Working with the alcohol industry locally?

I was at an LGA event on Tuesday called ‘Changing behaviours in Public Health – to nudge or to shove?’  (See #LGAcwb on Twitter.)  It certainly sparked my enthusiasm by showing how public health has been embraced by local authorities around the country, and how areas like Wigan and Hertfordshire seem to have successfully engaged wider partners, such as dentists and pharmacists, as well as getting councillors and council officers on board with the wider public health agenda.  These are all things I feel we could do much better in Dorset.

However, as usually happens with me, I saw things very much in light of what I’ve been reading and thinking about recently.

Claire McDonald spoke persuasively and openly about mobilising private interests to advance public health causes – mentioning Unilever’s initiative to boost handwashing (and/or use of Lifebuoy soap?) and her own initiative to prompt women to tell their GP ASAP (As Soon As You’re Pregnant).

I could feel myself bristling, simply because I have a natural suspicion of the profit motive.  However, given that we don’t have a nationalised food industry (although many public health professionals certainly aren’t comfortable with private food companies), I can’t help but accept that the market is perfectly capable of providing good things, and often efficiently.  If we want to wash our hands more often, and this is a good thing, what’s wrong with a company finding a niche (and some money) in this?

The workshop discussion on alcohol policy also raised the same issues of whether industry has a legitimate role to play, featuring Emily Robinson from Alcohol Concern alongside Elaine Hindal from Drinkaware (funded by the industry) and (much more open about his industry links) Henry Ashworth from the Portman Group.*

This discussion didn’t quite lead to the clear argument I experienced at last year’s DrugScope conference (perhaps an indication that Henry and Elaine pitched their message better to the audience than Mark Baird did there), but there was certainly some scepticism from those in the room as to whether the industry could really foster a healthier drinking culture (a straw poll revealed almost unanimous support for ‘shoves’ over ‘nudges’).

Now here’s my hobby horse (for this week).  I’ve been thinking about neoliberalism (resubmitting an academic article) – the point being that certain policy options around alcohol seem unthinkable because of the dominance of this ‘mentality of government’, when in fact they’ve been in place at various times and places in history.  Reading Intoxication and Society I was struck by the example from James Brown of schemes that pre-date the Central Control Board or Gothenburg System by hundreds of years – where government took the profit motive away from those running drinking venues, so that they didn’t have a reason to sell people more alcohol.**

Given that very few councils have introduced Early Morning Restriction Orders (EMROs) or Late Night Levies, it’s no surprise municipal pubs aren’t on the agenda.

But this isn’t all about the need to abolish the profit motive surrounding something that is ‘no ordinary commodity’.  Canada also had a comparable system of retail regulation, analysed in a new book by Dan Malleck: Try to Control Yourself.  Unfortunately, I haven’t read it yet (but consider this me proposing myself as a reviewer to any journal that will have me).  However, I have read the (free) review in Brewery History by Matthew Bellamy.  The review questions Dan’s argument that the regulation was a key element in reshaping Canada’s drinking culture such that, in Bellamy’s words, ‘Controlling oneself and drinking moderately continues to define an important part of what it means to be Canadian’ – in contrast with the situation before Prohibition in 1916, when ‘It seemed as though there were only two types of Canadians . . . those who drank to excess and those who did not touch a drop’.

Let’s set aside for the moment the point that immediately occurs to me, which is that, unhelpfully, we often have a similar (but mistaken) understanding of alcohol consumption in the UK today.

Bellamy’s critique of Try to Control Yourself is that actually the culture change isn’t all about the regulation.  It’s also about the brewers.  (He’s writing in a journal called Brewery History, after all.)  Having an (economic, profit-based) interest in temperance not winning the day, they found that they could embrace the model of the responsible ‘citizen-drinker’ the Liquor Control Board of Ontario envisaged.

You can see the same sort of motive operating in other times and places – Chris Routledge makes the point that the creation of the fantastic Philharmonic Dining Rooms (and other Cain’s pubs) in Liverpool was a deliberate move to generate a sense of respectability around drinking, enhancing its social, cultural – and therefore political and economic – capital.

And there are lessons in this commercial dynamic for us today.  Not only is the industry a legitimate stakeholder in alcohol policy formulation, but it’s not a monolith.  In the debate around MUP, some organisations were in favour, others opposed – the divisions weren’t always neatly predictable, and some companies shifted their positions.

