Issue 2 2003

Alcohol related brain damage on the rise

Scotland is experiencing an increase in rates of alcohol related brain damage. It has some of the highest rates of this condition in the United Kingdom. The diagnosis is associated with deprivation and is occurring in younger people.

The Scottish Executive makes a brief mention of services for this group in the Plan for Action on Alcohol Problems ⁽¹⁾ to the extent of commissioning an Expert Group to report on the condition. No commitment to resources has been made.

What is alcohol related brain damage (ARBD)?

Long-term excessive consumption of alcohol has a harmful effect on almost all organs of the body. Those particularly affected include the brain and the gastro-intestinal system (gut and liver). The effect of protracted excessive consumption on the brain varies from person to person for reasons, which are not yet clear. Theories include the style of alcohol consumption, for example, binge versus chronic consumption, and differences in an individual’s susceptibility, usually thought to be genetic.

ARBD incorporates a range of diagnoses and refers to the effects of changes to the structure and function of the brain resulting from long term consumption of alcohol.

There is no single cause of ARBD, which usually results from a combination of factors. These include the direct toxic effects of alcohol on brain cells, the effects of dehydration on the brain, vitamin and nutritional deficiencies, head injury and disturbances to the blood supply of the brain usually incurred whilst intoxicated.

A patient with alcohol related brain damage can present in a variety of ways. These include Wernicke’s Encephalopathy which is an extremely acute and reversible condition, difficult to recognise and treat as most people experience this at home and receive no treatment. Sufferers reach a catastrophically low level of the vitamin Thiamine in their system and as a result begin to have small bleeds into the areas of the brain most related to memory. They present with the classic signs of ataxia (staggering gait), nystagmus (paralysis of eye movments) and confusion (lack of orientation in time, place and person). The emergency treatment of this is immediate Thiamine administration by injection. This is a rare presentation as most individuals do not have all the clinical signs. If untreated this can lead on to Korsakoff’s Psychosis/amnestic syndrome. This is the more permanent deficit state seen either following untreated Wernicke’s Encephalopathy or presenting to services. The individual has sparing of most of their cognitive functions but a very dramatic deficit in their short-term memory. The main treatment for this is intensive neuro-psychological rehabilitation and total avoidance of alcohol. The individual may be so incapacitated by their short-term memory that they are unable to live outside an institution and may, for example, forget crucial new information such as the death of a spouse. This condition can be permanent or can slowly recover with some recovery occurring in up to 75 per cent of sufferers ⁽²⁾.

Alcohol Dementia presents as a more global deterioration in intellectual function with memory not being specifically affected. Sufferers can present in their early thirties although the more common age for presentation is in the fifth, sixth and seventh decades. This condition is not, as suggested, a true dementia, in that recovery is possible. This seems to be more common in women and the recovery rates are better than for Korsakoff’s Psychosis, provided correct support and alcohol abstinence is ensured.

Most presentations are somewhere along the spectrum between Korsakoff’s Psychosis and a global dementia. Others can present with damage to the frontal lobes to their brain which causes disinhibition, loss of planning, and executive functions and a blithe disregard for the consequences of their behaviour.

Treatment of ARBD.

This is a complex area particularly as knowledge of the conditions and their management needs to be improved amongst care providers.

Clear diagnosis rests on the assessments of a range of professionals, including social work, occupational therapy, medical and psychology services. In particular neuro-psychological assessment is crucial to making an accurate diagnosis and guiding rehabilitative efforts. Rehabilitation can be provided in a range of settings including the patient’s home if they are actively motivated and capable of making the judgement to abstain from alcohol.

Unfortunately, what happens in most cases at present is that either the case goes undiagnosed or patients spend long periods of time after diagnosis inappropriately placed. This includes patients remaining in an acute medical bed for several months while suitable placements are found.

Repeat neuro-psychological testing to measure progress is a requirement as a clear impression of the patient’s recovery is not obtainable until two years after they have stopped drinking.

Increasing Rates – True or False?

The impression of many clinicians is that there has been a true increase in the rate of this condition. While there has been some recent interest in understanding and treating this condition, perhaps resulting in increased rates of diagnosis, there is also clear evidence from hospital discharge rates and the numbers of patients with this diagnosis occupying a long-term psychiatric bed in Scotland, that there is a true increase in prevalence ⁽³⁾.

There are several potential causes of this, which include:

• advice from the Committee on Safety of Medicines that injectable vitamins cannot be given in settings where resuscitation facilities are not available. This means that alcohol dependent patients are no longer likely to be given top ups of vitamins by their GPs or by nurses undertaking home detoxification. This and the withdrawal of this product for a period of time in the late eighties did seem to exacerbate an already increasing problem ⁽⁴⁾. Oral vitamin supplementation in active drinkers is largely ineffective.
• While the Scottish Executive claim that the national levels of alcohol consumption remain static for the last twenty years, it is clear to those working in the addiction field feel that there is increased consumption of illicitly acquired alcohol imported from the continent. This is not recorded on Customs and Excise figures.
• The relative cost of alcohol has fallen making it possible for those even on the lowest incomes to maintain enormous levels of consumption. A recent survey carried out by nurses in my service found that alcohol could be obtained for 5p per unit in local supermarkets.
• Changing social trends and the increased number of single people in the population may have worsened the nutritional state in many alcohol dependent and alcohol abusing individuals making them more vulnerable to alcohol brain damage.

The Government’s Response

The services part of the Plan for Action on Alcohol Problems makes reference to commissioning an expert group to investigate this condition. Unfortunately, at no point in the Alcohol Action Plan is there any mention of increased resources for sufferers.

At the time of writing, the Report from the Expert group is in draft and its main recommendations are ⁽⁵⁾:

• to provide health promotion and prevention by increasing public awareness and to provide health promotion literature for young people, adults and older people. (There is no evidence that health promotion or information makes much impact on any aspect of people’s drinking behaviour other than drink driving.)
• to challenge stigma by increasing awareness and changing attitudes to ARBD.
• to carry out more research and evaluation into service design and delivery
• to provide information and training for front line staff.
• to develop agreed care pathways between addiction services, psychiatry, older people’s services, primary care, and local authority partners.
• Alcohol Action Teams/Alcohol Drug Action Teams agree arrangements for local integrated care pathways and identify local co-ordinators.
• the needs of people with ARBD must be included in the review of the new Mental Health Act and also within Adults with Incapacity legislation especially emphasising the need for review of these cases.
• raise awareness with organisations responsible for quality standards of the needs of this group.

