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Issue 3 2006

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'Compulsory sobriety' or 'drunken freedom'? The role of the state in changing behaviour

Governments have long acted to curb or encourage particular behaviour amongst their citizens.Debates about the correct levels of government intervention and how this fits with personal responsibility are as old as democracy.The quotes in the title of this article are taken fromdebates about the 1872 Licensing Act,yet could have easily appeared in media coverage of more recent legislation on alcohol.

The stance taken by any government sets out the limits of socially acceptable behaviour, whether by giving tax breaks to married couples, passing legislation aimed at preventing anti-social behaviour or fining speeding drivers.The New Labour government takes this further than most, by explicitly discussing the ‘social contracts’ and ‘rights and responsibilities’ which underpin their approach to social welfare.Together with an increased knowledge about what works in behaviour change, and growing understanding that government cannot tackle issues such as climate change alone, this has led to a greater focus than ever upon public behaviour and questions of personal responsibility. Policy areas including climate change and other environmental issues, health, crime and employment are seen to be insolvable without public buy in.

Broader social debates also contribute to the changing way behaviour is discussed.As the great Victorian civic infrastructure projects were implemented there was a heated public debate about the limits of state intervention.The current debate is characterised by a focus on the social costs of intensely personal activities. Behaviours in the home such as energy use, eating habits and waste disposal are all under scrutiny. Public views on risk are changing, and there is a greater reluctance to countenance risk than ever before,with strong calls for government intervention following food safety or transport crises.At the same time excessive caution about health and safety is heavily resisted and mocked.This sits alongside ongoing debates over surveillance and privacy in the wake of the London bombings in July 2005.

The government can intervene in different realms of public behaviour. It can act directly in behaviours thought to be personal, such as drinking or eating habits. It can aim measures at the relationships between people, such as improving parenting or reducing mugging, or the relationships between people and wider society, such as addressing climate change by reducing home energy use. Finally, the government can affect the environment in which individual decisions are made by regulating the market – for example, by pressurising supermarkets to reduce the amount of packaging they use, so that individual decisions about recycling are less important.

Social norms are enormously important in dictating the choices an individual makes – for example students arriving at university for the first time in the United States were told that the university culture is hostile to drinkers and that other students do not drink.The study found that these students did not go on to drink, even when others around them did. People – and young people in particular – want to conform to their peers.An important and long term role government can play is in shifting deep rooted social norms by influencing the wider environment, and changing people’s views through communications.

However, focusing solely on changing long term social norms ignores political realities, which are that governments need to focus on relatively short term political popularity alongside longer term measures. Which of these areas government aims to affect is inevitably affected by political considerations – in other words, will the public accept that the government has a legitimate role to play? There is generally considerably greater public acceptance – and indeed philosophical justification – for interventions aimed at preventing harm to others. Measures aimed at preventing crime and disorder are much more publicly popular than those targeting behaviours thought to be private, such as reducing obesity.This is partly because these kinds of behaviours are thought to be committed by ‘other people’ – therefore,measures to prevent binge drinking amongst young people are always going to be more popular amongst older voters than any aimed at reducing alcohol consumption in the home.We tend to be reluctant to think that our own behaviour is a problem. But there is also a commonsense public understanding that government has an important role in preventing harm to bystanders.The debate over smoking was revolutionised when it was seen as being about passive smoking – particularly about harm to children – rather than as a personal health choice. Equally, the public tends to be supportive of measures which improve default choices, such as making all goods such as fridges environmentally friendly.

These political considerations influence the measures government feels able to take.Harsher measures such as taxation are very difficult to impose if the public does not see a wider social cost to their actions.Any government which attempts this will be politically punished, as, for example,with the fuel tax protests a few years ago.Government, therefore, needs to ensure that people know which actions do affect others – directly or indirectly. The default position otherwise is to provide people with information, and allow them to make the choices themselves. For many behaviours, particularly those which are addictive or very socially normal, simply providing information is not enough.We now know that many decisions are not based upon rational calculations about what is good for us, and policy needs to take this into account.

Any policy debate about changing a particular behaviour needs to be seen in this wider context, rather than as a narrow issue upon which the government will be able to act in isolation.This is partly to make sure that learning from one policy area is translated into another. Experts in environmental behaviour change rarely speak to experts in health behaviour change. But more importantly, it means assessing the public mood and understanding that people do not interpret government actions in silos. If the same people are targeted by poorly coordinated behaviour interventions their self efficacy and ability to change is potentially undermined. For example, the target groups for reducing anti-social behaviour, obesity and smoking are very similar. Equally, if conflicting messages come out of different government departments – for example, hearing about Heathrow Terminal 5 alongside the increase in air passenger duty – behaviour change messages are likely to be undermined. Alcohol policy is one area of many in which these debates about the limits to individual freedom are played out, and it is important to understand it within this broader framework. Alcohol is such an entrenched part of British culture that these wider issues about personal responsibility and the role of the state are particularly pressing; any intervention needs to have a solid grounding in strong moral, philosophical arguments if it is to have any chance of succeeding politically.

Too often alcohol misuse is seen simply as a matter of personal choice.The debate, therefore, gets trapped in terms of ‘good drinkers’ and ‘bad drinkers’.This ignores wider social harms, and the enormous costs in terms of the impact upon health services, upon crime and upon quality of life in town centres. It also casts alcohol and whether to drink purely as a rational choice.This ignores the broader issues which affect private decisions. At the individual level, alcohol is addictive.At the societal level, drinking – and drinking to excess – is completely normalised culturally and in our social set up. In many areas, going to the pub is the main available leisure activity.These social messages about the acceptability of drinking are reinforced by its price,which has fallen dramatically in relation to income over the last few years, and its ever widening availability. Messages about safer drinking and units, therefore, compete against extremely strong social and economic messages about how normal it is to drink.

For many people drinking is not, therefore, a rational choice that can be seen in terms of purely personal responsibility. Interventions need to move on from addressing it in these terms. Part of this is helping people to understand the wider social costs of their behaviour. But it is,more importantly, about changing the environment in which decisions are made, including by looking at price, availability and social norms. Whilst this may be politically challenging, it is socially responsible.

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Government launches 'Know your Limits'

In October 2006, the Home Office and the Department for Health jointly launched the ‘Know Your Limits’ Campaign,a high profile,£4million public awareness campaign aimed at raising awareness of the risks associated to ‘binge drinking’ among 18 to 24 year olds.

