ian Gilmore in commenting on the findings that drinking even within the government guidelines can be risky and has links with cancer.

There are genuine arguments here about how best to communicate public health messages.  However, I'm not sure that this is actually based on calculations about how to best to engage people or change their approach to alcohol.  It seems more sensible to view it in the context of the arguments about the appropriate role of the alcohol industry in policymaking and the assessment of evidence.

Taking this perspective, the whole approach of both 'sides' in the debate (public health and the industry) is somewhat dispiriting.  On the one hand the industry steps in to rubbish research findings, when what it's really saying is that regulation of the industry doesn't fit the principles of maintaining the free market and personal responsibility that the government is often keen on in other contexts.  On the other, public health lobbyists are driven to stress that any form of alcohol consumption is problematic, in order to compete with the attempts of the industry to downplay the link between consumption and health harm.

Neither of these positions is helpful for an open, clear debate.  I can get particularly frustrated with a public health position because I think there's real opportunities for great work in this area.  With the move to local authorities there could be steps to improve wellbeing by integrating work with transport networks to encourage walking and cycling, with schools to encourage healthy eating, and with adult and community services to look at fostering the sort of social capital that we know improves health in the long term.  There's the opportunity to take a broader view of people's health, and really consider the wellbeing element as well as health as the absence of sickness.

However, the sort of risk minimisation approach symbolised by the 'two beers' story and all the talk of 'avoidable deaths' is too narrow.  Risk is unavoidable, and all lives end in death.  This isn't just about a critique of the Longer Lives project; I want to suggest that a grown-up debate about wellbeing would accept that sometimes drinking at a 'risky' level could still be beneficial for someone's wellbeing - particularly later in life.  (And this is in addition to the point I've made before about how rationalism needn't be a universal aspiration.)

The reason the public health lobby can't bring itself to do this, I'd suggest, is that it sees itself as locked into some kind of dialectical confrontation with the alcohol industry.  It's taking the view of a hardened haggler in a market: start with a ridiculously low offer, and you'll end up with something reasonable and acceptable, because the seller will start with a price far higher than the item's worth.

I'd suggest that this kind of adversarial approach does nobody any favours.  Public health gets branded as a 'lunatic fringe', and the industry gets labelled as misrepresenting, distorting and undermining research evidence.  Drinkers probably simply get on with their lives none the wiser either way.

My soft spot for corporatism wants me to suggest that this would be the solution, getting everyone together to discuss the issues.  But actually this is a little naive.  I forget that this approach brought down both Tory and Labour governments in the 1970s.  To some extent you could see corporatism, with its views of opposing factions, as cementing this adversarial approach.

But, in that case, how else can we approach policymaking?  How can we ensure that stakeholders take a grown-up approach?  That fundamentally requires a certain level of trust from both sides that the other will be sensible too.  It requires the different players to understand their roles, and stick to them.  Public health won't want to stop (excessively) highlighting the health harms alcohol can cause while the industry keeps its current tack, as that would mean the overall balance of the message to the public on alcohol would be (in their eyes) too positive.

The only way to encourage this that I can see is to have a strong government that is clear about the different roles of the various stakeholders in the policy-making process.  I can't see that being the government we have now.

*This is particularly the case when 'binge' drinking is largely defined in terms of an attitude towards to alcohol (drinking to get drunk), and so those who deny this motivation are able to construct an idea of 'responsibility' that isn't exactly what the public health lobby, at least, would like to see.

Tobacco funding think tanks

A week ago, The Observer reported that the Adam Smith Institute and the Institute for Economic Affairs both accepted funding from 'Big Tobacco'.  Most people, I would have thought, would find this unsurprising.  I certainly did, but more importantly I don't find it particularly shocking or outrageous.

 

I'm slightly concerned about writing this post, as it could be read as support for the tobacco industry, and some might see it as naive at best in seeing them as having a legitimate role in society.  I want to make it clear that this isn't what I'm suggesting (or even discussing).  I think it's fair to say that the industry has not always accepted responsibility where it might, and I'm of the opinion that if tobacco were discovered today I wouldn't want it to be legal.  However, we are currently living in a country where tobacco is legal and it is important to analyse how people understand policymaking in relation to this issue.  I want to suggest that a black and white, good and evil framework for understanding the issues is unhelpful, and may serve to fuel people's opposition to public health aims.

 

As a starting point, it's worth noting that the fundamental basis for the industry funding of think tanks being a news story worthy of attention is that there is some concern about transparency: perhaps the ASI and IEA were being secretive about who gives them money, which potentially contradicts WHO guidelines.

 

I'd certainly want this information to be openly available, for reasons I'll discuss later, but this wasn't actually the tone of the article and people's responses to it.  According to ASH Chief Exec, accepting tobacco funding 'completely undermines' one's position on related policies.  David Nutt remarked in mock-shock on Twitter 'And they're influencing govt policy?'  Neither of these objections is based on the apparent secrecy; they're attacking the more fundamental (rather than procedural) point that the tobacco industry shouldn't influence government policy, however indirectly.