Disappointingly the document makes no recommendations whatsoever about funding or training and employing more specialist front line staff to manage this extremely disadvantaged group nor about tackling the prime causes of the problem which are the very low price of a unit of alcohol in the United Kingdom.

Dr Audrey Hillman

Dr Audrey Hillman is a consultant psychiatrist at Ravenscraig Hospital, Greenock

REFERENCES:

(1) Scottish Executive. Plan for Action on Alcohol Problems

(2) Victor, M., Adams, R.D. and Collins, G.H. The Wernicke-Korsakoff Syndrome and related neurobiological disorders due to alcoholism and malnutrition (1st Ed) Philadelphia, PA. F.A. Davis

(3) Smith, I.S. and Flanigan, C. Parenteral Thiamine and Korsakoff’s Psychosis. Alcohol and Alcoholism. Vol. 33. No. 5, pp. 549-553, 1998.

(4) Jauhar, P. and Ramayya, A. Increasing incidence of Korsakoff’s Psychosis in the East End of Glasgow. Alcohol and Alcoholism. Vol. 33. No. 5, 1998.

(5) Report of the Expert Group on Alcohol Related Brain Damage. Consultation Draft. Dementia Services Development Centre, University of Stirling.

24 hour drinking hits the statute books

Editorial

The Licensing Act is law. Explanatory notes have been prepared by the Department of Culture, Media and Sport and begin with the key aims set out in the original White Paper: to reduce, crime and disorder; to encourage tourism; to reduce alcohol misuse; and to encourage self-sufficient rural communities.

If these are the “key aims” then these are the areas on which the success or failure of the Act must be judged. It might seem fair to allow the Act time to bed in before any conclusions are reached, but on at least two of these aims there is already sufficient information available to suggest that the Act will achieve the very opposite.

Already in Alert we have pointed out that all the available evidence is that crime and disorder are increased by an opening hours free-for-all. The Irish Government, for example, has recently taken emergency action to re-impose limitations on the licensed trade in reaction to the efflorescence of problems after their move to liberalisation. The UK Government has produced no data to show that their assertion that liberalisation on this side of the Irish Sea will have a different effect is correct.

The claim that the Licensing Act will result in reduced alcohol abuse is mind-boggling and flies in the face of almost all expert opinion. It emerges presumably from the equally dubious claim that the end of last orders and drinking up time will miraculously end the culture of binge drinking. It is a particularly odd claim at a time when the World Health Organization is about to publish a report which implies that the overall effect of the Licensing Act will increase alcohol abuse.

As for the other two aims, time will tell whether the liberty of landlords of village pubs to open round the clock, should they wish to do so, will “encourage self-sufficient rural communities” – it seems rather a large claim for so specific a measure, unless self-sufficiency lies in the removal of any need to travel into a city centre in order to drink at three in the morning.

It will also be interesting to see whether tourism is encouraged by the new drinking culture which the Government sees spreading benignly across the land. The example of Bath is not encouraging. Visitors to that beautiful city have been deterred by the disorderly nightlife which has grown-up there. The Society of London Theatres has expressed concern at the provisions of the Act as they see the tourists being put off using the West End given the predictable increase in disorder and alcohol abuse.

It is possible that the Licensing Act is one which will fail to satisfy any of the parties. Even the industry, for which so many of its measures appear to be shaped, is unhappy about the transfer of licensing powers to local authorities, seeing potential for political interference with its commercial activities. For everyone else, the Act is a leap into the unknown, especially where the effects of the abolition of permitted hours on town centres are concerned.

Residents’ Associations throughout England and Wales are opposed to the overall tenor of the Act and envisage a considerable increase in disorder, crime, and alcohol abuse. Local councils suspect that, whilst being given the responsibility of managing the new licensing system, they will neither be given the necessary resources (although the alcohol industry is also concerned about the level of fees which might be charged) nor receive sufficient authority to implement a meaningful licensing policy. It is intended that costs will be decided on a system of geographical banding, so it is likely that some local authorities will lose out whilst others make a modest profit.

The Government itself cannot be entirely happy with the Act which has reached the statute books. It has been forced to concede important amendments which were bitterly fought in the House of Lords. At one point it appeared possible that lack of agreement would mean that the Bill failed to clear all the parliamentary hurdles in order to receive the Royal Assent during this session.

The concessions made by the Government include the measures relating to children. Although “the prevention of children from harm” is given as one of the four purposes of the licensing system, the original intention was that children would be allowed unaccompanied onto licensed premises, although, of course, prevented from buying or consuming alcoholic drinks. Both Conservative peers and trade lobbyists combined to fight this provision which was seen as likely to put children at risk and place an unnecessary burden on landlords and bar staff. Further concessions were made on live music which was seen as being put at risk by the first draft of the Bill.

It was not until almost the end of the process that the media realised that the provisions of the Licensing Act, as it now is, were likely to cause major problems, especially in town and city centres. On the BBC Newsnight programme it was pointed out that, whilst England and Wales were going in one direction, Ireland was going in the other. The Republic had experimented with liberalisation but, given the resulting startling increase in associated disorder and alcohol problems, took urgent measures to reimpose closer regulation .

The Guidance to the Act, to which the relevant authorities are statutorily obliged to pay heed, is not yet published. As this has to pass both Houses of Parliament and will affect the interpretation of the law, there remains a great deal of uncertainty as to how the Act will operate.

Timetable

A provisional timetable of the steps needed to implement the provisions of the Act envisages that the Ministerial Guidance will be published by the end of September. Local Authorities will then publish a statement of licensing policy by February or March, 2004, and new licences or certificates will take effect in January, 2005.