In Bellamy’s interpretation, it’s the brewers who put the pressure on the hotel [pub] managers to run things smoothly.  However, this needn’t be the dynamic today.

To bring us back to the LGA conference, in the alcohol workshop discussion, there was little mention of on-licensees.  Where retailers were concerned, ASDA was mentioned, but most of the discussion was implicitly focused on the producers that fund the Portman Group – perhaps because this organisation is more open about its industry links, whereas Drinkaware is less directly the CSR arm of its myriad of funders (including plenty of organisations with on-trade interests, such as Admiral Taverns, JD Wetherspoon’s, Punch Taverns and Marston’s, for example).

To be fair, Henry mentioned schemes such as Best Bar None, and there’s plenty of work local authorities and public health teams have already done with such initiatives and more, working with the on-trade.  However, I’d suggest that if we’re looking for innovative ways to change drinking cultures, there’s more that can be done.***  There is serious mileage in Henry’s proposal for encouraging the ‘nudge’ of house wines being weaker, for example.  And in the context of Claire’s enthusiastic (or pragmatic?) embrace of Unilever and Merck/MSD as partners for public health change, the idea of having to shove the industry seemed dispiriting.  (Of course, we could come back to the idea that, unlike Lifebuoy soap, alcohol is no ordinary commodity, but then neither are pharmaceuticals.)

Thinking about culture change locally, the alcohol policy options that have been pursued in the past, and the possibility of harnessing private enterprise to benefit public health, it’s not so much the producers who are worth targeting as the retailers – and, I would argue, the on trade specifically.  This is particularly the case in the LGA context, when licensing (as opposed to MUP or taxation) is in the hands of local authorities.

The reason I think there’s more opportunity to engage the on-trade, if we’re interested in changing cultures around alcohol, is that the on-trade is no longer overwhelmingly reliant on the trade in alcohol.  That is, to some extent the situation produced by state regulation in Carlisle or Gothenburg has come about organically.  Although it’s an unusual case, I believe the majority of the turnover these days in student unions such as Bournemouth’s is on food and soft drinks including coffee and tea, rather than alcoholic drinks.

In the case of handwashing, Unilever have an interest in selling soap, but public health professionals want to encourage people to use soap, so working together seems plausible.  In the case of the on-licensed trade, the mix today is such that the interest in profit doesn’t need to be an interest in selling (only) alcohol – and so there may be a potential overlap between the licensee’s interests and public health.

There are of course several issues with this claim.  Most importantly, not all venues have the same model, and it’s those which are the most dominated by selling alcohol at the moment that are most likely to worry public health teams – and they’ll also be the least likely to have common ground.  However, the converse point is to look at research like this (by Adrian Barton) and see that ‘pre-loading’ often happens in part because drinkers don’t like the option they’re being provided with by such venues, particularly early in the evening.  And yet drinking at home isn’t always the best idea either from the perspective of government and public health, as an uncontrolled environment with little precision around units.  Might one potentially beneficial outcome for both public health professionals and local licensees be to encourage people it’s better down the pub – or at least certain pubs?

There are also wider challenges in shaping the policymaking context.  The argument that the brewers in Canada were in favour of the responsible ‘citizen drinker’ depends to some extent on the spectre of temperance and prohibition, when, as Brian Harrison put it, the world of temperance can seem a long way away, with ‘unfamiliar arguments and forgotten attitudes’.  And yet for such a faraway movement it provided the policymaking context for the drinking laws that were in operation when Harrison was writing and, in slightly altered form, for the rest of the 20^th century.  One can trace the influence of such campaigning even if none of the key demands are met.

Similarly, organisations like Alcohol Concern can see themselves as providing a counterbalance to the drinks industry, and helping to shape the terms of the debate and possibilities seen by government, merely by being part of public discussions.  Andrew Barr suggests that the formation of the Portman Group itself was a response to an emergent neo-temperance movement.

Thinking of Alcohol Concern as a counterbalance as a positive development sits somewhat at odds with my previous complaint of the zero-sum, realpolitik of the two apparently opposing sides in alcohol policy debates – though to be fair I did talk about the ideal dream world where different stakeholders come together for open and honest debate with their different perspectives...