 

Setting aside the issue of transparency (which admittedly is genuinely serious and raises fundamental questions about the role of business in policymaking), there are two reasons why I'm not perturbed - or at least, don't think this funding is illegitimate or shocking.

 

First, I've got a bit of a soft spot for corporatist, stakeholder government/decision-making, which probably influences how I start to think about the issue.  This is probably in part a romanticising of beer and sandwiches and life before Thatcherism - and it's certainly a romanticising of the role the tobacco industry has played in policy debates over the years.

 

However, it does have a sound basis simply because most policy issues have multiple implications and almost infinite possible perspectives, as I've suggested before here and here.  All policy-making is something of a compromise, so it's probably helpful to listen to a range of perspectives and points.  The tobacco industry will obviously defend itself, but then you'd also listen to a public health perspective, or someone with a more critical view of the role of corporations and profit in society.

 

Now, this might seem in contradiction of the WHO guidance on tobacco and policymaking, but actually what those guidelines talk about is partnership between government and industry, and voluntary codes of regulation.  They don't suggest banning the industry expressing its views as much as actually participating in the drafting of policy.

 

The second reason I'm not so shocked is that I think I take a slightly different approach to people's motivations.

 

The tobacco industry, like the alcohol industry, will use liberal (or libertarian) arguments to claim that individual consumers' choices should be respected and it's simply supplying a legal product in a regulated market.  On the other hand, some public health campaigners would characterise big tobacco as 'evil', self-interested and calculating - or even say that 'evil' isn't a strong enough word.

 

I'm interested here in analysing these ideas of free market liberalism presented by the industry.  I would emphasise at this point that worldviews and ideology aren't neutral, consistent, coherent, objective or independent and impartial.  My worldview is likely to say something about my background and my current activities (though it won't entirely explain them or be consistent with them).  This is partly because I might try to do things that are consistent with some set of values I consider to be important to me.  However, it's also because a worldview is in some senses a rationalisation of where we find ourselves, to help ensure some kind of psychological coherence.*

 

That people who work for tobacco firms have free market views isn't just a front; it's likely to be both cause and effect of their working for these firms.  It would be hard to work for an industry if you didn't, at some level, believe in some principles that make the tasks you undertake legitimate, even if this is some warped notion of the 'invisible hand' and the magic of the market that sees individuals' selfishness as part of a functioning mechanism that delivers positive outcomes for all.

 

The think tanks the Observer article mentions have mission statements that fit perfectly with such an outlook on political economy:

 

            The IEA is the UK's original free-market think-tank, founded in 1955. Our   mission is to improve understanding of the fundamental institutions of a free           society by analysing and expounding the role of markets in solving economic     and social problems.

            The Adam Smith Institute ... works to promote libertarian and free market    ideas ... the Institute is today at the forefront of making the case for free   markets and a free society in the United Kingdom.

I might be being generous, but I would suggest that those working for these think tanks 'genuinely' believe in these principles, rather than seeing themselves as some kind of Trojan Horse or entryists changing the nature of political debate to benefit their sectional interests.  Their acceptance of tobacco money should not be seen as some kind of Faustian pact, because this is not how they would see it.  Rather, it should be understood as the coming together of two similarly-minded actors in the policy debate.

 

It is not simply because they're taking tobacco money that the IEA and ASI are against increased regulation of the tobacco industry; the tobacco industry supports these particular think tanks because they are against industry regulation to begin with.  The same arguments apply to Labour and the unions, for example.

 

This is not a one-way causal relationship, as I've already suggested, and as such this is the point where the importance of transparency comes in.  Worldviews are not neutral, objective or impartial; they are particular perspectives, which owe something to the position and experiences of their adherents.  It's not unimportant that free market ideology in this context benefits big tobacco, and so if the argument is coming from this perspective, that might mean something different than if the claim is coming from a public health expert.  If organisations aren't clear about the sources of their funding it makes it more difficult to assess their perspective.

 

However, this is quite a different thing to considering the view irrelevant or illegitimate.  The public health perspective is equally as partial when it claims that smoking 'brings nothing but bad breath disease & death'.  The questions are about balancing freedom, profit, health, pleasure - and at a societal level, not as an individual, personal decision.

 

We don't get any closer to a resolution of the issue by framing the debate as a battle of good and evil.  Instead we should debate openly the principles that should underlie tobacco policy, the perceived problems and benefits of smoking and the industry according to these principles, and then assess proposals as potential solutions to these.  We're not helped in this if we see think tanks as amoral puppets of an amoral tobacco industry.

 

*I'm not saying that we ever achieve this kind of coherence - and crucially, it's not entirely conscious or calculating, just like worldviews themselves.  (Otherwise we wouldn't need analysis; people would just tell us what they think and that would be that.)  This is a common way of looking at how people understand and negotiate the world across the social sciences, not just in psychology.  The idea of habitus outlined by Bourdieu and others is one example.