The main provisions of the new Act

• The amalgamation of six existing licensing regimes (alcohol, public entertainment, cinemas, theatres, late night refreshment house and night café).
• A single integrated scheme for licensing premises which sell alcohol, provide entertainment to the public, or provide refreshment late at night.
• Transfer of responsibility for alcohol licensing from magistrates’ courts to local authorities.
• Premises licence to incorporate licensing operating conditions (e.g. hours, fire exits, capacity) addressing the key areas of crime and disorder, public safety, public nuisance and protection of children from harm. They will be set locally, if necessary, on the basis of the balance of, among other things, operators’ requirements, residents’ views and police and fire authority assessments in the overall public interest.
• A new system of personal licences which allow holders to sell or supply alcohol for consumption on or off any premises in respect of which there is a premises licence. (Those providing regulated entertainment or refreshment at night which do not involve alcohol, would require a premises licence only).
• Personal licences to be issued for 10 years to those aged 18 and over following a test of knowledge of licensing law and social responsibilities and subject to police scrutiny if relevant or foreign offences have been committed, with provision for suspension or withdrawal of licences within that period: abolition of “fit and proper person” test in respect of licences to sell alcohol.
• Personal and premises licences to be issued by licensing authorities: generally local authorities.
• Premises licences to be supported by flexible range of remedies following review (including temporary reduction in opening hours) instead of present single all or nothing sanction available to licensing justices of loss of licence if conditions have been breached.
• An avenue of appeal for parties (including the police and local residents following representations) to the magistrates’ courts.
• The abolition of permitted hours for the sale of alcohol, allowing potentially 24 hour trading, seven days a week
• Children under 16 to be allowed access to pubs only if accompanied by an adult. Licensing authorities to have the ability, if necessary, to restrict or deny access for children to unsuitable licensed venues following representations.
• The legal age for drinking alcohol on licensed premises and for buying it there, whether as off-sales or on-sales, both to remain at 18. An exception will allow 16 and 17 year olds accompanied by an adult to consume alcohol of less than spirits strength with a table meal on licensed premises.
• New requirements in the wake of the Thames Safety Inquiry for licensing the sale of alcohol, and the provision of entertainment and late night refreshment on boats travelling within England and Wales.
• New arrangements for non-profit making qualifying clubs supplying alcohol to their members which preserve their special status.
• Incidental live and recorded music to be exempted from licensing for the first time.
• Unamplified, live music in small venues to be treated exceptionally to ensure traditional and amateur folk music thrives.
• For the first time, the provision of entertainment in a school and sixth form college by the school or college will be exempted from the licensing fee associated with that provision.
• The current exemption from the payment of fees for entertainment in every village hall, church hall and community building outside Greater London, and extending it throughout the whole of England and Wales.
• Power for the Secretary of State to declare special hours up to 24 for all premises on special international, national and local occasions, like World Cups, Royal Jubilees and Commonwealth Games.
• Abolition of a range of ancient and special privileges regarding sales of alcohol held by the Crown, certain theatres, the Vintners of the City of London, the Vice Chancellor of the University of Cambridge.
• Repeal of the Welsh Sunday Opening Polls which can result in the sale of alcohol on Sundays being prohibited in Welsh Districts.

Ireland reacts to liberalisation failure

In Ireland, where the liberalisation of alcohol laws has been declared a failure, the Government is taking a very different attitude to its counterpart in London.

This is evident in the Irish Government’s swift moves to curb alcohol abuse.

Measures which, it is hoped, will pass through the Dail and the Senate in six weeks, include a ban on serving people who are already drunk and making it illegal for under-18s being in pubs after 8.00 p.m.

The Bill introduced by the Minister of Justice will also make licensees responsible for the conduct of drinkers on their premises, ban “happy hour” and “drink as much as you can” promotions, allow the covert monitoring of bars by police, the restriction of opening hours on Thursdays, and allow for the temporary closure of bars which violate regulations.

Between 1989 and 1999 consumption of alcohol in Ireland increased by a staggering 41 per cent, bringing the country to the top of the European league. In the last thirty years consumption has tripled. Ireland also has the unenviable distinction of leading Europe in the amount of 15 and 16-year old binge drinking whilst at the same time being the only country where girls now equal boys as far as this particular phenomenon is concerned.

The refusal to deregulate pub closing times contrasts strikingly with the conviction of the British Government that this is a key element of its crime and disorder strategy. The liberalisation of licensing law in Ireland is seen as contributing to the problems its Government is now seeking urgently to remedy. The influential Irish Times says in an editorial: “The consequences of excessive drinking are visible late at night on the streets of our cities, towns and villages. They are reflected in crowded accident and emergency wards in hospitals and, all too frequently, victims of alcohol-related violence end up on mortuary slabs.

“The rise in alcohol consumption was facilitated by longer pub opening hours, introduced some years ago, and it has been reinforced by extensive advertising and promotional campaigns.”

Michael Martin, the Irish Minister of Health, is promoting a new Bill set to impose strict limitations on alcohol advertising. Mr Martin intends to restrict where such advertisements can be exhibited, forbid sponsorship of children’s and adolescent’s leisure activities by the drinks industry, stop advertising campaigns designed to appeal to under age drinkers, and impose a “watershed” on television, cinema and radio advertising in order to minimise the exposure of children to the alcoholic products. No alcohol advertising would be allowed near schools or on public transport.

In this context, the Minister attacked the sponsorship deal between the Gaelic Athletic Association (GAA) and Guinness: “I believe Guinness supporting All-Ireland hurling is the wrong message to be sending out to the young people of this country. Alcohol should not be associated with sporting success.”

Stephen Rowen, the Director of the Rutland Centre, a leading agency in Ireland for residential treatment of addiction, discussing what needs to be done to tackle the chronic problem of alcohol abuse, says, “Rolling back the pub opening hours to where they were before the summer of 2000 would help

“The hospitality industry has benefited greatly from the prosperity of the past decade. Irish people should be justifiably proud of the successes in recent years in successfully competing for the excellence of the products of our thriving economy. But there is a dark side to our prosperity. That dark side must be carefully examined in the contest of too much suffering for Irish people caused by drink.”

In its report on the detrimental effects of Ireland’s liberalisation, the Republic’s Commission on Licensing commented on the undesirable effects of such measures as are contained in the UK Licensing Act. The United Kingdom Government has dismissed these warning signs and the mounting body of evidence as inapplicable.

