11th December 2009
Politicians must stand up to the alcohol industry just as they stood up to the tobacco lobby, says the British Medical Association (BMA).
Vivienne Nathanson, BMA head of science and ethics, said: “Politicians showed courage before by not bowing to the tobacco industry – they need to do the same now and make tough decisions that will not please alcohol companies.”
She was speaking at the recent launch of the BMA report, Under the influence, on ways to address society’s “excessively pro-alcohol social norms”, particularly their effect on young people.
Among the many “tough decisions” recommended in the report were a minimum price per unit of alcohol and a ban on all alcohol advertising and marketing.
Is this pie in the sky or are we, as many believe, at a comparable point with alcohol to that of smoking a few years ago?
The CIEH played a key role in the smoke-free legislation and, at the time, sections of the press complained about unnecessary intrusion and “nanny-statism”. However, it seems unlikely now that many people would like the law overturned. Then, campaigners cited the example of seat belt laws, introduced under similar protests but which few rational people would want repealed. So is the tide turning for alcohol?
The Department of Health recently announced that, without strong action, liver disease would overtake coronary heart disease and stroke as a leading cause of death within 10 to 20 years, and NHS information centre figures earlier this year showed that alcohol-related hospital admissions had risen by more than two thirds in the last five years, with more than 860,000 last year alone.
“I think the public is beginning to realise there is a cost here – a human cost and a social cost,” says Alan Maryon Davis, president of the Faculty of Public Health. “Where you come up against a block is the idea that most people are very sensible about their drinking and why should they suffer for the sake of the few?”
Elaine Rodger, chair of the UK Public Health Association’s alcohol and violence special interest group, says: “There are similarities with smoking. The north-east had a tobacco office called Fresh and it’s just established a similar office for alcohol called Balance.
“There are similar techniques at work, but alcohol has a way to go to catch up with tobacco. People are much better disposed towards alcohol. Rates of cigarette smoking have been shrinking since the 1970s especially, in this country, among the higher social classes. Alcohol has more of a spread across the socioeconomic scale.”
Isn’t alcohol just a harder sell than smoking for the public? Most people don’t smoke, but they do drink and probably don’t think they’re doing themselves any significant harm. “I think it is a harder sell,” says Mr Maryon Davis. “There’s some evidence that it’s not all bad, that in moderation your health outcomes actually improve. But beyond that, obviously, the curve zooms up.”
One parallel with the road to smoke-free legislation is that then, as now, Scotland was ahead of the game. A smoking ban in public places was implemented there before England, and it is pushing ahead with a minimum price per unit of alcohol.
Sir Liam Donaldson, England’s chief medical officer, made the case for a minimum price last year but it was not included in the government’s forthcoming mandatory code on alcohol.
The Scottish government recently commissioned researchers from Sheffield University to develop a minimum-price model for Scotland after it declared in March that, “strong drinks will no longer be sold for pocket-money prices in Scotland”.
The researchers found that a minimum price of 40p a unit, combined with a promotions ban, would mean harmful drinkers paying an extra £137 per year, while moderate drinkers would pay only £11 more. Savings across the health, crime and employment sectors, however, would add up to £60m in year one and £950m over 10 years. There would also be a drop in alcohol-related deaths by nearly 19 per cent by year 10. At the moment, alcohol is estimated to be responsible for more than a quarter of deaths in Scottish men aged between 35 and 44 and up to one in 20 Scottish deaths as a whole.
South of the border, however, the reaction to the proposed minimum price provoked a hysterical response in some sections of the media. The same newspapers that complained about antisocial behaviour saw the move as an attack on freedom of choice and moderate drinkers. Meanwhile, organisations such as Alcohol Concern pointed out that only harmful drinkers would notice the difference in terms of price. Is the battle with the press winnable?
“The print media is predominantly right-wing, with the whole nanny-state thing, so if you come up with anything like that they’re immediately against it, and they can be quite irrational,” says Mr Maryon Davis. “There’s the rather more balanced set of the media that have understood that it’s not talking about a massive tax hike on all drink at all levels. I think sections of the media just didn’t understand it.”
Tough laws
But the battle doesn’t stop with the press; there is also the alcohol industry to contend with. While voluntary self-regulation is not effective, is any government – at a time of plummeting tax revenues – likely to introduce tough legislation?
“They’ve got an interesting approach in that, rather than an across-the-board, minimum price they’ll go for higher alcohol content, very highstrength lagers, and drinks that appeal to young people, like alcopops,” says Mr Maryon Davis.
Whatever the outcome of the election, however, the industry remains on a charm offensive, trying to convince the public and policymakers of the effectiveness of voluntary regulation. The most recent example was full-page press advertisements stating its commitment to not using anyone under 25, or who looks under 25, in its advertising.
The BMA report also drew attention to the industry’s use of “stakeholder marketing”, including strategic partnership working and the funding of sensible drinking campaigns, which enable it to influence policymakers and regulators. Having the industry involved in advising the government on alcohol reduction campaigns was akin to putting “the fox in charge of the chicken coop”, says Ms Nathanson.