The campaign’s main element was a supposedly hard hitting advertisement, broadcast in cinemas and on television, warning the audience that ‘alcohol makes you feel invincible when you are most vulnerable’.The campaign illustrated a series of different scenarios where young people, thinking they were 'superheroes’ while drunk, took risks with their health and safety, for example, falling off high scaffolding. The advertisements were spread across cinema, radio,magazines and online throughout November 2006.

Launching the campaign, Public Health Minister Caroline Flint said: “In England it is estimated that 5.9 million people drink to get drunk.Males and females aged 18 to 24 are our priority in this campaign as they are the most likely to drink irresponsibly.

“We are not trying to demonise alcohol or stop people enjoying themselves.This is about encouraging young people to still have a good time but to know their limits, and to take responsibility for how much they drink.“Drinking too much alcohol alters your judgement and perception and can lead to people taking risks with their health and safety that they would never normally even consider while sober.

“This high profile advertising campaign will support the actions that the Government is taking to tackle the problem of alcohol related harm and we hope it will help create a culture where drinking responsibly is the norm.

We need to get the responsible drinking message across as 80 percent of pedestrian deaths on Friday and Saturday nights are drink related and nearly three quarters of peak time A & E admissions are alcohol related.”

Home Office Minister Vernon Coaker said: “We all have the right to enjoy a few drinks with friends and family but in doing so we have a duty of care to behave responsibly and not risk the safety and well-being of ourselves or other people.

“People who drink to excess put themselves in unnecessary danger and have to live with the consequences of their actions, whether that’s being arrested, an £80 fine or the unpleasant prospect of physical harm.

“This new £4 million advertising campaign illustrates the consequences people could face for drinking to excess. I want people to continue enjoying their nights out but urge them to drink sensibly to avoid situations that could result in police involvement, injury or worse.

“The Government is dedicated to reduce alcohol related harm and will continue to work with the police to clamp down on irresponsible drinkers and retailers while strengthening our partnerships with the alcohol industry to entrench responsible alcohol sales.” The campaign was welcomed by Srabani Sen of Alcohol Concern, David Poley of the alcohol industry’s Portman Group and Dr Ian Gilmore of the Royal College of Physicians.

At the campaign’s launch, when asked by the Institute of Alcohol Studies whether a mass media campaign was the most fruitful way of channelling limited resources,Vernon Coaker replied that the campaign formed part of the Government’s integrated approach towards alcohol policy. While the IAS did not oppose the campaign, it suggested that high profile but short lived campaigns of this type were unlikely to have much if any lasting impact.

The limitations of advertising initiatives are well documented - indeed, the evidence suggests that the effectiveness of such campaigns on actually changing behaviour is limited, although the impact may be difficult to quantify. People may notice, remember or even identify with a scenario portrayed in an advert, but they may not necessarily change their behaviour as a result of it.

Professor Martin Plant from the University of West England suggests that “this type of campaign is politically appealing because they suggest that the government is ‘acting’; [however they] are expensive, and invariably do not change drinking habits or reduce alcohol problems.Moreover, there is a real danger that [it] may simply serve to sensationalise, glamourise and add to the rebellious appeal of heavy drinking. Shock horror tactics have long been discredited as a basis for public education”

Plant,M & Plant,M (2006) Binge Britain:Alcohol and the National Response,Oxford,Oxford University Press. [p:95]

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ACPO study finds alcohol to be the main 'date rape drug'

There is no evidence to suggest the widespread use of so-called date rape drugs such as Rohypnol. Instead, alcohol appears to be the intoxicant involved in the great majority of such cases.

These are the findings of Operation Matisse, a study for the Association of Chief Police Officers of all or alleged or suspected cases of drug-facilitated sexual assault over a twelve month period in the Metropolitan Police,Greater Manchester, Derbyshire, Northumbria and Lancashire police forces as well as the Walsall area of the West Midlands Police.

A total of 120 cases were considered as part of the study. Each participant was asked to provide information via a questionnaire which contributed to the analysis of samples by the Forensic Science Service.

Rohypnol was not detected in any of the cases.However,there were ten cases which appeared to be linked to the use of a sedative or disinhibiting drug, and another eleven in which the possibility could notbe discounted due to a lack of clarity surrounding the circumstances of the case.Gammahydroxbutyrate (GHB)was detected in two cases.

However, in most cases, the alleged victims had consumed alcohol voluntarily and in some cases, to dangerous levels.

119 of the 120 victims had reportedly been drinking alcohol, although alcohol was only detected in 62 cases. In 22 of these 62 cases, blood alcohol levels at the time of the incident were estimated to be 200mg%or greater – more than two or three times the drink drive limit.

In 57 cases, controlled or prescribed drugs were detected, cannabis and cocaine being the most commonly detected drugs.

The study thus suggests that high alcohol levels, especially if combined with sedating or disinhibiting drugs, play a major part in these types of cases.A modus operandi of some offenders is to facilitate sexual assault by administering drugs, including alcohol, to victims. Other offenders exploit the incapacitation of the victim due to alcohol or drug use by committing opportunistic assaults after the victim has become intoxicated by her own use of alcohol or other drugs.

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Juries reluctant to convict in rape cases involving alcohol

Changes in the law that were supposed to make it easier to convict men of rape might not result in more convictions in cases in which the woman was drunk,according to new research funded by the Economic and Social Research Council.

Under the current law in England and Wales, rape can only be established if it can be demonstrated that sexual intercourse took place to which there was no consent and that the defendant lacked a reasonable belief that such consent had been given.The 2003 Sexual Offences Act changed the criteria for the defendant believing he had consent from being a view he 'honestly' held to one that was 'reasonable' for him to hold - this was intended to ensure that defendants were held to a higher level of responsibility.

However, researchers have found that jurors often took the view that it was ‘reasonable’ for a man to assume that silence represented sexual consent, even if the silence was due to the fact that the woman was totally intoxicated.

Because it is unlawful to conduct research with real juries, researchers,Emily Finch and Vanessa Munro,used trial and jury room simulations to find out how the legislation was working.

Their other main findings were:

  • In situations where the woman had become involuntarily drunk,many jurors continued to hold her partially responsible for what took place - either because she accepted drinks from the defendant, failed to stand her ground against pressure to drink more or did not take adequate care to ensure that her drinks were not 'spiked' (by either extra alcohol or drugs)
  • Even when a woman had unknowingly drunk spiked drinks, juries were reluctant to convict defendants of rape unless they were convinced that the drink had been spiked with the specific intention of sexual assault, as opposed to 'loosening up' a reluctant partner.
  • It also emerged that jurors were less inclined to equate 'taking advantage' of a drunken women with rape in situations in which the woman's normal behaviour was to drink heavily in the company of men
  • By contrast, in cases where the date rape drug - Rohypnol - had been used, jurors were more inclined to hold the defendant responsible for rape, even though the effect of the drug on the woman was the same as if she were very drunk.