Views from interested parties on the effects of the new bill on their communities.

More cafes – fewer pubs

There are too many drinking venues in our town and city centres, says a parliamentary select committee

The United Kingdom needs an inclusive continental-style café culture during the evening and fewer pubs. This is the conclusion of the Housing, Planning, Local, Government and the regions Committee of the Office of the Deputy Prime Minister. Although the reference to the way things happen in southern Europe may indicate a similar approach to that taken by the Department of Culture, Media, and Sport during the debate on the Licensing Act, the reality is that this cross-party group of MPs has reached quite different conclusions.

Both minister and officials of the DCMS have asserted that the provisions in the Act which abolish old-style pub closing times will lead to the end of binge drinking and inaugurate an era of continental drinking patterns. The DCMS refused to include residents’ and amenity associations in the Advisory Group set up to assist with the shaping of the legislation, whereas the Select Committee actively sought their opinions and took them into account when forming their recommendations.

What emerges is that the urban renaissance, which the Government wishes to encourage, will be hampered rather than encouraged by the liberalisation. The “livability” of town and city centres, to use the Prime Minister’s word, is likely to be diminished. As Christine Russell, MP, Chairman of the Committee, said, “A successful urban renaissance depends on striking a balance between a good night out for some and a good night’s sleep for others.”

The Committee’s Report recommends “that the Government conducts upper capacity pilots in city centres that have experienced the effects of cumulative impact.” This, of course, reflects one of the major concerns of amenity groups and local authorities. The Government is in the process of formulating the statutory Guidance to the Licensing Act which will prevent those local authorities establishing a policy which sets limits of licensed premises in a particular area and so is clearly at odds with the Committee.

The Government argues that a direct causal connection between capacity and crime and disorder must be demonstrated. The Committee is impatient with this argument, saying, with a refreshing acceptance of the obvious, that “it does not need to be demonstrated that the presence of large volumes of people in a small area will impact upon residential amenity if not controlled”.

It is interesting to note the Government’s response when the proof of the “direct causal connection” was asked for during the debate on the Licensing Bill in the House of Lords. Lord Avebury asked whether the Government “will collect and publish statistics of the number of licensed premises and their aggregate capacity, the number of offences of violence against the person and the number of calls to the ambulance service, for every area in which corresponding figures are available in England and Wales, so that licensing authorities can pay regard to this evidence in carrying out their duty to promote the prevention of crime and disorder.” For the Government, Lord Mackintosh of Haringey said, “No.”

On the density of licensed premises, the Committee recommends that “local authorities conduct studies to ascertain the number of different premises an area can sustain, whilst retaining its character and remaining true to the concept of a mixed-use area. Planning policy can then be used to prevent excess.” Although it sees planning playing this role, the Committee is sceptical of the Government’s stated reliance on this tool: “We recommend the Government reconsider its desire to deal with issues of cumulative effect exclusively through the planning system.

We continue to be convinced that cumulative effect is best dealt with through the more flexible licensing system.”

The Committee says that some changes to the planning system would make a big difference to local authorities’ ability to balance evening and late-night uses of town and city centres. The Use Classes Orders currently allow dramatic changes of use within the same class. For example, it is possible for a cinema to become a night-club without changing Use Class, but the impact on an area is very different. Another problem is premises not operating in the evening as they do in the day. Café bars, for example, may clear away chairs and tables at night and become a jostling, crowded bar where people drink standing-up at a much faster pace.

Interior planning constraints would help solve this problem. Whilst referring again to the difficulty of maintaining a balance between a good night out and a good night’s sleep, the report argues that a review of the Building Regulations and Noise Acts would show commitment to tackling this problem.

There has been widespread alarm that under the new Act, residents will be put at a considerable disadvantage when objecting and the Committee shares this. “We reiterate that the Licensing Act 2003 places too much emphasis on residents to provide “evidentiary” proof in order to lodge an objection to a licence. Providing such evidence is difficult and costly. Few residents, either individually or collectively, will be able to provide the required evidence. We repeat our recommendation that licensing authorities should be given powers to accept residents’ sworn evidence of nuisance.” Alert has been pointing out throughout the passage of the Bill through Parliament that to place a burden of before-the-fact proof on local residents, in the case of new licences, is quite unreasonable, especially when they will be faced with the legal might available to the drink industry.

The Committee is aware that, in the words of one of the authorities it quotes, “the mortality rate from alcoholic consumption is rocketing at the moment”. Whilst acknowledging that the Government’s submission accepts the fact that a further expansion of the evening economy will “have cost implications for the Health Service”, the Committee “are [sic] concerned that this implication has not been fully explored in relation to the new Licensing Act”. Most of those involved in this question professionally would describe this as a remark of courteous understatement. In the contest of health, the report looks forward “to the publication of the national Alcohol Harm Strategy”.

The “polluter pays” principle is touched on in the report when the difficulties facing the police in the light of possible results of the Licensing Act are discussed. “We are concerned that the extension of licensing hours under the Licensing Act 2003 could stretch police resources to an extent where anti-social behaviour tools will be ineffective. Further time-expansion of the evening economy will need to be monitored carefully.” The Committee suggests that, if it becomes apparent that it is beyond the police to meet the problems arising from the expanded evening economy, the Government talks with the drink industry in order to find sources of additional funding which “may include the possibility of a 1 per cent levy on the annual turnover of private operators”.

The Committee points out that the successful management of the evening and late-night economies will require action plans and strategies which take into account both planning and licensing regimes. It recommends that the ODPM require every local authority to produce a strategy and to develop this “in conjunction with all relevant parties and should include baseline data regarding: number and concentration of licensed premises and late-night take-aways; environmental problems, including fly-posting, rubbish and street urination; crime and disorder, including graffiti and vandalism; availability of public and private transport, including late night car parking facilities; closing times of public conveniences; policing resources; cleansing times and records of complaints, especially relating to noise”.