But rather than this pessimism, I’d rather end in the same vein as I began: extolling another potential opportunity for innovative, helpful public health work.  Now would seem as good a time as any to think about how the on-trade could be encouraging public health.  Although there’s been good work so far, the opportunities for development are plentiful: as well as offering an alternative to pre-loading in city centres, the idea of the pub as the hub will resonate in more rural areas, enhancing social capital (and therefore health).  In such a world, the industry doesn’t sound an amoral product of the profit motive.  Maybe I am converted to public-private partnership…  (Well, not quite yet.)

If you’re aware of interesting, effective work already going on please let me know.  As far as I'm aware, the sort of development I'm proposing doesn't seem to have been a feature of Community Alcohol Partnerships, for example, but if things are happening that would keep the fire of my enthusiasm (and envy) burning a little longer...

*In a shameless act of self-promotion, here’s the link to my previous post on this issue – and here it is in a more public forum.

**For those who don’t know about these schemes, I can’t recommend highly enough reading about them in, for example, James Nicholls’ The Politics of Alcohol or Paul Jennings’ The Local.

***This raises the question of whether we actually want to change drinking cultures, and whether this is a legitimate aim of public policy.  I’m not actually sure, but for this article it’s taken as read because it’s clearly a current public health aim.  And, as I mention, there is something to be said for the industry representing its own interests and public health representing its own.  They might sometimes overlap, but they won’t always and that’s why it’s useful and interesting to hear both perspectives.

Breathalysers and drunk tanks

This morning I saw a story about breathalysers having been used in Norwich city centre to test people entering nightclubs.  I wasn’t excited or outraged by this, just confused.  I couldn’t see how it could be helpful.  However, it’s been bouncing around in my head, and after some helpful Twitter responses, I seem to have come round to thinking that it might be worthwhile after all.

Most of my posts on this blog are somewhat reactive and negative – talking about something that’s annoyed me, whether it’s Brighton’s focus on happiness in their Public Health strategy, the government’s decision to move substance misuse services into local authority Public Health teams, or the tactics of both the alcohol industry and public health campaigners.  The list could go on.  So it’s nice to actually write something vaguely positive for a change – and to feel that I’ve listened and had a think and changed my mind.

In the Norwich example, one of the points that made me initially sceptical was that as far as I could tell (and I watched the video through twice to try to make sure), there was no limit at which people would be turned away.  It seems more likely that bouncers would focus on the usual techniques of judging whether someone is drunk by their behaviour.

This raises all sorts of questions about the adequacy of breath tests.  First, there’s the claim that they are not an accurate indication of pharmacological intoxication.  Then, there’s the issue of whether a test that measures one’s blood alcohol concentration (BAC) gives us an accurate idea of what we might call ‘drunkenness’.  Although some previous research (thanks Matt Hennessey) has found a pretty decent match between BAC readings and subjective judgements of drunkenness, it’s clear from the approach taken here that, as entry will still be based on observed behaviour, there’s something of a PR exercise going on here.

As I’ve been reminded several times, we shouldn’t overstate the rationality or calculated nature of policy.  Sometimes, policymakers are as keen to be seen to be doing something as to actually do something effective.

However, let’s assume that it’s possible there’s something more to this initiative.  Even if it only runs for one weekend, it has still gained some press coverage and might highlight the issue of venues serving intoxicated customers, and the possibility of them being turned away at the front door.  As James Nicholls points out, clubs would have an interest in turning people away not just to please the police but if it changed people’s expectations about how much they could drink before going out while still getting into a club: the clubs will have an interest in initiatives that reduce pre-loading and push people to go out earlier and/or wanting more alcohol to get to their desired level of drunkenness.*

That is, the aim is that people will change their behaviour, seeing that they’re likely to get turned away if they arrive drunk, but I fail to see how this is likely unless there’s a fundamental change in the admission/serving process – which seems unlikely when bouncers are to rely on the same tried and tested observation techniques.

Moreover, drunkenness is seen as desirable by many in the night-time economy.**  That study that showed how observations of how drunk people seemed generally matched BAC figures also noted that for most people knowing their BAC would be irrelevant to their drinking levels over the rest of the night.  Where it would change people’s behaviour, it would be mostly for them to drink more (24.7% of those surveyed), rather than less (just 3.5%).

However, it’s possible that this might reduce drinking levels amongst those going out, as with observational assessments there’s always the feeling that you can beat the bouncers, pretending to be more sober than you are.  People are likely to think it’s more difficult to fool a bouncer who’s liable to breathalyse them.