Vanessa Munro of King's College London, commenting on the findings said: “These findings reflect the hold that gender stereotypes still have.They suggest that ‘rape myths’ can have a profound influence upon jurors. In cases in which the evidence suggests clear links between excessive alcohol consumption and sexual assault, these findings suggest that more needs to be done at both legal level and in society as a whole, to secure justice for victims of rape.”

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Government 'should raise tax on alcohol' - Advisory Council on Misuse of Drugs

The Government should seriously consider progressively raising the excise duty on alcohol and introduce a much stricter code for alcohol advertising and sponsorship.

These are two of the main recommendations of the Government’s own Advisory Council on the Misuse of Drugs (ACMD) in its report ‘Pathways to Problems – Hazardous use of tobacco, alcohol and other drugs by young people in the UK and its implications for policy’.* This is the first report from the Advisory Council which has included alcohol as one of the drugs under review, and the Council also recommends that alcohol should now be explicitly included within its terms of reference.The Council has a duty “to keep under review the situation in the United Kingdom with respect to drugs which are being or appear to them likely to be misused and of which the misuse is or appears to them capable of having harmful effects sufficient to cause asocial problem and to give ministers advice on measures which ought to be taken for preventing the misuse of such drugs or dealing with social problems connected with their misuse”.

The ACMD has previously focused most of its attention on drugs that are subject to the controls and restrictions of the Misuse of Drugs Act (1971), and has not, so far, considered alcohol to be within its remit. Having now considered the clear scientific evidence that nicotine and alcohol have pharmacological actions similar to other psychoactive drugs, that they both cause serious health and social problems and there is growing evidence of very strong links between the use of tobacco, alcohol and other drugs, the ACMD has decided that they can no longer neglect these two areas.

The report states that numerous recent surveys of schoolchildren in the 11-16 age range have demonstrated that, by 15, the majority of young people in the UK have smoked tobacco or cannabis or drunk alcohol, and a large proportion are using one or more regularly. By the age of 15, and with the exception of smoking among boys, levels of tobacco, alcohol and other drug use in the UK are among the highest in Europe.Concern about the potential harm of early drug use has led to efforts by government, education and health authorities and other agencies to discourage young people from using drugs. In May 2003, the ACMD agreed that it was time to take a fresh look at the patterns, trends and determinants of early use of psychoactive drugs by young people in the UK and it asked the Prevention Working Group (a sub-group of the ACMD, composed of members of the Council itself and other individuals co-opted for their particular expertise) to conduct this inquiry, under the chairmanship of Dr Laurence Gruer OBE.The main aim was to generate new insights and better advice on how to reduce the number of young people whose lives are blighted by their use of drugs.

The researchers found that,in the UK at present, 20-25% of 15-year olds are regular smokers, with females now outnumbering males; around 40-50% are drinking alcohol at least weekly; and 20-25% are using other drugs – mainly cannabis – at least monthly. Regional differences across the UK are not great. Among the 6.8 million 16-24 year olds in the UK, there are an estimated 2.1 million daily smokers, 1.9 million who drink more than twice the recommended daily alcohol limit at least once a week and 1 million who have used another drug in the past month. Because many young people use more than one drug, there is much overlap between these groups.The most alarming development in the past decade has been the growth in the number of young women who are drinking frequently and to excess.During this time, the proportion of women drinking more than twice the recommended weekly limit has doubled.

The report found that there are many factors which influence whether or not youngpeople will use tobacco, alcoholor other drugs hazardously, butthat it is difficult to predict those who will develop serious problems.The most important influential factors include early life experiences, family relationships and circumstances, and parental attitudes and behaviour.While many young people first use tobacco, alcohol or other drugs in their early and mid-teens, hazardous use often starts in the late teens or twenties.Of all drugs, the use of alcohol has shown the greatest recent growth and causes the most widespread problems among young people in the UKtoday. It is also the least regulated and the most heavily marketed. Most schools in the UK provide drug prevention programmes but research indicates that these probably have little impact on future drug use.

The Report states that, as their harmfulness to individuals and society is no less than that of other psychoactive drugs, tobacco and alcohol should be explicitly included within the terms of reference of the ACMD.The ongoing debate about how best to bring up children should be informed by the evidence that good parenting and stable family life can reduce the risks of hazardous tobacco, alcohol and other drug use by young people. The Government should continue to invest heavily in minimising the number of children and young people in relative poverty and also in protecting and supporting the most disadvantaged and vulnerable young people in the UK.Additional measures are needed to reduce the overall consumption of alcohol in the UK. Among other things, the researchers felt that the Government should seriously consider progressively raising the excise duty on alcohol.There should be a careful reassessment of the role of schools in drug misuse prevention and the emphasis should be on providing all pupils with accurate, credible and consistent information about the hazards of tobacco, alcohol and other drugs, including volatile substances.

* Advisory Council on the Misuse of Drugs (ACMD), September 2006. Ref: 275432

Taxing time for Health Secretary

Health Secretary Patricia Hewitt got into trouble with the Chancellor of the Exchequer when she followed the advice of the Government’s own Advisory Committee on the Misuse of Drugs and wrote to the Chancellor asking him to increase the tax on alcohol,
especially alcopops, to tackle binge drinking. Evidence from Government research shows that alcopops are popular with young drinkers, especially underage drinkers. The two most popular drinks among 11 and 12 year old boys and girls are alcopops – WKD and Bacardi Breezer.

Ms Hewitt gave the story of her letter to a children’s newspaper, First News. She said: “I am asking Gordon Brown, as the Chancellor, when he comes forward with his Budget next year, to really increase taxes on alcohol. And particularly things like alcopops and some of the stuff that quite a lot of teenage boys and girls are drinking because we’ve got a real problem with binge drinking among young people.”

Ms Hewitt commented on the ‘enormous numbers’ of young people ending up in casualty departments of hospitals because they are drunk, especially on Friday and Saturday nights. She thought that putting up taxes would help discourage young people from spending too much money on alcohol.

In this she was supported by a range of public health bodies, and also the Association of Chief Police Officers.However, she was criticised by the alcohol industry’s Portman Group, and it is understood that her suggestion was not well received at the Treasury. Some media reports suggested that Ms Hewitt was ‘rebuked’ for sending the letter and told that the idea of increasing alcohol tax was ‘not a runner’.

Treasury spokesmen are reported as saying that doing what Ms Hewitt suggested would take at least two years because it would unravel the current taxation structure and also require discussions with the European Commission.However, increased taxes on alcopops have already been introduced successfully in other some other EU countries, France,Denmark and Germany, and, outside the EU, in Switzerland.