The report makes it clear that the Licensed Trade has a responsibility to deal with problems relating to the consumption of alcohol and the late night economy. “Private operators should take as many steps as possible to educate their customers about the potential impact of their behaviour.” This responsibility, the Committee says, is held along with the Department of Culture, Media and Sport, under whose aegis the Licensing Act reached the statute books. According to the Committee, the DCMS should work with the industry to ensure that there is a proper dissemination of good practice. The Committee rejects the industry’s long-held position that its co-operation in these matters is best left at a voluntary, self-regulatory level. “The Department must bring in legislation making participation of operators in partnerships aimed at reducing anti-social behaviour a licensing condition”.

The Committee Report is clearly at odds with the approach taken by the Government in its Licensing Bill. It takes into consideration many of the factors dismissed or ignored by the DCMS during the consultation process. It is ironic that so many of its recommendations will be specifically forbidden in the Guidance to the Act currently being formulated within the DCMS.

Demand for ban on television alcohol advertising

Doctors’ leaders have called for a ban on alcohol advertising to curb the epidemic of binge drinking among young people which is fast becoming a serious threat to their future health

The call came at the annual conference, held in Torquay, of the British Medical Association. In a challenge to the drinks industry, the power and influence of which is evidenced in the nature of the Licensing Bill soon to reach the statute books, the BMA demanded an end to advertising worth £270m every year promoting sales of beer, wine and spirits.

The head of science for the BMA, Vivienne Nathanson, said the first move should be to prohibit the advertising of alcohol on television.

“Ten years ago we were told we would not be able to secure our aim of banning the advertising of tobacco. We went for television first and we want now to target the inappropriate images that encourage binge drinking,” said Dr Nathanson.

This is the first time that the BMA has gone so far as to call for an alcohol advertising ban, but the annual conference overwhelmingly supported a resolution proposed by Leigh Bissett, a medical student at the University of East Anglia.

“Alcohol harms and we want to see the glorification of it upon our television screens ended,” said Mr Bisset in his speech at the conference. “Adverts don’t say have a glass or two. They portray people getting off their face on alcohol.”

He pointed out that 4,000 deaths a year were directly related to alcohol and 28,000 indirectly. “Our casualty departments see increasing workloads and on a Friday and Saturday the extra violence faced by staff is unacceptable. We are not calling for a ban on alcohol, but we want the government to stop the glorification of it on our television screens. Some people will argue that a ban would infringe our basic human rights, and contravenes the European Convention on Human Rights [but] as health professionals we have a duty to protect our patients.

Let us send a clear message to the public about how we feel about alcohol and its misuse. Protect our children, protect our population and protect our doctors.”

Echoing the remarks by the Government’s Chief medical Officer, Sir Liam Donaldson, in his annual report for 2002, Dr Nathanson said that binge drinking was leading to an increasing number of people in their twenties and thirties suffering liver failure. There are already hundreds of cases a year, principally among young men but an upward trend is now clearly observable among young women.

Dr Nathanson added that binge drinking was causing huge damage to many individuals and the cost of liver transplants was a drain on the NHS.

A spokesman for the Portman Group, set up by the industry to promote “sensible” drinking, opposed the idea of an advertising ban.

“The Advertising Standards Authority and the Independent Television Commission already have strict guidelines to protect the public and these are well observed by the alcohol industry,” he said.

He went on to claim that the guidelines prevented the showing of anything that would encourage the misuse of alcohol, drinking in inappropriate circumstances or drinking for the wrong reasons.

However, Sir David Carter, who chairs the BMA’s board of science and education, also referred to the worrying increase in binge-drinking among the young. “We see more young people with acute and chronic liver toxicity, and end-stage liver disease,” he said. “This is a result of binge-drinking.”

Alcohol and illicit drugs – what the people think

Attitudes in society seem to be changing and it is apparent that public opinion on illicit drugs is not always in tune with expert medical opinion and practice. For example, while we seem to have a more relaxed view of cannabis these days, there are warnings that its use may lead to psychosis. But when it comes to alcohol, the public and doctors are at one on the need for health warnings.

On the one hand – Attitudes to cannabis

The British people are becoming more tolerant towards the use of cannabis, but there are still clear limits to what is acceptable in the area of illegal drug-taking. This is the conclusion of new research funded by the Economic & Social Research Council (ESRC).

Opinions on cannabis have changed considerably during the past twenty years, with 41 per cent of Britons now supporting its legalisation – a rise from just 12 per cent in 1983. However, only a small minority (eight per cent) support the view that adults should be free to take any drugs they please, says the report of the team of researchers led by Nina Stratford of the National Centre for Social Research.

The views of a thousand people in England and Wales and one thousand six hundred in Scotland were surveyed. In contrast to attitudes towards cannabis, those towards heroin remain very negative with ninety per cent believing it should stay illegal – the same proportion as in 1993.

Ecstasy is regarded in much the same way, again with nine people out of ten believing that it should remain illegal. Only seven per cent agree that ecstasy is not as damaging as some people think, and seventy-five per cent believe that the liberalization of the law would lead to an increase in addiction. The view that ecstasy is a ‘soft’ drug similar to cannabis has little public support.

A considerable majority of people (86 per cent) support the belief that doctors should be permitted to prescribe cannabis for medical purposes. As was shown in research carried out in 1995, certain groups – the young, the more highly educated, professionals, and people living in London – have a more liberal attitude towards the drug.

Nina Stratford points out, however, that the increase in these liberal attitudes is not confined to those categories. She said: “It is a society-wide phenomenon affecting all ages and social backgrounds.”

Fewer people now think that cannabis is harmful or addictive or that it causes crime and violence. When those surveyed were asked which drugs were the most harmful to regular users, heroin, cocaine, tobacco and alcohol came at the top of the list.

In contrast, perceptions as to the damage inflicted by heroin have not change. In fact, today more people link it with crime and violence than ten years ago.

The research, published by ESRC as The Measurement of Changing Public Attitudes Towards Illegal Drugs in Britain, supports the notion that the use of cannabis is becoming as acceptable as drinking alcohol or smoking cigarettes, especially among young people, indifferently as to whether they use the drug or not Two-thirds of 18-34 year-olds admit to having a friend or family member who has used illegal drugs, half have tried cannabis themselves, and only a third think that cannabis should remain illegal. More than half (55 per cent) accept that the illegal use of drugs is a normal part of some people’s lives – an increase from 41 per cent in 1995 – and even those young people who have never used cannabis have more liberal views as to its legalisation.

