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Alcohol strategy questioned

The long-awaited Interim Analytical Report of the Cabinet Office Strategy Unit was finally published in September, months after it was originally promised. The Report is intended merely to describe the nature and scale of the problems and to summarise the available evidence in regard to methods of ameliorating them. The Government’s Alcohol Harm Reduction Strategy, outlining the policies it intends to implement to tackle the problems, is not expected to appear for some time. The Government is saying publicly that it will appear as scheduled in late autumn, but it is widely believed that it will not in fact be published until next year.

The only real surprise in the Strategy Unit’s analysis are the new estimates of the costs of alcohol problems. At approaching £20 billion per annum these are higher than previous estimates, and are considerably in excess of the revenue raised from the sale of alcoholic drink.

Predictably, reactions to the report were mixed. In the main, the alcohol field welcomed it though a number expressed disquiet at changes that were made to the original text presumably at the behest of the alcohol industry (see below).

It was also noticed that the report contains one particularly glaring omission, any attempt to relate the level of harm to overall national consumption of alcohol. This is akin to developing a national plan to combat obesity whilst avoiding any consideration of the average intake of calories. This is a key issue for alcohol policy and one which tends to divide the scientific community on the one side from the alcohol industry and the Government on the other. Further evidence of this divide is provided by the fate of a special sub-group of advisers set up to assist the Strategy Unit which presented evidence in regard to the importance of average consumption for the level of harm. This was disbanded, it is believed because the research evidence it presented was inconsistent with the view the Government and the industry wish to promote. Clearly, these developments cast considerable doubt on the degree to which the Strategy Unit was allowed to conduct a genuinely impartial and objective review.

Speaking for Alcohol Concern, Eric Appleby said: “Overall this is a good piece of work and the best summary of the state of the alcohol nation that we have had. The Unit have grasped some nettles that government has previously been scared to touch, on advertising, for example. However there are some others, such as availability, that remain untouched and we still need a much more vigorous argument for the vital and overdue expansion in treatment services.”

Despite the clear biasing of the report in their favour, and the fact that the industry formed part of the Advisory Group to the Strategy Unit, alcohol industry spokesmen still chose to attack it for allegedly exaggerating the scale of the problem. Rob Hayward, chief executive of the British Beer & Pub Association, accused the Strategy Unit of “overplaying the numbers and using out-of-date information”. He said: “The Strategy Unit used an out-dated measure to define the scale of heavy drinking. Weekly units were replaced by the Department of Health in 1995 by the daily benchmarks of two to three units for women and three to four units for men. Consequently, many people drinking within those guidelines have been defined as heavy drinkers in this analysis.”

In reality, as can be seen from the illustration below, the Strategy Unit simply followed existing practice, defining as `moderate to heavy’ drinkers those consuming between 14/21 and 35/50 units per week for women and men respectively, and as `very heavy’ drinkers those consuming 35/50 or more units per week.

Ironically, in view of his colleague’s incorrect claim that the Strategy Unit was guilty of exaggeration, Mark Hastings, another spokesman for the British Beer and Pub Association (BBPA) made an even more inaccurate allegation in relation to the Strategy Unit’s criterion of binge drinking as consumption of eight or more units of alcohol in a day. He said: “This means that a fifth of pensioners are binge-drinkers, as is 40 per cent of the population. It is ludicrous and undermines the strategy as a whole. The real focus of the strategy needs to be on what motivates a small minority of people to go out and behave in a disorderly way.”

However, even this was not sufficient exaggeration for Kieren Simpson of brewers Scottish and Newcastle. Addressing a fringe meeting at the Labour Party conference he upped the stakes even further and insisted that on the basis of the Strategy Unit’s definition, “a quarter of all pensioners are binge drinkers.”

The most generous explanation of these wildly inflated claims is that Hastings and Simpson were overcome by wishful thinking. Government drinking surveys report that in the population as whole 20per cent men and just 8per cent women drank more than twice the recommended daily maximum of 8/6 units in a single day. In men aged 65 and over, the proportion fell to 6 per cent, and in women of pensionable age to 0.5 per cent.