Subsequently,Department of Health spokesmen explained that Ms Hewitt’s letter simply expressed her own personal point of view.

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Tory party accuses Government of complacency over alcohol issues

The Government has an ‘official policy of insouciance’ in relation to alcohol issues according to the Conservative Party’s Social Justice Policy Group, which has now published its interim report on the state of the nation - Breakdown Britain.The Group accuses the Government of being guilty of a double inaction with regard to alcohol,with a massive under-provision of alcohol-related funding and treatment facilities in relation to the scale of the problem. It contends that the Government has ignored the body of research evidence showing that control of the population’s consumption is the most effective way to reduce harmful and/or hazardous use of alcohol and alcohol dependence – a body of evidence that is backed by the majority of specialist doctors.One of these doctors has described the Government of being guilty of ‘official insouciance’.

The Social Justice Policy Group (chaired by the Rt Hon Iain Duncan Smith MP) has been commissioned by the Party Leader, the Rt Hon David Cameron MP, to make policy recommendations to the Conservative Party on issues of social justice. Ian Duncan Smith states that the ‘report is about understanding the causes of Britain’s most acute social problems’ and he describes it as ‘the first stage in a process of developing policy proposals to stabilise and strengthen society, rather than punish those whose lives are products of the self same causes that have been ignored for too long’. The Policy Group will study the nature and extent of social breakdown and poverty in Britain today, together with the causes of poverty and policy solutions to social breakdown and exclusion. The group will look at a number of different factors,which contribute to poverty, and have identified five key ‘paths to poverty’:

  • family breakdown
  • educational failure
  • worklessness and economic
  • dependence
  • addictions
  • indebtedness.

This new report covers phases 1 and 2 of the study areas. The full Report is due to be completed within months and policy recommendations will be made to the Conservative Party in June 2007. The Group will also look at increasing the role of the voluntary sector in providing local, effective and lasting solutions for poverty.

The Group used a three pronged process of evidence gathering for the Report:

  • academic research,
  • anecdotal/qualitative data and
  • original random sampling.

The methodology involved extensive academic research including contributions from over 50 leading practitioners with many years of experience. There has also been extensive public consultation including a YouGov poll of over 40,000 people (also broken down according to the five relevant pathways to enable more focused analysis), direct consultation with over 800 individuals and organisations, online consultation via www.povertydebate.com and public hearings and visits to London, Birmingham, Glasgow, Brighton, Carlisle, Devon and Wolverhampton.

Policy confusion…

Chapter 3 ‘Addictions’ deals with what the report calls ‘ the Government’s confusing and contradictory drugs policy’, stating that ‘Government ‘treatment’ is almost always limited to harm reduction.’ The Policy Group is in the process of taking evidence from those involved with alcohol addiction to find out what type of service provision and treatment is likely to have the best outcomes.

The researchers state that ‘young adults are engaging in a new culture of intoxication’ and ‘national statistics for both children and adults are likely to be underestimates as the prime drug-using sub-groups – truants, excludees and children in care, the homeless and prisoners are not surveyed.’ The Report details the rise in addictive problems and outlines the health and social costs as well as the impact on children and on the cycle of deprivation, noting that ‘substance misuse appears to be as much a catalyst for family disruption and dysfunction as it is an outcome.’ The report finds that drug misuse is perpetuating social disadvantage and is associated with definable social groups and its impact is particularly severe for the least well off,who have the fewest resources to cope with addiction or to recover from it. It finds that young, predominantly single, under-educated and unemployed boys and young men are amongst the most badly affected and the most at risk.

Ineffective Drugs Policy

The Report concludes that the current structure of drugs policy is not targeted at those areas where drug and alcohol dependency are most concentrated and where children are most affected. It states that the Harm Reduction Strategy has pushed treatment in the wrong direction, preferring maintenance to recovery. Referring to this policy as ‘state-sponsored addiction’ the Policy Group maintain that this method has had minimal impact on re-offending figures and a non-existent impact on rehabilitation and recovery. They say that the current system is unsustainable and driven by the National Treatment Agency’s requirement to meet government targets. The current implementation of Drugs Treatment and Testing Orders was rolled out before its efficacy was proved and has damaged the perception of the treatment system in the eyes of both substance abuse workers and of those trying to access treatment.

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Treatment for alcohol problems saves public money

National Treatment Agency Review of Effectiveness

Evidence-based alcohol treatment in the UK could result in net savings of £5 for every £1 spent for the public sector and providing effective treatment is likely to reduce significantly the social costs relating to alcohol,whilst increasing individual social welfare.This is the view put forward in a recently-published review of the effectiveness of treatments for alcohol problems,which will be of interest to managers,commissioners,providers, service users and key stakeholders in the provision of alcohol treatment services.

The Review of the Effectiveness of Treatment for Alcohol Problems,written to support the implementation of the National Alcohol Harm Reduction Strategy and specifically to complement the Models of Care for Treatment of Adult Drug Misusers (MoCAM) initiative was published by the National Treatment Agency for Substance Misuse in November 2006. It is intended as a key reference tool to facilitate the development of effective local alcohol treatment systems,which can contribute to the reduction of alcohol-related harm within communities. By covering the published international research literature on alcohol interventions and treatment and by describing the effectiveness of the various interventions and treatments available, it is hoped that the Review will enable local services and partnerships to assess current provision and plan future developments to meet the needs of their populations.

At the outset, the authors, Duncan Raistrick,Nick Heather and Christine Godfrey, identify 10 key themes which inform the document. Briefly, these are:

  • Drinking takes place within an influential social context.
  • People move in and out of different patterns of drinking without recourse to professional treatment.
  • Help-seeking usually follows prolonged alcohol-related problems, notably related to health, relationships and finances, after unassisted attempts to change drinking patterns have failed.
  • Treatment effectiveness may be as much about how treatment is delivered as about what treatment is delivered.
  • There is a choice of effective treatments to suit the variety of potential service users.
  • Psychiatric co-morbidity is common among problem drinkers and this is likely to make treatment more challenging and of longer duration.
  • Treatment for alcohol problems is cost-effective. Alcohol misuse has a high impact on health, social care and criminal justice systems, where major savings can be made.
  • Interventions of all kinds are only effective if delivered in accordance with their current descriptions of best practice and carried out by a competent practitioner.
  • Stepped care is a rational approach to developing an integrated service model that makes best use of a finite resource.
  • The evidence base for the effectiveness of alcohol problems interventions is strong.The UK contribution is considerable and merits further financial support to research programmes.