The research may have shown that attitudes to cannabis have become more tolerant, but it also uncovered clear limits to peoples’ tolerance. Whilst Nina Stafford and her team found that the idea of giving users clean needles was backed by nearly two-thirds of adults and that giving harm-reduction information to young people was also accepted by 55 per cent in Great Britain as a whole and 47 per cent in Scotland, when it comes to prescribing drugs, people’s attitudes were very restrictive. Ms Stratford said: “We found that very few people support allowing doctors to prescribe drugs for addicts – something which has been an established part of medical practice for almost a century.”

And on the other – Cannabis-induced psychosis

As has long been suspected, heavy use of cannabis may well be a cause of psychosis, according to Robin Murray, professor of psychiatry at the Institute of Psychiatry and consultant psychiatrist at the Maudsley hospital in London. He believes that society should think carefully about the potential consequences of its increasing use.

He says that in the last year and a half, an increasing body of evidence has grown up that cannabis causes serious mental illness. Most particularly, research carried out in the Netherlands, involving a study of four thousand people from the general population, discovered that those taking large amounts of cannabis were almost seven times more likely to display psychotic symptoms three years later.

Speaking in Edinburgh at the annual general meeting of the Royal College of Psychiatrists, Professor Murray said, “This research must not be ignored.” He was already on record in the national press as saying that he had been surprised that the discussion around cannabis had avoided the issue of psychosis. Psychiatrists had known for 150 years that very heavy consumption of cannabis could cause hallucinations and delusions. “This was thought to be very rare and transient until the 1980s when, as cannabis consumption rose across Europe and the USA, it became apparent that people with chronic psychotic illnesses were more likely to be regular daily consumers of cannabis than the general population.”

He further added that, in the United Kingdom, people with schizophrenia were about twice as likely to smoke cannabis. The reason for this appeared to be the effect that the drug has on chemicals in the brain. “In schizophrenia, the hallucinations and delusions result from an excess of a brain chemical called dopamine. All the drugs which are known to cause psychosis – amphetamine, cocaine and cannabis – increase the release of dopamine in the brain.”

Drawing attention to the effect cannabis has had on many of the most talented young people, Professor Murray said, “Like any practising psychiatrist, I have often listened to the distraught parents of a young man diagnosed with schizophrenia tell me that as a child their son was very bright and had no obvious psychological problems. Then in his mid-teens his grades began falling. He started complaining that his friends were against him and that people were talking about him behind his back.

“After several years of increasingly bizarre behaviour, he dropped out of school, job or university; he was admitted to a psychiatric unit overwhelmed by paranoid fears and persecution by voices. The parents tell me that, at some point their son was heavily dependent on cannabis.”

The previously held view was that the high numbers of psychotic patients taking cannabis could be explained because they used it to alleviate their symptoms. The recent research, however, has studied large populations free of mental illness and looked at the numbers of cannabis takers within them who have developed psychosis. Call for health warnings on alcohol

The country’s leading liver specialists want official health warnings on all alcoholic drinks. Their call to the Government comes as a result of a dramatic rise in alcohol-related illness among young people.

A petition signed by five hundred senior doctors has been delivered to the Prime Minister. They want to see the number of units of alcohol and the agreed “sensible drinking limits” printed on all containers.

Figures from the Department of Health show a four-fold increase in deaths in men aged 45 to 54 and three-fold increases in deaths in women from cirrhosis during the past 30 years. In the younger age group, 35 to 44, the increase in deaths rose eight times for men and seven times for women. These astonishing increases were highlighted by the Government’s Chief Medical Officer, Sir Liam Donaldson, in his 2002 Report and the doctors are now demanding action. They are acutely concerned about the effects of the increase in binge drinking in young people which is contributing to the 4,000 deaths every year from liver disease.

The doctors want the labels on all drinks containers to say: “HM Government Health Warning. This product contains x units of alcohol. Consumption of more than 21 units/week for men and 14 units/week for women can damage your health.”

The Registrar of the Royal College of Physicians, Professor Ian Gilmore, said: “Fifty per cent of our patients with cirrhosis are not alcoholics. They are not dependent on alcohol, but they have advanced liver disease.

“People grossly underestimate the amount that they drink. We need better labelling so you know just what you are doing.”

Dr Christopher Record, a consultant physician from Newcastle, added: “We intend to win this battle, it is in the best interests of our patients and we will not let go until it is done.”

The industry’s Portman Group has consistently opposed health warnings. Its Chief Executive, Jean Coussins, said, “We don’t know of any evidence that putting health warnings on alcoholic drinks has significant effect on behaviour. However we would encourage all drinks producers to ensure where possible the number of units of alcohol contained is clear on all labelling.”

A spokesman for the Department of Health said: “The Cabinet Office is developing a National Alcohol Harm Reduction Strategy which should be published in the autumn. It is considering a range of issues including placing information on labels.”

The opinion of the public on the subject of health warnings was recently reflected in a poll conducted by OMD Snapshots. Fifty per cent believes that the responsibility should be on the alcohol industry to run advertising campaigns preaching responsible drinking, whilst 38 per cent say the government should do so.

Just over one thousand people took part in the survey in which three-quarters agreed that alcohol brands should carry health warnings similar to those on tobacco packets. However, almost half said they would take no notice of a television campaign such as the one recently launched by Smirnoff which reminds drinkers that “it’s good to know when to stop”.

Costing Smirnoff’s parent company Diageo Great Britain £500,000, the campaign is called ‘Congratulations’, and thirty second spots on ITV, Channel 4, Channel 5, and satellite TV mean that over half the core audience of 18-34 year olds will see the advertisement at least once.

“The new advertising was developed to help consumers understand their limits and to drink in moderation,” says Diageo. The “Knowing when to stop” metaphor was in the United States last year and, according to the company “performed exceptionally well. Research in that market shows that respondents enjoyed watching it very much (20 per cent higher than average) and a high proportion found it involving (40 per cent higher than average).”