A different reaction came from brothers Sudarghara and Ajmail Dusanj, the owners of Cains brewery in Liverpool, the first British brewery to be owned by an Asian family. The brothers announced that bottles of Cains 2008 Ale, brewed to mark Liverpool’s status as a Capital of Culture, will carry advice and a health warning. The warning, which will later appear on other Cains products, reads: “Alcohol advice: Robert Cain supports responsible drinking. Excessive drinking can cause harm. Observe the daily guidelines for sensible drinking. Do not drink and drive.”

Sudarghara Dusanj said that he hoped other brewers would follow suit. He did not think the heavy drinking culture that was causing health problems in the UK could be turned round overnight, but it was important that the whole industry took positive action rather than just talking about it. He continued:

“There is mounting pressure to tackle the issue of binge drinking in the UK. We think that the brewers – along with the spirit and premixed alcoholic drinks manufacturers – have a responsibility to promote sensible drinking to our customers. We’re leading by example and doing our bit by packaging and marketing our products in a responsible manner. It seems that many of our competitors are just sitting on the sidelines and getting caught up in debating the Government’s definition of binge drinking rather than taking action. It’s this type of indecision that could harm the industry’s reputation.”

Strategy Unit ignored expert advice, then sacked the adviser

The services of Professor Sir Michael Marmot, one of the country’s leading epidemiologists, were dispensed with by the Strategy Unit after he produced a paper containing research findings that conflicted with the line preferred by the Government and the alcohol industry. Professor Marmot was a member of a special sub-group of the Advisory Group set up by the Strategy Unit to help prepare the national alcohol strategy. His paper brought together the evidence establishing that the amount of harmful drinking is a function of how much alcohol is consumed by the population as a whole. The obvious implication of this finding is that policies to reduce the harm caused by alcohol must be embedded in policies to control the overall level of consumption. In other words, to be effective the Strategy must be on alcohol, and not just on ‘alcohol misuse’.

While this conclusion is regarded as a truism by most alcohol researchers and by many other western Governments, it is seen as highly objectionable by the alcohol industry and, it seems, the British Government. They prefer to promote the idea that there are two distinct populations of drinkers – the great majority of the population who are responsible drinkers and, apparently, never have any alcohol problems, and a small minority of deviant individuals called `alcohol misusers’, who have or cause all the problems. The implication of this view is that preventative policies should ignore the overall level of consumption and focus exclusively on the small minority of ‘misusers’ so as not to ‘punish’ the responsible majority.

Professor Marmot’s analysis was therefore regarded as decidedly unwelcome, and the special sub-group was promptly disbanded. The members of the sub-group, like all the advisers, are inhibited from speaking publicly because all meetings and communications were held on a confidential basis. However, Alcohol Alert understands that a special group which included Sir Michael Marmot has been convened under the auspices of the Academy of Medical Sciences, a joint initiative of the Royal Medical Colleges, with a view to ‘putting alcohol back into alcohol policy’. The group is due to report in January 2004.

Changes to the text

Other evidence of possible alcohol industry influence on the Strategy Unit is also provided by changes to the text of the Interim Analysis. The final published version was notably different in certain key respects from the earlier draft.

Extracts from the Draft analysis of August 2003 read as follows:

Extract 1
“There are two main supply side levers, price and availability, which can be used to influence alcohol use and misuse….Availability is governed by a number of factors: number and density of outlets; opening hours; regulation on who buys” (p. 150 –now page 152 of final report).

Extract 2
“As with price, restrictions on availability reduce general consumption and therefore general levels of harm. Conversely relaxing availability increases general harm whether through more outlets (Finland), denser outlets (California), longer hours (Western Australia) or reducing minimum age (New Zealand) where measures are not taken to pre-empt the consequences…” (p. 152, now p.154)

Extract 3
“Supply and Pricing: Key Findings….Availability: Number and density of outlets and opening hours: where there are too many outlets, too densely packed, harm results. Communities need power to choose, and to respond where there is clear harm” (p.154, now p.156).

In the final version of the report as released for public consumption on 19 September 2003, the analysis is notably different. All mention of the control of outlet numbers/density and opening hours has been removed, and the research findings from Finland, California and Western Australia in this regard have also disappeared.