The first part of the report sets the scene by giving the background to the review and putting it in context against current alcohol policy.This is followed by an overview of treatment and interventions to reduce alcohol-related harm and consideration of ways in which the base of treatment for alcohol problems needs to be broadened from the traditional exclusive focus on ‘alcoholics’. Summaries are then provided of the Mesa Grande project, together with three recent systemic reviews and two large multi-centre trials of alcohol treatment, known as Project MATCH and the United Kingdom Alcohol Treatment Trial.The authors then consider how treatment should be delivered rather than what treatment should be delivered, covering therapist characteristics, service user groups and settings in which to deliver services.

Before reviewing treatments themselves, the authors review commonly used screening tools, such as questionnaires, and consider the use of screening instruments in various settings, including Antenatal clinics and A & E departments, as well as looking at biological and clinical markers of alcohol misuse. It is recognised that early detection is an essential element of broadening the base of treatment to detect problem drinkers before they become help-seekers. The authors consider which evidence should be included in a comprehensive assessment and review commonly used assessment tools, noting that treatments are only of value if they deliver useful outcomes, and exploring some of the problems concerned with measuring outcomes.

Four chapters follow which deal specifically with core psychosocial treatments for alcohol misuse – brief interventions, less intensive treatment, alcohol-focused specialist treatment and nonalcohol focused specialist treatment. Brief interventions are described in different populations and settings; medical, non-medical and educational, and the authors identify specific barriers to the implementation of screening and alcohol brief interventions in primary healthcare. Less intensive treatments,which are still considered brief but are aimed at help-seekers and extend over a number of treatment sessions, are then considered, including condensed cognitive-behavioural therapy, brief conjoint therapy, motivational interviewing and motivational enhancement therapy.

The chapter on alcohol focused specialist treatment looks at the effectiveness of psychosocial treatments focused on the service user’s drinking and alcohol-related problems, which are mainly relevant to service users with moderate or severe alcohol dependence. Several treatment options are considered, namely the community reinforcement approach, social behaviour and network therapy, behavioural self-control training, behaviour contracting, coping and social skills training, cognitive behavioural marital therapy, aversion therapy, cue exposure and relapse prevention.The subsequent chapter on non-alcohol focused specialist treatment covers coping skills, counselling, family work and complementary therapies.

Pharmacotherapies and their interaction with the psychosocial interventions discussed earlier in the Review are then considered.These are categorised as detoxification, relapse prevention and nutritional therapy.The authors then look at how alcohol misusers can help themselves to recover from their problems without the aid of formal treatment.Distinguishing between individual self-help and collective mutual aid, the authors consider computer and web-based self-help programmes, 12-step facilitation therapy and 12-step residential treatment, amongst others.

The authors consider the prevalence of psychiatric comorbidity and note that most of the interventions described will be helpful to people with mental health problems, although they may require modification.The Review concludes that there is theoretical and anecdotal evidence to favour either an integrated or shared care approach and that there is a need to configure services and construct care pathways in such a way that people with comorbidity are not excluded from treatment and are not moved from one agency to another.

The authors then turn to the crucial question of the cost-effectiveness of treatment and its relevance to the provision of treatment for alcohol problems in England, concluding that alcohol treatments are highly cost-effective in comparison with other healthcare interventions. In the final chapter, the treatment journey is put in context, and the authors point out that treatment is one of the many different influences on an individual’s drinking. Directly or indirectly, they say, treatment probably accounts for around one-third of all improvements made.UK and international research has shown that alcohol treatment can be an effective and cost effective response to alcohol problems. While there is compelling evidence for investment in alcohol treatment, the review makes clear that it will be essential to invest wisely in interventions of proven effectiveness.

The Review provides a well-organised, systematic evaluation of the wide range of treatment options available to deal with alcohol-related problems and will be an invaluable resource for anyone with an interest in this field.

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'Should we cut children's exposure to advertising?'

A meeting of the All Party Parliamentary Group on Alcohol Misuse in December 2006 was devoted to the question of children’s exposure to alcohol advertising.The meeting was organised by Alcohol Concern, the National Agency on Alcohol Misuse, and chaired by Rob Flello MP,Officer of the All Party Group,accompanied by another member of the group,Russell Brown MP. Srabani Sen, Chief Executive of Alcohol Concern and Jane Landon, Deputy Chief Executive of the London Heart Forum, gave short presentations.

The meeting was attended by the Suzy Lamplugh Trust, the Royal College of Physicians, the Institute of Alcohol studies, Representatives of Ofcom, and the Directors General of the Association of Advertisers and the Institute for Practitioners of Advertising.

The meeting sought to address three main points: Is the evidence base linking the advertisement of alcoholic beverages and underage consumption credible? Is the regulatory framework currently in place sufficiently protective of children? And finally, are politicians, rather than regulators who have to balance a greater range of statutory obligations, better placed to make decisions of this nature?

The meeting took up the theme of the watershed, drawing upon the National Heart Forum’s impressive campaigning - and lengthy battle with Ofcom, the independent regulator competition authority for the UK - for a ban of the advertising of junk food targeted at children.

Srabani Sen, in her presentation, highlighted the imbalance which exists between the potential impact of alcohol advertising and marketing, and public awareness campaigns: in 2003, the alcohol industry spent £203 million on advertising - this figure stands in stark contrast to the £4 million the Government spent on the ‘Know Your Limits’ Campaign, launched last month by the Government, and aimed at raising awareness of the risks of binge drinking among young people. She also emphasised the evidence cited in the report ‘Alcohol in Europe’, published by the Institute of Alcohol Studies, showing a clear relationship between UK Advertising expenditure on alcohol between 1992 and 2000 and levels of alcohol consumption among 11 to 15 year olds during that period. She noted that rules set out by the Advertising Standards Association (strengthened by Ofcom in October 2005 to prohibit advertising likely to appeal to under 18’s, as opposed to advertising deliberately targeting under 18’s as was the case previously) were still not sufficient to prevent adverts appealing to younger children from reaching the marketplace. Srabani Sen called for more robust measures to be put in place; the watershed could represent an effective way to protect children from the influence of alcohol advertising.

The spokesperson from Ofcom claimed she was “not convinced that there was a problem, and that by and large, the content rules were very effective”. She also reiterated the plural nature of Ofcom’s duties, which mean that, as an independent regulator, it must create standards of advertising in order to protect vulnerable groups (such as young people) but it also has to balance the rights of commercial expression of manufacturers and retailers.The representative of the Association of Advertisers referring to the issue of a junk food ban, ridiculed the model provided by the Food Standards Agency, classing products such as milk and cheese as ‘junk food’; he suggested that a ban on advertising alcoholic products in order to protect young people ignored the fact that three of the major soap operas in the UK were heavily centred within a pub setting.He suggested such decisions should be left up to the regulators,who implement ‘evidence based’ bodies, rather than ‘opinion based’ politicians.