The television commercial opens on an attractive couple, Hank and Cindy, enjoying a romantic meal at a restaurant. They are approached by a man who is an old friend of Hank’s. He hears they have just got engaged, congratulates them and then starts reliving the good old days back at college, when Hank was allegedly a bit of a ladies man. As the conversation progresses, the woman looks more shocked. The advertisement finishes with the end line: “Knowing when to stop is a good thing”.

Tony Mair, Diageo GB Corporate Affairs Director says: “We believe that the launch of the new Smirnoff responsible drinking campaign marks a major step forward for the industry, and that we have a role to play in educating consumers about how to drink responsibly.

“As market leader and founder member of The Portman Group – set up by leading drinks companies to promote sensible drinking – we have always encouraged drinking in moderation. We are now taking the step of introducing this new advertising initiative in our own name and would always welcome the continued support of others in the industry to encourage responsible drinking amongst consumers.

“We feel really positive about the Smirnoff ad’ launch. Learnings from US research show us that consumers understand the message behind the ad’ and we know the Smirnoff brand has strong appeal for our core audience of 18-34 British consumers.”

Many may be sceptical about the motives of Diageo and see the move as an attempt to head off increasing demands for a curb on alcohol advertising, especially that aimed at young people. They may also feel that the campaign does little to counteract the overwhelming emphasis on the link between drinking alcohol and a glamorous lifestyle.

It may also prove difficult to achieve the same success in the United Kingdom for the campaign which Diageo claims for the USA.

Asked whether they would take more notice of such a campaign if it were run by alcohol brands or by the government, 42 per cent said “neither”.

The OMD Snapshots survey asked:

Should alcohol brands have to put a warning on bottles about the dangers of excessive drinking?
Yes	67 per cent
No	29 per cent
Don’t know	17 per cent

You’re not coming in

Andrew McNeill reviews Bouncers: Violence and Governance in the Night-time Economy Dick Hobbs, Philip Hadfield, Stuart Lister, and Simon Winlow Oxford University Press 2003

What occupation has the best claim to being most representative of modern times?

Even, or perhaps especially, those living in the old industrial cities are unlikely any longer to say miner or factory worker: call centre operative, possibly. But ‘bouncer’ is a more plausible candidate. Bouncers are in evidence in almost all town and city centres across the country, admittedly not always during daylight hours, but night life in our main urban centres increasingly depends on them. They are at once bully, hero, villain, gentleman and street-corner politician, according to the authors of this interesting new study of the craft which places bouncers in the context of the whole night-time economy, of which it provides a vigorous critique.

The book is a mixture: part sociological treatise, with requisite jargon; part political tract; part journalistic expose based on first hand observation, and part resource book for town centre managers. Throughout there are periodic diatribes against capitalism, here personified not by the black-hearted mill owner, whom progress if not the proletariat has forced aside, but by the rather more colourless figures who run the alcohol industry and who are wreaking havoc on our town centres. The book, in the authors’ words, is not a moral panic against the young but an attack on the relentless reorganisation of society on free-market principles without much reflection on the human costs.

Some might think there is a hint of a contradiction here. If the alleged harms caused to and by young drinkers can be dismissed as a moral panic, of what real crimes are free-market principles supposed to be guilty?

The authors’ political agenda is unfortunate because wholesale denunciations of capitalism do not lead anywhere. There is a lot of despair and anger about the problems afflicting town centres, especially of course, on the part of those who live in them. Telling residents that the only real solution is to wait for the total transformation of society is not much use: they may as well sell up now.

On the other hand, it must be conceded that for those who want to denounce capitalism, there is a lot to be said for selecting the plunder and pollute approach of the big pub companies.

As the authors explain, the need to regenerate towns whose old industrial base has passed into history has spurned the growth of the night time economy. The future is seen to be in leisure. The rhetoric is in terms of the meeting of culture and commerce, of the creation of an inclusive, continental-style ambience which will civilise the town centre while also generating employment and revenue.

The reality is a youth-dominated night-time economy based on the mass intoxication for profit of unprecedented numbers of young people seeking pleasure, excitement and excess. They now flood into town centres which at night become commercialised play-zones offering a cocktail of alcohol, sex and drugs.

These entertainment areas may be dead during the day, but at night they provide a passable imitation of the old American frontier. Police resources are overrun and large parts of town centres become zones of hedonistic lawlessness. Hence the bouncers. They fill the void created by the scarcity of the public police. They are barely regulated by the state and represent a powerful subculture rooted in routine violence and intimidation, but at two o’clock in the morning they may well be the only law and order there is on the street. A combination of hypocrisy and incompetence, the authors say, has ensured the night-time economy undercuts and overwhelms the state’s capacity to protect individuals and communities.

The book includes a special case study of Manchester, a leading advocate of the 24 hour city and a pioneer of liquor licensing liberalisation as a means of creating a vibrant, continental café-culture. The authors explain that Manchester now has the highest overall crime rate in England and Wales, and that it appears to have lost control of door security to criminal gangs whose activities have frightened off some of the flagship elements of the city’s ‘entertainment offer’. As a resident of the city comments, “It’s certainly very continental out there, but less like Paris, more like the Somme.”

The villains of the story are the alcohol industry, the magistrates who have been handing out too many liquor licences, local authorities which have either allowed themselves to be bullied into letting the industry have its way or deluded enough voluntarily to encourage it, and inadequate systems of public control.

Of course, a new villain has now entered the stage, the Labour Government whose Licensing Bill represents a further triumph of free-market principles in relation to the supply of alcohol. Government ministers insist, and may even believe, that the lawlessness and disorder characterising the night-time economy is the result, not of the sociological changes well described in this book, or of free market principles, but of too much state control, – the imposition of ‘artificially early’ fixed closing times. Only abolish these, the Ministers say, and all will be well. Binge drinking and disorder on the streets will melt away. The drinking culture will be transformed. Young people will learn to drink ‘sensibly’.

The trouble is, ‘sensible’ drinking is what the middle aged do, and if there is one thing young people are not notably keen on it is being middle aged. Moreover, the impression of a hedonistic environment devoid of restraint is central to the appeal of the night-time economy. Late night venues branded as ‘sensible drinking bars’ are likely to deter rather than attract the young, not at all what the pub companies which have lobbied so hard for licensing de-regulation have in mind.