The Analysis now asserts that, as levers of harm reduction, price and availability:

“…act in the context of a complex range of other factors that influence consumption (culture, advertising, setting and market innovation described earlier in the analysis). This means that changes in price and availability alone will not always affect behaviour, and that changes in behaviour may come about for other reasons (p.152 final version)

…In New Zealand a reduction in the minimum drinking age led to a perceived increase in anti-social behaviour by young people. But again the evidence suggests that the issue is more complex (p.154 final)

…So the issue is more complex than simply restricting price and availability for the whole population…The impact of policies involving price and availability will depend upon the range of different factors that influence consumption…there are limitations in using the evidence base to predict the response to specific policy measures on actual consumption. Whilst there is a clear association between price, availability and consumption overall, there is less sound evidence for the impact of introducing specific policies in a particular social and economic context and determining the right level. Other factors have to be taken into account too: Targeting-restricting price and availability would affect all drinkers, not just those experiencing problems. Limiting choice to reflect the needs of a minority who do experience problems may raise questions about fairness and acceptability….All of this suggests that price and availability, whilst important, are not the only levers and that they interact with other factors in ways which can have unintended consequences” (p.155 final).

“Supply and demand: key findings- Price and availability are important levers on overall consumption: there is clear evidence of links between price and availability and overall consumption, and hence harm. However, the evidence is less able to demonstrate the likely impact of specific measures: in some cases measures which should have reduced consumption have failed to do so; and in other cases consumption has fallen independent of policy measures. The interplay with other factors is crucial in determining overall behaviour. This means that policies can have unintended consequences…policies on price and availability have to be seen in a wider economic and social context” (p.156, final).

The issues involved in these changes are at the heart of the debate around the whole nature of the alcohol strategy and, in particularly, the management of the night-time economy. The original text was clearly inconsistent both with the views of the Portman Group and with the assumptions underlying the new Licensing Act, which are of course one and the same. The Strategy Unit refused to say at whose behest these changes were made, explaining that advice from its expert panel was confidential.

In the House of Lords, in an attempt to get to the bottom of the mystery, Liberal Democrat peer Lord Avebury wrote to Lord Mackintosh of Haringay seeking an explanation, but the answer eventually came from Home Office Minister, Hazel Blears, sponsor minister to the Strategy Unit project. In her reply, Ms Blears gave Lord Avebury a good ticking off for having seen the working draft which “was circulated to our advisory group on a personal basis and on the understanding that, being a draft, it should not be circulated further.”

Ms Blears went on to say that as the whole point of the process was “to enable us to draw on expert advice and, consequently, to present the best possible analysis”, it was hardly surprising that the draft changed as a result. Ms Blears, in concentrating on this statement of the obvious, did not explain in detail how the quality of the Analysis was enhanced by the sudden omission of well-recognised research findings nor at whose behest the decision to excise them was made.

It is particularly ironic that the minister’s comment coincided with the publication of the recent authoratative work on alcohol policy, Alcohol: no ordinary commodity for the World Health Organization. The book is the work of a group of leading scholars on the subject from around the world and among their conclusions they state: “In general, effectiveness is strong for the regulation of physical availablility and the use of alcohol taxes. Given the broad reach of these strategies, and the relatively low expense of implementing them, the expected impact of these measures on public health is realtively high.” For example, Alcohol: no ordinary commodity, in comparing the impact of different policies, shows that restrictions on the density of outlets is not only very effective but is supported by the widest range of research. Conversely, stategies such as alcohol education in schools and colleges, public service messages, and warning labels on alcohol containers - the strategies the government appears to be considering most seriously - score zero for effectiveness.

Alcohol Alert has established that none of the academic or expert advisors to whom it has spoken asked for those changes to be made, or was even given prior notice of them.