So by this logic the point of breathalysing people isn’t to actually change their immediate desires for drunkenness; it’s to push them to arrive at the club more sober.

At the same time, this doesn’t undermine the initiative.  We know that interventions that deal with immediate desires can in the end reshape culture as different drinking practices just become normal.  Think of licensing restrictions originating in the First World War that seem to have had a long influence on this country and what forms of drinking were considered normal.  And the current context for policymaking is arguably one in which we’re more likely to accept that people are irrational, and so changing the ‘choice architecture’ that affects their decisions is sensible.

At first sight it would be easier if there were a clear line of BAC that would be unacceptable, as this would reduce the opportunity for just taking a chance with drinking beforehand, assuming that your level won’t be too high, or the bouncer won’t check you, or you’ll be able to explain away a high reading.  However, there are issues with this in practice.  Just to give a couple of examples, the same BAC won’t imply the same effects for all in terms of intoxication, affecting coordination, reasoning and so forth – those things that make it undesirable for a club to let in people who are very drunk.  Second, drunkenness is learned, social behaviour, so even the same level of strictly defined ‘intoxication’ might produce more or less problematic behaviour in different people.

So, having begun the day thinking this was a pointless PR exercise, I’m wondering if there might be some mileage in it after all.

Thinking in this way about an idea that initially seemed unhelpful prompted me to look again at drunk tanks.  (This was also of course so I could end the post on a typically negative note.)

‘Drunk tanks’ as I refer to them here are distinct from triage style units that take the heat off emergency departments because, according to the ACPO proposal, the individual drinker pays for their confinement.

Such a scheme can have two possible aims (which may be connected).  First, to recoup the costs associated with drunkenness.  In this sense, as I discussed in my previous post, the responsibility for drunkenness lies almost entirely with the individual.  This shouldn’t be taken for granted, particularly if we are in this new policymaking world of understanding individuals as inherently irrational.

In this sense, the drunk tanks would work perfectly well if run efficiently.  However, ideas such as a late-night levy, or (in order to capture the off-trade’s role in this issue) simply funding these initiatives through taxation on alcoholic drinks would seem perfectly reasonable.  Such approaches would acknowledge the role of availability of wider structures in shaping culture and desires.

One concern of mine is the involvement of private companies, implying the addition of a profit incentive.  Even if one accepts that an individual should pay for the cost of their care, it’s another step to suggest that they should generate profit.  Of course the argument would run that the private company could provide the care and the profit at a cheaper rate than the existing state institutions, but I’d be baffled as to why that couldn’t already be done within the current system***, or why a third sector provider wouldn’t be able to provide the same or a cheaper service than the private sector.

However, there’s a second possible aim of the drunk tank, and that’s to re-shape behaviour.  It’s here that I think other approaches are likely to be more effective.

The drunk tank as deterrent relies on people reacting to the spectre of having to pay for their care by being more careful about their behaviour.  However, such attempts to re-shape people’s decision-making are not always effective.  Women in particular are frequently reminded of the importance of safekeeping strategies.  You might think of articles like this or campaigns like this, this or this.  However, research (not just mine) suggests that often what is the more likely consequence is ‘safety talk’.  One example in my research was a young woman who took a fixed amount of cash out with her, and no debit or credit card, so she couldn’t drink more than she felt was good for her.  She also took out an extra tenner, hidden in a ‘secret pocket’ so that if she lost her bag, or drank the full amount she had with her, she’d still have the money for a cab home.  Only, in practice, she knew that money was there and her drunken self would end up spending it on alcohol and deciding to walk home.  Regularly.

This highlights Harry Sumnall’s issue with the idea of the participants in the research cited above who said they’d drink more if they were given a BAC reading: “at time of interview subjects had drunk 10-16 units. I dont trust their answers”.  It’s a good point: we are different when we’ve had 10 units or so.

And that’s why I’m not sure about drunk tanks changing behaviour.  They might, as a spectre, but we’re also very capable of explaining away our drinking and underestimating our risk when we’re thinking of things we like.  Moreover, it’s unlikely to seem such a frightening prospect when we’re getting out that ‘secret tenner’.  At this point, we maybe do need some ‘nudging’ rather than an appeal to our rational, better natures.