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Licensing Act 2003 - one year on

November 2006 saw the anniversary of the controversial new Licensing Act which abolished fixed pub closing times and was the subject of much debate as to whether allowing longer drinking hours was a way of tackling the binge drinking culture or whether it would make it worse.

Here Emilie Rapley reviews the evidence.

The Licensing Act 2003 came fully into force in England and Wales, on 24 November 2005, effectively combining seven licensing regimes into one, and transferring licensing responsibilities from the Magistrates Court to the Local authorities, in order to allow, in principle, a more comprehensive and localised approach to the issues of licensing and nighttime economy management.

The former licensing regime was often described by politicians and representatives of the alcohol industry as ‘outdated’ and ‘restrictive’, in imposing ‘artificially early closing times’ for pub goers, and, was blamed by them for binge drinking and alcohol related crime and disorder.The new regime allows a more ‘flexible’ system for licensed premises, and in theory, staggered closing times should in turn allow a more gradual dispersal of late night revellers, alleviating pressure on police resources in town and city hotspots during peak times.

However, in fashioning the Licensing Act 2003, the Government was accused of playing down warnings from police, senior judges, experts in the alcohol field, and of dismissing international scientific evidence showing that longer opening hours are not the panacea to solving the problems of binge drinking and alcohol related harm in Britain, now ranking as the third worst ‘binge drinking nation’ in Western Europe .

While critics of the Government’s original plans did succeed in bringing about substantial changes to the legislation as it went through Parliament, increasing the level of protection of the public against adverse consequences, there remained considerable anxiety about the impact of the new Act.

Year of transition

One year on, it is difficult to assess the impact of the Licensing Act on health, crime and disorder; indeed,many critics of the legislation have suggested it could take at least five years to see its true impact, and that any notable changes with regard to drinking behaviour and attitudes towards alcohol could possibly take up to a generation to emerge.

The first reason why it is difficult to assess the impact of the new Act and of the extended drinking hours it allows is that the introduction of the Act was accompanied by a range of other measures and initiatives also designed to have an impact on crime and disorder, most obviously the two high profile Home Office Alcohol Misuse Enforcement Campaigns, costing £2.5 million each. A smaller scale ‘underage sales crackdown’ was also carried out in conjunction with Trading Standards over the first three weeks in October 2006.These two campaigns were carried out at pivotal times before Christmas, and during the summer, before the Football World Cup in Germany - periods known to be particularly problematic in terms of alcohol related crime.

In addition to these specific initiatives it is reported that the introduction of the new Act resulted in significantly increased spending on policing of the night-time economy. For example, in Brighton, extended drinking hours resulted in twice the number of police being on patrol in the city centre at weekends, at an additional cost in overtime of £170,000.

Secondly, evidence regarding the effect of the Act at a local level remains largely anecdotal, and, therefore, does not provide a national picture. For example, whereas the Broad Street area of Birmingham has been flagged as having successfully reduced the toll of alcohol related crime and disorder as a result of longer hours (although it should be noted that this area has received substantial funding for community safety initiatives- for example street wardens- through the ‘Business Improvement District Scheme’ ), reports from Brighton, on the other hand, remain dismal despite the extra spending on policing. Roger Rolfe, a Brighton resident, member of the Kingscliffe Society and of the Open All Hours? Network, claims that noise, nuisance and disorder has not diminished as a result of the Act, but instead, had been displaced later into the night: “Whereas before, noise and chaos outside my window occurred between 11 pm and midnight, now it just goes on until the early hours”. Lastly, a number of reports across the local and national media seemed to suggest that a year on, business was simply ‘going on as usual’; given that one of the clear mandates of the legislation is to reduce binge drinking significantly as well as alcohol related antisocial behaviour and disorder, these claims do clearly not translate into any kind of ‘victory’.

One year on… a confused picture

On the year anniversary of the Act, opinions were divided, as expected, leading to the unavoidable polarisation of the debate, increasingly centred upon the misguided notion of ‘24 hour drinking’. Indeed, on 24 November 2006, Licensing Minister Shaun Woodward claimed that there had not been an ‘explosion’ in all-night venues and there were ‘encouraging signs’ that the new laws were working. He said “only 3000 out of 200,000 licensed premises have applied for such licenses, [which] in effect equals to less than two per cent of licensed venues, and many of these stay open all night only on special occasions”.The Independent echoed this view by dismissing the forecasts of ‘peddlers of hysteria and fear’, suggesting that “the reality of the past twelve months has been very different from the cataclysmic picture conjured up by the opponents of the reform (…) Britain is finally beginning to see with a clear head”.The British Beer and Pub Association, in their press release ‘Whoops,No Apocalypse’ reported the findings of their poll carried out by YouGov showing that over 86% of people had not changed their drinking habits as a result of deregulation, and that alcohol consumption has seen a fall of 2%, the first decrease in six years.

These voices of early triumph were counterbalanced by the more guarded comments made by the Association of Chief Police Officers (ACPO), who suggested it was “far too early to assess the true impact of the act given that the night time economy is complex and there are number of variables at play (…) the police service will continue to work closely with local authorities and the trade to deal with the negative effects of a culture of excessive drinking that still exists in our society”. The British Association of Emergency Medicine reported that Friday and Saturday night alcohol related Accident & Emergency attendances had simply been displaced later into the night as a result of longer hours.The London Ambulance Service reported that alcohol related call-outs actually increased by 3 per cent in the year following the introduction of the Licensing Act, and that there was no indication of any change to the number of alcohol-related incidents occurring during the period 11pm to 2am, despite the Government’s hope that the new Act would reduce the ‘alcohol flashpoints’ around the old closing times.

Towards ‘diversity’ and the ‘café culture’?

The move towards liberalisation has been forecast by the Government to create a ‘continental café culture’ though the means of a diversification of the night-time economy, presently geared towards the 18- 24 year old age group, based upon the consumption of alcohol and exemplified in the emergence, over the last two decades, of chain pubs and themed bars now found in every town and city centre in Britain. Indeed, John Tierney, from the University of Durham, suggests that ‘diversity’ has become an ideal for which to strive, and that in some ideal future according to Ministers- our presently saturated ‘monocultural’ night time economy ‘will be transformed into a multifaceted,multicultural and safe environment similar to that found in Europe’.