The members of the Advisory Group are:

  • Eric Appleby
    (Alcohol Concern)

  • Mary Agnew
    (No10 Policy Unit)

  • Peter Barnett
    (Service User Representation and Lambeth Drug Action Team)

  • Jean Coussins
    (Portman Group)

  • Andrew Cunningham
    (Department of Culture, Media, and Sport)

  • Professor Colin Drummond
    (Royal College of Psychiatrists)

  • Professor Griffith Edwards
    (National Addiction Centre)

  • Mike Gillespie, Peter Edwards, Joan Bonelle
    (Home Office)

  • Professor Ian Gilmore
    (Royal College of Physicians and Liverpool University)

  • Cathy Hamlyn
    (Department of Health)

  • Mark Hastings
    (British Beer and Pub Association)

  • Peter Keown, Rob Taylor
    (Association of Chief Police Officers)

  • Suzanne Payne
    (Local Government Association)

  • Mela Watts
    (Department for Education and Science)

The inclusion of representatives of the alcohol industry would seem to be in contravention of the European Alcohol Action Plan, agreed to by this Government, which says that health policy on alcohol should be formulated without influence from the industry. Similarly, the Declaration on Young People and Alcohol, which again was signed up to by the Government, states: “Public health policies concerning alcohol need to be formulated by public health interests without interference from commercial interests.”

Alcohol Industry Submissions

The nature and quality of alcohol industry arguments is revealed in their responses to the Strategy Unit Consultation Document. These have now been published. There was one joint submission on behalf of the alcoholic drinks industry, representing the views of the British Beer and Pub Association, Business in Sport and Leisure, The Advertising Association, The Association of Multiple Retailers, the Bar Entertainment and Dance Association, the British Hospitality Association, the British Institute of Innkeeping, the British Retail Consortium, the Federation of Licensed Victuallers Associations, the Gin and Vodka Association, the Guild of Master Victuallers, the National Association of Cider Makers, The Restaurant Association, the Scotch Whisky Association, the Society of Independent Brewers and the Wine and Spirit Association. There were in addition separate submissions from the Advertising Association and the Institute of Practitioners in Advertising, Anheuser-Busch, Coors, and, of course, the Portman Group.

Some of these submissions are mainly restricted to the sections of the Consultation Document concerned with the role of the alcohol industry, but some are more wide ranging, reiterating all the familiar industry arguments– that the overwhelming majority of people – apart, presumably, from high proportions of old age pensioners - ‘drink sensibly’ and that alcohol problems are restricted to a small minority of deviants; that any problems of ‘binge drinking’ are the fault of pub closing times; the customary denials that there is any significant causal relationship between alcohol and crime, or between the overall level of alcohol consumption and the amount of harm.

What makes these submissions, from a certain point of view, extremely entertaining is that, presumably because of the terms of reference of the Strategy Unit which at least in theory require it to take an evidence-based approach to policy formation, their authors clearly felt obliged to pay lip service to science while of necessity actually trying to subvert its influence. This exercise in sustained hypocrisy is elevated to an art form in the submission of the Portman Group.

Founded in 1989, the Portman Group’s origins can be traced to five years earlier when Tim Ambler of Grand Metropolitan set out in a paper not intended for general circulation what he considered to be the principal dangers facing the beverage alcohol industry. These were:

  • Excise duties to be raised faster than inflation

  • More vigorous measures to reduce drunken driving

  • Restrictions on retail hours, licences etc

  • Funding rehabilitation for those suffering the effects of alcohol abuse

  • Advertising and other marketing restrictions

  • Warning labels on alcoholic drinks, and

  • Ingredient labelling.

Ambler stated that “it is generally agreed that the tobacco industry reacted to not dissimilar threats in a passive, inadequate manner and most of all too late…” What was later to become known as the Portman Group was thus an expression of the alcohol industry’s determination not to go down ‘tobacco road’. The Group is generally regarded as the most successful of the industry’s ‘social aspect groups’ that have now spread across Europe and much of the rest of the world in heading off what are regarded as threats to the interests of the alcohol industry whilst cultivating a public image of caring social responsibility.