If we’re serious about changing behaviour, I’d be interested in more structural solutions – and that could include initiatives like the Late Night Levy, even – or perhaps especially – if the costs are passed on to the consumer.  Certainly there are problems with how this would apply if it only affects the premises that are open late at night, ignoring the role of the off-trade; that’s one of the reasons MUP is attractive.  At the moment, though, I remain fascinated by the Gothenburg model of alcohol retail, largely removing the profit motive from the trade.

*This doesn’t necessarily mean they’d be keen on a strict definition of who they should be letting in and serving and agree with the police.  In a 2008 study, only around 60% of staff surveyed knew it was illegal to serve drunk people alcohol, and even of those who did know, over 8% of those still felt it was part of their job.

**There’s loads of stuff on this, but as well as my work, these two articles are particularly useful.

***For example, if it’s expensive because the police/ambulance staff are overqualified for the role they’re performing, a solution like the Cardiff triage centre solves precisely this problem by employing people and resources to fit the precise issue.

Drunk tanks, free school meals and universalism

In the past week, a couple of stories caught my eye, as they sparked considerable media attention.  Nick Clegg promised free school meals for all children in their first three years of primary school, and the Association of Chief Police Officers (ACPO) proposed ‘drunk tanks’ for those who were so drunk they were ‘incapable of looking after themselves’.

At first sight, you might think there’s little to connect the two policies, but I’d suggest they’re two sides of the same argument, regarding universalism.  This sparked me thinking about the ideas I'll ramble about in this post.

Daniel Sage has talked about this (relatively) recently over at his blog Knowledge is Porridge.  His argument was that Labour seemed to be moving away from the idea of universal benefits, and suggested that it’s universal services that command support and engage people – think of the NHS, most obviously, but also schools and public transport (especially for pensioners).

Nick Clegg’s free school meals, and Labour’s recent announcement on childcare, can be understood in this light: providing universal services to all children.

However, there’s immediately a potential problem with this initiative being classified as ‘universal’: if we take the unit of analysis as an adult (rather than all children) then it could be argued that the service only immediately benefits those who have children.

I have heard this same argument advanced in all sorts of contexts.  For example, people sometimes complain that their union does nothing for them – which can often be seen as a positive thing if this is because they’ve never had cause to draw on legal support, other funds or the helplines provided.

The idea in the back of people’s minds when they say this is that people should pay for what they use – and this is not the principle behind the NHS or union services.

Examples of this idea in practice might include the suggestion that those who consume particular amounts of alcohol or fatty foods should pay for their own medical treatment, rather than relying on the NHS, because they have caused their own illness.  This is what distinguishes ACPO’s proposed ‘drunk tanks’ from triage models already in place in town and city centres which mean that drinkers aren’t admitted to hospital emergency departments at great cost: the drinkers themselves would face fines to pay for the service they have received.

However, it’s hard to draw the line as to where someone is at fault for their illness.  Thinking of alcohol-related issues specifically, alcohol is understood to distort reasoning through its effects as both an intoxicant and an addictive substance.  For centuries the British legal system has struggled with the issue of how alcohol affects a person’s responsibility, and we still don’t have an entirely satisfactory answer.*

On the other hand, there’s the suggestion that actually addiction isn’t so opposed to rationality as we might sometimes think.

One response to this issue, particularly for those on the left, is to argue that, yes, people are rational and they should take some responsibility for their actions, but they don’t start from equal positions in the game of life.  This can mean in practice an emphasis on cultural or wider structural factors that affect people’s propensity to behave in certain ways.  ‘Lifestyle’ might be a class issue.

This doesn’t in itself undermine the agency or rationality of those who do behave in ways that might be deemed damaging to their health.  The link above about addiction and rationality points to an interview with Carl Hart from Colombia University (I’d also recommend the Q&A on his own website).  His train of thought isn’t to say that crack addicts, being rational, therefore have themselves to blame because they could theoretically make different decisions.  Rather, he suggests: “If you’re living in a poor neighborhood deprived of options, there’s a certain rationality to keep taking a drug that will give you some temporary pleasure”.  The whole point is that his experimental work presented crack users with genuine choices – which meant that they often chose something other than crack.

However, these arguments are unlikely to persuade those who have a worldview that emphasises personal autonomy and responsibility – precisely those who are most likely to be opposed to the idea of universalism in the first place.**  Such a worldview, with an emphasis on the market, tends to take something of a moral or natural selection view of life: people sink or swim, win or lose, live or die by their own merits and luck.