In 2005, the Institute of Alcohol Studies published a paper highlighting the international scientific evidence pertaining to the effect of increasing hours of alcohol sale, in other jurisdictions,with ‘similar’ drinking cultures - Ireland, the Netherlands, Latvia, Russia, Iceland,Australia and New Zealand - argued to be culturally ‘closer’ to Great Britain in terms of alcohol consumption patterns than Mediterranean countries .Generally, the evidence suggests that while increased hours of trading may not increase the overall level of alcohol consumption (at least where alcohol is already widely available), they do increase the problems associated with consumption. Overall, the large body of scientific evidence on this topic shows that “increases in hours of sale are consistently related to increases in alcohol-related harm, including traffic injury, street disorder and violence. Later and longer hours for alcohol sales contribute disproportionately to heavier drinking and drunken behaviour.”

Hazel Blears:
no café culture for the British

The Labour Government’s claim that the introduction of liberalised licensing laws would signal the end of British binge drinking by ushering in a continental-style cafe culture appears to have been rejected by one of the ministers responsible for the new Act.

Speaking to the Sunday Times, former Home Office Minister Hazel Blears, now the chairman of the Labour Party, said that she thought the licensing changes would not have the desired effect because the British were incapable of drinking in a more civilised way. She attributed this incapacity to their being Anglo-Saxon. Ms Blears said:

“I don’t know whether we’ll ever get to be in a European drinking culture, where you go out and have a single glass of wine.Maybe it’s our Anglo-Saxon mentality.

“We actually enjoy getting drunk. I think there is a bit about risk-taking — people want to push the limits of danger. So as a politician I don’t think there are any easy answers.” However,Ms Blears defended the new Licensing Act on the basis that it had not had the catastrophic consequences predicted by some police and opposition politicians.

“The 24-hour drinking was supposed to be the end of life as we know it. That hasn’t happened,” she said. But she added: “The health implications worry me. “People are getting quite serious health conditions earlier — things like liver problems in their twenties and thirties that perhaps before only came out in their forties and fifties.

“I think we’ve got to do more education now – that has to be the absolute priority.” She said alcohol manufacturers and retailers also had a duty to market their products more responsibly.

Alcohol Misuse Enforcement Campaigns

These enforcement campaigns, carried out by the Home Office in conjunction with Trading Standards, involving all 43 police forces in the country and costing £2.5 million each, form part of the Tackling Violent Crime Programme, a targeted programme focusing on alcohol related crime and domestic violence in high volume crime areas.The ‘crackdown operations’ were carried out in the run up to Christmas and over the summer, in anticipation of the football World Cup; in addition to extra police powers embedded in the Licensing Act, these campaigns form an integral part of the Government strategy to counter the possible upsurge in alcohol related disorder resulting from the implementation of longer hours. While the outcome of these campaigns on the toll of crime and disorder is difficult to measure, the Government’s willingness to release politically motivated misleading figures, and to downplay the gravity of the situation, remains of great concern.Results of the first AMEC were claimed to show a‘decrease in violent crime’, while the second uncovered alarming rates of failed test purchases,with one in three underage drinkers being able to purchase alcohol from licensed premises; these findings were described by Shaun Woodward as ‘disappointing’.

Professor Mark Bellis, Director of the Centre for Public Health at Liverpool’s John Moores University, suggests that current indications of the effects of the legalisation have largely been based on police statistics and assessment of the effects of the Alcohol Misuse Enforcement Campaigns on the outcome of test purchasing . Indeed, in their report, the researchers from JMU highlight that “police data have shown no indication of a rise in levels of violent offences as a result of the change in licensing legislation”. Evidently, this fact has been used to the advantage of the Government, keen to portray the liberalisation as a success, but also to that of the licensed trade. On 9 November 2006, the Publican reported that “first hard indications that the Licensing Act is having a positive effect on crime are emerging”; in effect the paper reports figures compiled from the Metropolitan Police suggesting that reports of common assault in the capital fell 13.4 % between December 2005 and September 2006; criminal damage fell by 10.4% over that period, and ABH fell 4.9 %; total crime was down 5.5%.However, a spokeswoman from the Metropolitan Police echoed these concerns and said “it was still to early to say what the full effects of the Act were”.The researchers further suggest that these evaluations are “inherently related to police activity and therefore cannot be considered an independent measure of intervention and legislative change on levels of violence”. Moreover, recorded crime statistics from 2004/2005 show signs of a fall in crime, prior to, and independently of the implementation of longer hours; also ONS figures show that the levels of men exceeding the government’s sensible drinking benchmarks began to decrease in 2003/2004, before the introduction of the new Act. On the other hand, alcohol related deaths and admissions to hospital have seen a steady increase since the 1990’s.

Evaluation of the Effects of the Act

The Government Evaluation of the impacts of the Licensing Act on crime and disorder is seldom referred to in any detail in press releases or statements made by Ministers; this apparently undisclosed process adds to the already well established doubts surrounding the Government’s alcohol policy agenda.The Crime Statistics for England and Wales, a compilation of Police recorded crime and British Crime Survey Data, were released in the summer of 2006; the graph above shows violent offences and criminal damage from October 2004 to March 2006 recorded in 23 police forces, between the hours of 11pm and 2 am.

As mentioned above, scientific evidence from around the world suggests that a consequence of longer hours of alcohol sale is a temporal displacement of offences, a situation which has already been confirmed by the British Association of Emergency Medicine.The Home Office response to this is the graph above,which is described as showing no indication of a rise in the overall level of offences or a shift in the timing of offences as a result of the change in the opening hours of licensed premises.The Home Office states that more detailed results will be published in due course.

 

 

However, the figures presented in this graph are ambiguous.Not only are they figures of offences recorded by police, and thus subject to the same difficulty of interpretation as all police figures in regard to whether they reflect actual levels of crime or, rather, levels of police activity, they also leave open the possibility that levels of crime increased after 2am, one of the issues at the heart of the debate.

The rather elusive Home Office Evaluation contains two strands; night-time economy modules added to the British Crime Survey (BCS) 2005/ 2006, and the Offending and Crime Justice Survey (OCJS). In addition to this, five Local Authority Areas have been selected as case studies,which will include a residents’ survey, focus groups with key stakeholders, and interviews with licensees and late night business owners.A research team at the University of Huddersfield will be carrying out additional quantitative analysis, measuring crime and disorder in and around licensed premises.

References

Anderson, P & Baumberg, B (2006) Alcohol in Europe:A Public Health Perspective, Institute of Alcohol Studies, London.

The Independent, 23 November 2006 ‘A Timely lesson in Trusting the People’

BBPA Press Release ‘Whoops,No Apocalyspe’, 24 November 2006) www.beerandpub.com

DCMS Press Release, ‘Licensing Act, One Year One’, 24 November 2006,De Haviland.