Actual as distinct from imaginary evidence that abolishing closing times will lead to people becoming less of a drunken nuisance rather than more of one is very hard to find. The Bill has been pushed through in spite of rather than because of the evidence. But time will tell. If the Government is right, once the new legislation has taken effect there will be less alcohol consumed, less drunkenness, less crime and disorder, and, presumably, less need of bouncers.

If the Government’s critics, who include the authors of this book are right, the Licensing Bill will exacerbate the problems and the only real beneficiaries will be the alcohol and the private security industries. If the police are overwhelmed now, how will they cope when the fun and games last potentially all night, seven days a week? In this scenario, the bouncers have a bright future, as responsibility for law and order in our main urban centres at night will in effect be further privatised, handed over to a group of shaven-headed, tattooed men accountable not to the crown, the state or the public but to the private companies which pay their wages.

One of the many problems here is, as the authors put it when they are being very serious sociologists, is that “the quasi-liminal zones that have developed in our urban centres are essentially non-conducive to normative comportment.”

Mark the bouncer, quoted in the book, who knows a thing or two about normative comportment, and to whose profession the future likely belongs, puts it slightly differently:

“If it looks like it’s going to get rough I’ll give them a clip. if you’re standing there and you’ve got some c*** in front of you whose letting his mouth go, you know what’s going to happen. It might be a job but it’s me whose going to take the dig and job or no job you’re not just going to stand there are you? F***ing right you’re not.”

Booze and Politics

Professor Rob Baggott reviews Drink and British Politics since 1830 – A study in policy-making, by John Greenaway

At the heart of Greenaway’s excellent book is a intriguing puzzle. Over the years alcohol has presented politicians and policy makers with a range of difficult problems. It has, in some periods, enjoyed a high political profile. Yet at the same time there has been a relative lack of interest in the issue on the part of historians and political scientists.

This neglect has not, of course, been total. There have been a number of excellent studies such as Harrison’s ‘Drink and the Victorians’ and Betsy Thom’s authoritative analysis of alcohol policy in the modern era, to which, among others (including my own modest contribution to the literature), Greenaway appropriately refers. Nonetheless, the attention received by alcohol is often much less than the sum of its parts. Greenaway explains this in terms of the changeable and elastic nature of the issue. Moreover, there is little consensus on the issue, and it interacts with others in the policy arena in complex ways. The problem of alcohol is defined in different ways, and shifts and changes over time. The boundaries of the issue are very flexible and make it difficult to mark out the territory and conduct a meaningful analysis.

Greenaway seeks to correct this relative neglect with a book of high scholarly quality. His work is based mainly on primary and archival research, while making good use of the secondary sources available. The product of his labours is an account of the main phases of the politics of alcohol since the Victorian period up to 1970. Each chapter is well constructed, clearly written and full of insights. Not content with mere description, Greenaway seeks to explain the often complex policy streams, broader political context, and motivations of the various ‘dramatis personae’. The marvellous thing about the book is that one does not have to be an expert on political history to follow his account. Although he is authoritative, Greenaway is at the same time rather kind to the reader and painstakingly explains the significance of events and developments.

While Greenaway correctly identifies the importance of the ever changing political context, and shows how the political response to the alcohol issue has reflected these dynamics, his account also tells us that some things do not change. His description of licensing debates at the beginning of the twentieth century (p77), for example, could easily apply today.

‘A pattern of controls and regulations already existed. Difficulties arose because there were fundamental divisions concerning the purpose of control, the nature of the problem and the means by which a ‘solution’ could be secured.’

The historical account also contains insights and lessons for today’s policy actors.

For example, Greenaway shows how division in the temperance movement proved a major obstacle to reform in earlier times. In highlighting the importance of a coherent lobby, he provides a useful message for those campaigning for action on alcohol problems in the present day. The power of the industry within the political process is also a constant theme. Again, those seeking to influence policy in this field, must not only understand this, but formulate strategies that reflect this reality. Greenaway also conveys an impression that alcohol has been a rather dangerous issue for politicians over the years. It is an issue that they cannot control and where they can easily be accused of failure. The same is probably true today, with ministers not wishing to be criticised for proselytising about alcohol, but also wary of criticism in the light of evidence on alcohol related harm.

Of course some things have changed. Alcohol no longer has the presence in high politics that it had in the late Victorian and Edwardian period, when, as Greenaway informs us, Cabinet Meetings debated licensing bills in depth and politicians spent hours concocting various schemes on alcohol control. The issue was at this time a major bone of contention between leading politicians in the government, and not only because of differences of principle. Hence, Greenaway argues, Harcourt’s succession of local veto bills in the 1890s should be seen mainly an attempt to outsmart his arch-rival Rosebery in the Liberal Cabinet of this period. The chapters that cover the high politics of the Victorian and Edwardian periods are particularly rich in content, and, despite the complexity of both the issue and the political context at this time, remarkably clear and cogent.

As a history of the politics of drink, the book could have very easily been rather dull, particularly for those who find politics and/or history a little boring . Aside from Greenaway’s writing style, which is always clear and concise, the attention of the reader is sustained with nuggets of detail and background, some of which are quite amusing. For example, on p139 Greenaway describes the bizarre activities of some trade ‘agent provocateurs’ in the 1920s who were trying to denigrate state run outlets by posing as tourists and attempting to buy alcohol out of hours, while generally snooping around the accommodation. In one case we are told that these efforts were countered by a formidable ‘Miss Ferguson’, who refused these impertinent requests, and a vigilant local state manager who was able to telephone colleagues in the vicinity about the activities of the troublemakers.

Greenaway reluctantly, and perhaps wisely, ends his analysis proper at 1970, the date at which public records became unavailable. He does, however, provide a useful epilogue for the post 1970 period. The politics of alcohol over the last thirty years, as Greenaway himself notes on p175 ‘can offer interesting insights into the policy process in the modern British state. It should provide future historians with access to official records a rich seam of material to quarry.’ Anyone attempting this in future would be well advised to emulate the approach taken by John Greenaway in this excellent book.

Rob Baggott is Professor of Public Policy at the De Montfort University