When it was first set up the Portman Group was listed in the telephone directory as providing “research and media releases for the drinks industry” but it subsequently put on a new disguise and re-branded itself as both the alcohol industry’s “watchdog” and at the same time its `initiative against alcohol misuse’. To achieve credibility, an important element of this re-branding has been the adoption of the appearance of scientific objectivity and attempts to cultivate relationships with the scientific community. This last strategy has necessarily had to be implemented in a world in which, from the point of view of the Portman Group’s paymasters, scientists have the irritating habit of coming to highly inconvenient conclusions. Fortunately, the Group discovered early on that it has the means to deal with this problem – money.

In 1994 the Portman Group was discovered offering secret payments to academics to ‘rubbish’ a major research report from the World Health Organisation. The Group’s activities were exposed by journalist Leonard Doyle. Writing in The Independent under the headline ‘Pro-alcohol academics paid by drinks lobby’, Doyle revealed that the Group, having somehow obtained a pre-publication copy of the new WHO report, promptly offered secret payments to a number of academics to produce anonymous critiques of the book and its findings.

The story received considerable publicity in the UK and generated intense debate over the ethics of academic research and possible conflicts of interest. Doyle quoted an unnamed senior Government medical scientist as saying:

“The secret inducement to academics by the Portman Group is a classic example of the sort of underhand tactics that the drinks industry engages in all the time to prevent good research on the harm that is caused by alcohol.”

Doyle referred to an internal drinks industry memorandum which stated that one of the aims of the Portman Group was ‘dominating research into alcohol policy’, and academic recipients of the Portman Group’s largesse were conspicuous among those found expounding the alleged health benefits of alcohol consumption and in pressing for the ‘sensible drinking’ limits to be raised.

Subsequently, the Portman Group commissioned reports from researchers prepared to come up with the, to its sponsors, extremely welcome findings that alcohol is not really a cause of violent or any other form of crime, and that the statistics on alcohol-related crime and disorder are almost entirely meaningless.

The secret payments prompted Professor Griffith Edwards, doyen of British alcohol researchers and one of the lead authors of the WHO report, to compare the Portman Group’s tactics with those of the tobacco industry in trying to neutralise unwelcome medical evidence. Writing in the British Medical Journal he said: “If the drinks industry goes on behaving in Britain and in other countries in its present unethical manner, it will inevitably and deservedly join the tobacco industry in a pariah status.”

It is unlikely that such critics of the Portman Group will change their view as a result of reading its submission to the Strategy Unit. This is given the appearance of a properly researched and referenced piece of work, and indeed contains repeated demands that the national alcohol strategy must be based on ‘the best available evidence’ and on ‘robust research evidence and sound data’. Unfortunately, the submission’s scientific credentials turn out to be more appearance than reality. For one thing, issues on which the whole debate hinges are conspicuous only by their absence.

Firstly, and bizarrely, there is no acknowledgement of the rising levels of health harm from alcohol in Britain, let alone any exploration of why there should be an increase. There are of course numerous references to the alleged health benefits of alcohol consumption. The submission even seems reluctant to concede plainly that alcohol is a cause of accidents, preferring instead to refer to ‘drinking to intoxication (being) highly correlated with accidental injury..’ But then, it could hardly be conceded that raised blood alcohol levels falling short of outright intoxication increase accident risk without undermining the Portman Group’s highly successful campaign to retain a high legal alcohol limit for drivers in the UK.(see below)

Even more importantly, what passes for a discussion of contemporary drinking patterns carefully avoids any reference to the fact that in Britain, as in all English speaking countries, about 10 per cent of the drinking population accounts for around 50 per cent of the total alcohol consumed. This skewed pattern means that the alcohol market, and thus the profits of the companies that sponsor the Portman Group, are dependent on heavy drinkers. This is crucial because it is the basis of the conflict of interest that ensures that the Portman Group’s campaign for ‘responsible drinking’ must be a charade. The people the Portman Group tries to stigmatise when it is convenient as ‘irresponsible alcohol misusers’ are its sponsors’ best customers. If by some miracle they were persuaded to mend their ways and `drink sensibly’, the alcohol industry’s profits would plummet.