And indeed, those on the right may be as tempted as those on the left to argue that ‘lifestyle’ is a class issue – class (or more accurately groupings of people, say chavs, the underclass, the mass) can be mobilised as a negative concept, as much condemning as explaining.

What I want to suggest here is an alternative way of addressing this criticism of universalism.***

In the end, we come back to some ideas from my previous post about risk and population health.

A focus on personal responsibility tends also to mean an opposition to population-wide measures, as these are seen as hurting the ‘responsible majority’.  A targeted approach, according to this ‘consequentialist’ view, seems much fairer.  We should be left to get on with our own decision-making, with the attention directed at those whose actions produce negative outcomes – the doughnut eaters who end up with diabetes.

However, it’s revealing that a standard alternative offered to universal health care is an insurance-based system.  Such an approach highlights the importance of the concept of ‘risk’ in understanding alcohol harm.  Just like those union dues, we pay insurance because we don’t know how likely we are to suffer some form of misfortune.  And in fact, at our individual level, neither does the insurance company – rather, it aggregates the risk in the same way that a government would do in formulating a total consumption model of alcohol harm.

This idea of risk is generally accepted by liberals/libertarians – note Chris Snowdon’s comment on my last post: the government shouldn’t be intervening because the risks are ‘trivial’ at an individual level for the levels of consumption we’re talking about.

But inherent in risk is a lack of certainty.  And such a lack of certainty is hard to manage if you’re a rational actor.  This would be fine if you could be given probabilities of your actions: you pays you money, you takes your choice.  But we’re also told that the advice offered by medical practitioners regarding alcohol consumption is unreliable, with recommended daily consumption guidelines having been ‘plucked out of the air’.  That is, there are no reliable estimates at an individual level for the risks associated with drinking.  It’s precisely this point – that we’re not really able to assess our own level of individual risk – that lies behind population-wide interventions.

Of course one instant response is to say that such theoretical nuances don’t really apply to the reality of serious ‘lifestyle’ related illnesses – the alcoholic or the doughnut eater.  But thinking again of alcohol it’s not that easy to say that there are clear-cut cases.  Not all heavy drinkers suffer from alcohol-related liver disease, for example, – and certainly not cirrhosis – and on the other hand genetic or other compounding factors can increase your risk.  Moreover, there might be no outward warning signs until the liver has been extensively damaged.

That makes rational decision-making about one’s alcohol consumption pretty tough – especially if we are to disregard government recommended limits – which makes it harder to place the responsibility for an individual’s alcohol-related illness entirely at their door.  The alternative, I’d have thought, would be to accept some idea of reasonable risk metrics – and that’s something the temperance movement could perhaps help us with.  Though I’m not sure that would go down too well those opposed to universalism and population-wide alcohol control.

(This argument might apply more to the longer-term health effects of alcohol rather than the immediate ending up in a triage unit at 1am on a Saturday morning, but I’d like to think it’s still worth thinking about in alcohol policy discussions.)

*There are great chapters covering this issue here: http://www.palgrave.com/products/title.aspx?pid=550243

**Notably, the articles I link to above that mention people paying for care related to ‘lifestyle’ decisions are based on comments from individuals associated with Policy Exchange and the IEA, both of which advocate free market solutions to public policy issues – i.e. have considerable faith in models based on an individual rational actor.

***It should also be noted that rational-choice models can acknowledge the importance of context, just like Carl Hart’s model of crack users.  Iain Duncan Smith sees it as his mission to make work pay., his model could be understood as suggesting that people are simply taking rational advantage of an apparently warped system.

What are we arguing about?

Up to this point, I haven't used this blog for short, sweet pieces that simply point people to other articles, but there's always a first time.

This article in The Guardian outlines how we can end up talking at cross purposes when we haven't actually agreed the terms of the debate - or what we're arguing about.  (Reminding me of the social science injunction to 'define your terms'.)

In policy discussions this happens all the time, and is exactly what I try to use this blog to address - most recently in my exchange with Chris Snowdon about the utility of the total consumption model of alcohol-related or harm.  (Or were we talking about population level policy interventions?)

I can't think of a better short, sweet link to leave on a blog called 'Thinking to Some Purpose'.

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.