Ms Rodger adds: “The great similarity between the tobacco and alcohol industries is that they’re very crafty and very clever. They want to sell their product and they’ll market it in subtle ways. What we saw with tobacco is that as one door closed they exploited another.”
Hearts and minds
So how does the public health lobby win the hearts and minds of the public, considering the power and wealth of the industry? “With difficulty,” acknowledges Mr Maryon Davis. “But the idea is to lobby and advocate with three main audiences. One is working closely with other health professionals – the medical mafia if you like – talking about all the medical problems caused by alcohol, which is obviously a very long list. That’s the human cost, but there’s also sickness absence and all of that. If you tot it all up the cost is enormous.
“The second group is patients, public and the media, the public opinion angle. That’s a joint approach to try and get coverage or a quote from the alcohol lobby field. We’re trying to do an ‘ASH’ (Action on Smoking and Health), using media advocacy as an important tool. The third group is policy makers, MPs and other elected members and locally, councillors. Those are the three main audiences for framing our advocacy work.”
The National Institute for Health and Clinical Excellence has added its voice to the call for a minimum price. Its recent draft guidance stated that public health considerations should be taken into account whenever licences are considered. “Licensing is a real opportunity to try to shake things at local level and use a carrot-and-stick approach,” says Mr Maryon Davis.
“That means being pretty hefty with the stick, threatening to shut places down, but also – if people want to extend their licence or increase the size of their premises – incentivising them by saying ‘yes, but no happy hours, much more careful checking of ages’ and everything else.”
Another tack, says Ms Rodger, is pointing out the links between alcohol and violence, which her group does. “With the smoke-free legislation the line taken wasn’t ‘we want you all to stop smoking’ it was ‘we want you to stop smoking in indoor public spaces because second-hand smoke is harming other people’. If you look at alcohol, violence is one of the second-hand harms.”
A leaked letter from business, innovation and skills secretary Peter Mandelson recently suggested that a mandatory code on alcohol would not be implemented until 2011, assuming Labour was still in power. If there is a change of government, conventional Tory policy is industry friendly, but that would need to be squared with their tough talk on antisocial behaviour.
At the party’s conference in September, shadow home secretary Chris Grayling set out plans for “significant tax increases” on the drinks that fuel the weekend mayhem across Britain’s towns and cities, combined with a “much tougher licensing regime”.
All the talk a few years ago was about the “obesity time bomb” but, with levels of alcohol consumption among young people rising, people are now starting to talk about an alcohol time bomb. As alcohol is also high-calorie, the two are not mutually exclusive, but is alcohol as much a threat to the NHS as obesity? “Obesity shows itself in the vast numbers of people who get hypertension, diabetes and cardiovascular problems,” says Mr Maryon Davis.
“But the two are linked, and alcohol is linked to teenage pregnancy as well, so it comes into quite a few health inequality targets.”
People are also being diagnosed with liver cirrhosis at ever-younger ages. “That’s a definite worry,” he says. “We’ve been predicting that for some time, and we’re just seeing the tip of the iceberg. There’s lots more on the way.”
Health inequalities
While middle-class drinkers are increasingly coming under the spotlight, with 2008 statistics from the North West Public Health Observatory showing very high rates of “hazardous” drinking in relatively affluent areas of the south-east of England, alcohol remains one the key determinants of health inequalities in the UK, along with smoking, poor diet, unemployment and housing. “It’s predominantly younger people, aged 16 to 24, who are doing the excessive drinking, and there is a social divide,” says Mr Maryon Davis. “It’s men more than women, but the women are catching up fast, particularly in that age group.”
He is convinced that Scotland’s drive for a minimum price will “shame us, rather like the smoking did”. When it pushed for smoke-free, as in Ireland and New York, critics claimed the law would be unenforceable – and were proved wrong.
“I think the smoking ban has broken the mould,” he says. “The way it worked was about beavering away with the three Ps – professionals, public and policymakers. The professionals were always on board but as more and more of the public came round to the idea, the policymakers were suddenly on board – it was a genuine tipping point, and that’s how it got through.
“I think we will reach the same point with alcohol, as people fully understand the human and social costs and that we’re not punishing moderate drinkers.”
So might we see a point in the next 10 or so years when people will look back on a time when supermarkets could sell alcohol below cost price and clubs could offer “all you can drink for £10” promotions in the same way they remember smoky pubs and restaurants?
“I think we’ll find ourselves in a position where we look back and say ‘were people actually selling alcohol costed so you could get smashed for less than the price of a sandwich?’ ” he says.
“I think there will come a time where we’ll think it remarkable that we tolerated alcohol as much as we did. I think the smoking ban was the biggest step forward in public health since the birth of the NHS, and if we can get a similar step-change in terms of alcohol misuse, then that will be the biggest step forward since the smoking ban. It’s of that order.”