Changing the conversation

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Alcohol concernDDN reports from Alcohol Concern’s annual conference, where delegates heard about the need to reframe debate on alcohol, and how the call for minimum pricing was not going away.  

‘We still don’t talk about it enough – nationally, at home or in the workplace,’ said Alcohol Concern chair Richard Sumray of his organisation’s conference theme, Conversations about alcohol. Many people were unaware of the impact of their own habits, he said, while the industry had ‘held sway’ on minimum pricing. ‘But it’s not something we intend to give up on. We don’t intend to stay quiet.’

Although alcohol consumption in Europe had fallen in the 20 years to 2010, there were huge differences between countries, said alcohol and illicit drugs programme manager at the WHO regional office for Europe, Dr Lars Møller, with the UK’s consumption rising over the same period. ‘Even though it’s now stabilising, that’s still a message that should be concerning politicians, particularly with regard to groups like younger women,’ he said.

Britain was losing the fight against alcoholic liver disease, said Professor Sir Ian Gilmore of the Alcohol Health Alliance, with a ‘meteoric’ rise since 1970 and the standard death rate for liver disease in under-65s dramatically bucking the trend for other conditions. Alcohol-induced cirrhosis at 35 was no longer uncommon, he added. ‘When I became a hepatologist, cirrhosis was a disease of elderly and middle-aged men. But we can do something about it. We have a secretary of state for health who’s committed to reducing premature death, but he’s not following the evidence when it comes to things like pricing. Why does the precautionary principle not apply to alcohol – why is the onus on health advocates to prove harm? Because industry advocacy is more effective.’

The drinks industry ‘pushed the paradigm’ that harm was a problem of small specific groups like young binge drinkers, he said, rather than the product itself. ‘But alcohol is not an ordinary product. It’s a psychoactive substance and a drug of dependence. We need to begin to reframe the questions, and we do have the tools to change the culture. We need to work harder to bring society to where it will be ready to accept tougher regulation by working on the key messages of alcohol harm.’

‘I’m very keen that Public Health England (PHE) shapes up to do something about the alcohol agenda,’ its director of alcohol and drugs, Rosanna O’Connor, told the conference. ‘We all know the problems are widespread, and that this isn’t new. So why is it so difficult?’ Alcohol was legal, provided jobs and was associated with very powerful vested interests, she said. ‘And it’s very much part and parcel of people’s lives and culture. It’s absolutely ingrained, and excess use is condoned on many fronts. It’s in our face, all the time.’

PHE expected alcohol to be one of its top priorities for next year, she said, and the organisation would continue to ‘advocate the evidence base and challenge government on minimum pricing. Just because things are quiet doesn’t mean it’s gone away – there’s a lot of work going on to get it back up the agenda.’ 

PHE would also be producing guidance on using local health information to inform licensing decisions, she said, as well as encouraging people to drink within lower risk levels and working to reduce the impact on people who already experienced harm. ‘Most of the population is kidding itself,’ she told delegates. ‘There needs to be a big debate and turnaround of people’s attitudes. Alcohol is complex issue that needs a multi-layered approach at national and local level, but I take real heart in the way things have changed around smoking. I thought there’d be huge resistance to the smoking ban but people have really embraced the changes in policy.’

‘The next 18 months are going to be crucial,’ Alcohol Concern chief execu­tive Eric Appleby told the conference. ‘Is localism going to work, or will the lack of national direction leave local areas with too much of a challenge?’ However, local authorities had a better understanding of, and links with, comm­unities than PCTs, stated cabinet member for health, social care and culture at Hackney council, Jonathan McShane, and there was also great potential with health and wellbeing boards.

Scotland had decided to take a whole population approach to alcohol, which inevitably meant minimum pricing, said head of the Scottish Government’s public health division, Donald Henderson. ‘Price and afford­ability are an essential element. Lower prices equal higher consumption – that’s a truth within a market economy.’

The greatest benefit came from targeting what the heaviest drinkers consumed, he said, which was the cheapest alcohol. ‘We have a confidence in this policy, and we agree that if it doesn’t have an impact it shouldn’t be there.’ There was to be a review of its effectiveness after five years, and the ‘sunset clause’ meant that without a positive parliamentary vote the legislation would ‘automatically die’, he pointed out.

‘We’ve had minimum pricing for years,’ director of the Centre for Addictions Research of British Columbia, Tim Stockwell, told delegates. ‘All of Canada’s provinces have some kind of minimum pricing for off-sales and/or bars, but they’re not there for health reasons – they’re to protect local businesses and government revenue.’ However, when Saskatchewan had increased all of its minimum prices simultaneously in 2010 – and graded the increases according to strength – the results had been dramatic, he said. 

A 10 per cent increase in minimum price had been associated with an 8.4 per cent overall reduction in consum­ption – 10.1 per cent for beer, 5.9 per cent for spirits and 4.6 per cent for wine. ‘There was a significant shift away from higher-strength drinks, and deaths and hospital admissions were down in two to three years.’ This meant that the Sheffield model for mapping the impact of alcohol policies [DDN, June 2012, page 4] was actually conservative, he stressed, as it saw the chronic disease benefits of minimum pricing only becom­ing apparent after ten years. ‘Minimum pricing targets in a very focused way the people who are drink­ing the most and suffering the most harm.’

Ten per cent of the population drank around 47 per cent of all the alcohol consumed, said public health research fellow at the University of Sheffield, Dr John Holmes, part of the team that produced the model. Although it was frequently argued that minimum pricing would have an adverse impact on moderate drinkers on low incomes, ‘the benefits of this policy largely accrue to lower socio-economic groups,’ he said. ‘Lower income people aren’t in general heavy drinkers, but they do tend to suffer more harm as a result’, perhaps because of a combination with other issues like tobacco and obesity.

‘This is a fairly frustrating time,’ keynote speaker Alastair Campbell told the conference. ‘David Cameron came forward with what looked like a fairly decent alcohol strategy, and now that’s not happening. But the thing with campaigning is you just need to keep going. The arguments build and build and just when you the communicators are sick to death of saying the same thing over and over again, that’s the point at which it starts to touch the outer rim of public consciousness.’

Setbacks were inevitable but it was vital to ‘keep making the same point’, he stressed. ‘David Cameron said he was going to do minimum pricing. He didn’t, and deep down he probably still wants to. You just have to keep going. None of the big campaigns are easy but you have to keep working until you reach a tipping point.’ Most people that campaigners were trying to reach were not ‘inside your bubble’, he pointed out. ‘What persuades them in the end is the power of your arguments. Every time you make a point you’re landing a tiny dot on the landscape, and over time those dots join up.’

Alcohol had been normalised at every level of society, he said, and the industry had been very effective at persuading people that minimum pricing was regressive and that the problem did not lie with them. ‘These arguments have got to be countered, and it’s about making sure that governments know. With ministers, don’t assume too much knowledge – they’re bombarded all the time, so you need to get inside their big picture, not just your own. The change will come if enough people keep making the same points. However bad it feels at the moment, if you keep going you can get there.’