The bogus nature of the demand for robust evidence is also shown by the way the Group attempts to discredit authentic scientific research findings and to substitute the spurious ones that suit the interests of its sponsors. It is entirely characteristic, for example, that a demand that the National Strategy must be based “on the best available evidence”, is followed by the assertion that “education (is) the best form of prevention’, and by calls for more alcohol education in schools and renewed efforts to sell the ‘sensible drinking’ message. Needless to say, what the best available evidence actually shows is that school alcohol education may increase knowledge and influence attitudes but it rarely affects behaviour. There is no good evidence that the sensible drinking message, which has now been running for 20 years, has made any appreciable difference to what people actually do.

A key paragraph of the Portman Group’s submission attempts to debunk the ‘control of consumption’ approach – the approach that got Professor Marmot into trouble with the Strategy Unit.

This paragraph reads:

“There are those who still believe that reducing overall consumption is the best way of reducing alcohol misuse. These supporters of the control of consumption theory would argue that tax increases and tighter licensing and marketing restrictions should form key planks of the strategy. This theory has been widely discredited. Indeed, experience across the world in countries that pursue such policies has demonstrated not only a failure to achieve any significant reduction in alcohol misuse but perversely an increase in unhealthy drinking patterns and unregulated trading with all its associated criminal activities.”

The Portman Group’s scientific credentials are evident in the references selected to give credence to this succession of assertions. One of them is an out-dated pamphlet produced by a Home Office official which was roundly criticised by the scientific community when it first appeared 20 years ago, and which has failed to achieve any greater credibility in the intervening period.

The second reference, the scientific authority behind the revelation that all alcohol control policies everywhere in the world are always total failures, turns out to be the famously impartial and objective Brewers Association of Canada.

The most telling citation however is the third, that referring to the late Professor Geoffrey Rose. Here the Portman Group excels itself by totally misrepresenting the author as saying the exact opposite of what is actually in the text.

On the face of it, it is difficult to understand how this misrepresentation could have occurred by accident, for Professor Rose, far from attacking the ‘control of consumption’ approach, was well known as one of its leading advocates. The whole point of his book, The Strategy of Preventive Medicine, is to debunk the very idea fostered by the Portman Group and the alcohol industry that policies to prevent harm should focus exclusively on a minority of ‘sick individuals’, and to demonstrate, rather, that to be effective in reducing levels of harm they must address the drinking population as a whole. In Professor Rose’s words, it is clear “that any hope of controlling the alcohol problem depends on reducing the general level of alcohol consumption.” (p88)

The most successful pariah in Britain

The Portman Group’s pariah status in the scientific community has not in any way prevented its becoming easily the most influential lobby group in the alcohol field. The picture Leonard Doyle painted of the Portman Group was that of a highly sophisticated and successful public relations cum lobbying organisation for the drinks industry, having access to senior politicians and policy-makers and also having close links with the media, thus ensuring a steady stream of editorials, feature articles and television news items favourable to the interests of the drinks trade.

That was almost ten years ago. Its influence appears if anything to have increased in the intervening period. It’s director since 1996, Jean Coussins, is of course a member of the Advisory Group set up by the Strategy Unit. The introductory sections of the Interim Analysis extolling the benefits of alcohol is lifted almost verbatim from Portman Group publicity. The Group was the only non-statutory body acknowledged in the Government’s White Paper on licensing reform as having done any work of value in alcohol education, and it was a Portman Group report that provided the ‘evidence’, clearly considered spurious by most academic commentators, on which Ministers relied to justify the introduction of 24 hour licensing. Only last year, the House of Lords European Committee, in condemning the Government’s U-turn on lowering the drink drive limit, complained of the undue influence of the Portman Group which was known to have had a number of meetings with Transport Minister David Jamieson just before the decision was announced. The House of Lords Committee commented:

“We note that the (transport) department’s position coincides with that of the alcohol industry but is opposed by local authorities, the police, the British Medical Association, the Royal Society for the Prevention of Accidents, the Transport Research Laboratory and the Parliamentary Advisory Council for Transport Safety.”

Interestingly, the previous director of the Portman Group, Dr. John Rae, did finally appear on TV saying that the Group’s sponsors should not have required it to oppose a lower limit, but that was only after he had left the job.

The Government’s own research suggests that the refusal to lower the legal limit to 50mg is costing in the region of 50 lives a year.