Spokesperson from the BAEM, Five Live, 14 November 2006)

Tierney, J (2006) ‘ We Want to be More European’, Social Policy and Society,

McNeill (2005) Binge Drinking, Crime and Disorder and the Licensing Act 2003, Occasional Paper, Institute of Alcohol Studies: London.

Belis,M,Anderson,Z and Hughes,K (2006) Effects of the Alcohol Misuse Enforcement Campaigns and the Licensing Act 2003 on Violence’ , Centre for Public Health, Liverpool John Moores University.

The Publican, 9 November 2006 ‘Crime Down Since Launch Of Licensing Act’

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Poverty and deprivation - key causes of mental health problems in children

Children from poorer backgrounds, children in care, asylum-seeker children and those who have witnessed domestic violence, are all at a higher risk of developing mental health problems, according to a new BMA report.

Alcohol and misuse of other substances are featured as causes or consequences of mental health problems,which can range from sleep disorders, excessive temper tantrums to depressive and obsessive disorders.

The report, Child and Adolescent Mental Health – A Guide for Healthcare Professionals, finds that mental health disorders in children are on the increase and that poverty and deprivation are major risk factors. One in 10 children between the ages of one and 15 has a mental health disorder – in real terms, this suggests that around 1.1 million children under the age of 18 would benefit from specialist services.These problems have a huge impact on families and carers, as well as on the individual.

On alcohol and substance misuse, the report says that these are sometimes linked to mental health problems, and of course a significant proportion of young people take alcohol and other drugs.Alcohol and other drugs can both exacerbate and trigger mental health problems; those with mental health problems are at greater risk of misusing drugs and alcohol and drug misuse can cause mental health problems.Alcohol can be attractive to those suffering from depression, for example,because it can increase confidence and produce feelings of well-being, drowning out problems in the short-term.However, alcohol its itself a depressant drug and so can also worsen the symptoms of depression, and increase the risk of suicidal thoughts and behaviour.

Dr Vivienne Nathanson, Head of BMA Ethics and Science, said today: “Children from deprived backgrounds have a poorer start in life on many levels, but without good mental health they may not have a chance to develop emotionally and reach their full potential in life. For example, 45 per cent of children in the care of local authorities suffer from mental health problems.These children may have come from socially and economically deprived backgrounds, and are more likely to under-perform at school.There are a number of government policies currently being rolled out that are aimed at tackling these problems. It is essential that they deliver what they promise.”

A key barrier to young people using mental health services is that they are not tailored to meet their needs, says the report. For example, young people are more likely to access services that are open after school and not too far from where they live.The BMA says services need to take account of language and cultural differences.

According to the report, rates of mental health problems tend to be higher among children from black and minority ethnic groups, as they are “more likely to experience risk factors such as deprivation, discrimination and poor educational and employment opportunities”, the report claims, yet they often do not receive appropriate treatment.

There is a worrying shortage of mental healthcare professionals, including those from black and minority ethnic backgrounds, and this needs urgent attention, says the BMA report.

Key recommendations from the report include:

  • The reforms outlined in the Child Poverty Review must be implemented to end child deprivation and therefore reduce risk factors for mental health problems.
  • Children and young people need innovative and flexible health services that suit their ages and lifestyles.
  • Current strategies for addressing child and adolescent mental health problems must be fully implemented.
  • The media has a role to play in tackling the stigma of mental illness – a study of British tabloid newspapers found that 40 per cent of daily articles about mental health used derogatory terms such as ‘nutter’ or ‘loony’.
  • The government must address the current shortage of mental healthcare professionals
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Book review - Alcohol, Addiction and Christian Ethics

Christopher C H Cook

(Cambridge 2006) ISBN 0521851823

This is an entirely praiseworthy attempt by Chris Cook to open the ethical debate on alcohol questions amongst Christians after many years of embarrassed silence. One hundred years ago every mainstream denomination had a public policy position on alcohol questions and many required of their members abstinence from all intoxicants.

That intensity of moral purpose has now been transferred to other causes. Social drinking has resumed among most church members and drink-related problems are once more on the increase.Chris Cook comes to this area of ethical concern both as committed Evangelical Christian and someone with a long experience of treating drink dependency.Although he addresses a breadth of ethical questions raised by alcohol it is to the addiction issues set out in his title that he keeps on returning.

The methodology he adopts is to survey scripture and tradition, including an analysis of leading texts from the nineteenth century temperance movement. The heart of the book consists of this disciplined and analytical work, rather than the incremental building of a particular ethical case.The author is too generous a person to pronounce his anathema against the demon kings of his world,whether they be the corporate leaders of the drink industry, ambivalent about public health, or the obsessive teetotalers, who substituted abstinence for the Gospel. If he reaches a conclusion it is that Christians need to re-examine their ethical stances on alcohol and to drink sparingly as a result.

More could have been said about the role of modern science in complicating traditional ethics.As Christians have discovered in the debates about the origins of life, there are hermeneutic problems once we turn to the Biblical text or the works of Augustine.Their arguments are based in the limited biological knowledge of their day.Chris Cook takes up the case for a modern psychological understanding of dependency and sees how it might be rooted in authors such as Aquinas,who had no first hand knowledge of such a discipline.There remains a further science-based debate about the nature of the human personality and will, rooted in our enlarged understanding of neurology.This discipline is driving us back to the more holistic view of the person which we find in the Hebrew Bible and putting question marks over the Greek distinction between body and soul. Although the primary impact is in arguments about immortality, neurological science does also demand we revisit questions of will-power and addiction. Similarly, in a book of this length and scope one can understand the limits to what can be said historically, but to introduce the nineteenth century temperance movement in a British and American context with no reference to the role of women is surprising.

This leads to the hope that Chris Cook can be persuaded to write further in this neglected area of ethical enquiry. Christians cannot go on ignoring what secular agencies have identified as an area of major challenge for those who promote public health and public order.The nineteenth century history, especially, is suggestive of further fruitful work.Clearly, the lead in promoting abstinence was taken by ‘Free Church’ denominations in the Evangelical tradition,with the Anglicans and Roman Catholics drawn into the debate. What would be fascinating to see is how far the Holiness Movement within Evangelicalism fuelled the growth of tee-totalism, especially as Pentecostalists remain largely committed to abstinence. On the basis of what Chris Cook has already said about Donatists and Manichees in the present volume there are promising possibilities. He obviously believes in a life affirming Christianity. Christian ethics, for most people, seems to suggest the opposite.

Stephen Orchard

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