Alcohol Assertions – Consume with Caution

I attended a conference today. In among some very interesting and perceptive discussions about how important parents could be in supporting young people around alcohol issues and what they needed in turn to enable them to carry out this role, there were some inaccurate or misleading assertions and selective uses of statistics. There were several fairly self-congratulatory statements about the alcohol problem getting significantly better when in fact, as a population, we are drinking vastly more than we did 20-30 years ago and levels of alcohol-related harm, though they may not be at their peak, are still a huge cause for concern. I know that the statistics in relation to alcohol use will always be debated but alcohol industry retailers do not help clarify the position by maintaining their secrecy around sales figures.

Among today’s assertions, this one:

There are fewer young people drinking than ever before.

This was based on the annual schools survey in England and Wales, exclusively self-reported, which doesn’t in fact track back to “forever”. Nonetheless, the positive impression is given when in fact,  the welcome recent reductions in young people’s use have come after a period of sustained year on year increases. As well as this, even though fewer young people may be drinking now than in the recent past, the drinkers are consuming vastly greater quantities than in the past.

If we take the long view, we can see that alcohol consumption in the UK was very high at the beginning of the twentieth century and then dipped significantly mid-century. Our current, albeit improving, situation is still markedly closer to those early twentieth century figures than to the mid-century position. Now, as then and in line with other health-related issues, the harm caused to poor and socially-disadvantaged communities is disproportionate. It is inexcusable and misleading to present only positive short-term improvements and ignore the sustained and serious increases in alcohol-related harms that have crept up and overwhelmed contemporary society.

Across Europe, alcohol is the world’s number one risk factor for ill health and premature death among the 25-59 year old age group and Europe is the heaviest drinking region in the world. The UK government (2012) estimates that in a community of 100,000 people, each year:

• 2,000 people will be admitted to hospital with an alcohol-related condition;
• 1,000 people will be a victim of alcohol-related violent crime;
• Over 400 11-15 year olds will be drinking weekly;
• Over 13,000 people will binge-drink;
• Over 21,500 people will be regularly drinking above the lower-risk levels;
• Over 3,000 will be showing some signs of alcohol dependence; and
• Over 500 will be moderately or severely dependent on alcohol.

In Scotland, the alarming rise from the early 1990s has now stabilised but alcohol-related harm continues to be at historically high levels with alcohol-related deaths more than doubling since the 1980s and alcohol-related hospital discharges more than quadrupling since the early 1980s. There were over 40,000 hospital discharges in 2007 and alcohol related mortality has more than doubled in the last 15 years. In addition, Scotland has one of the fastest growing rates of liver disease and cirrhosis in the world. The Scottish government (2009) estimates that alcohol misuse costs Scotland £2.25 billion every year.

A couple of today’s speakers usefully drew attention to the impact that easy availability of alcohol has on people’s behaviours. In support of this, WHO (2011) has argued that,

Of all alcohol policy measures, the evidence is strongest for the impact of alcohol prices as an incentive to reduce heavy drinking occasions and regular harmful drinking. The health gains are greatest for heavier drinkers and there are also considerable gains in the well-being of people exposed to the heavy drinking of others.

The BMA has identified minimum price per unit as the most effective of all available price-related policy options for reducing alcohol-related harm. Yet the alcohol industry has consistently tried to block statutory regulation which would impact on sales of the cheapest, most harmful products. Indeed, the Scotch Whisky Association is currently engaged in legal action to try to block the Scottish Government’s planned introduction of Minimum Unit pricing. One of the industry’s speakers today said that he “believed that it wouldn’t work”. This flies in the face of real-life evidence from Canada of the impact of the introduction of Minimum Unit Pricing there (Stockwell et al., 2012).

We need public health focussed interventions in the markets, permitted by national and international law and to my mind, required by laws of social justice, to change our drinking cultures and behaviours.

Instead of this, the overwhelming theme today was the need for more education and information campaigns. As a champion myself for many years of alcohol education and its continuing supporter, I also know that education on its own is not going to achieve very much. We should always interrogate claims that are made about interventions that are deemed to be effective, even where there do appear to be signs of positive impacts. For example, the most notorious high-level failure in drugs and alcohol education was DARE, a high profile multi-million pound programme that was delivered across the USA for decades with no significant impact. Even with Life Skills training, Gorman et al (2007, p.585) have argued that:

far from supporting the evaluators’ claims concerning the rigour of the findings and their generalisability and public health significance, the results are very fragile, of little practical significance and quite possibly analysis-dependent.

This is not to say that Life Skills training should not be promoted – indeed I would strongly argue the contrary case. We must not, however, overclaim for it. Stothard and Ashton (2000) argue that there is insufficient consistency in the findings to be confident that implementing Life Skills will cut legal or illegal drug use, only that it can do and has done, most consistently in relation to smoking.

Regarding information campaigns, the BMA (Hastings & Angus, 2009) has argued that:

while alcohol industry- sponsored marketing seems like a good idea, its public health value is questionable, and given its stakeholder marketing agenda, the effects are likely to be counterproductive. Such activity also focuses attention on individual rather than population level solutions, and can delay more effective statutory measures.

The BMA also argues that messages such as:

We promote responsible drinking and find innovative ways to challenge the national drinking culture and tackle alcohol misuse

reinforce the idea of ‘safe limits’ rather than relative risks and the impression is erroneously given that problems only arise when the product is used in specific ways , for which it is not intended.

Today’s conference facilitator called for more accurate representation of drinking behaviours in the media, arguing that we should celebrate  the fact that the numbers who do drink are (according to him) falling quite sharply. I’m sorry but I think it’s a bit premature to be thinking about cracking open the (non-alcoholic) bubbly!

BMA Board of Science 2012, Reducing the affordability of alcohol, London.

Gorman, D.M., Conde, E., & Huber Jr., J.C. (2007). The creation of “evidence-based” drug prevention: a critique of the Strengthening Families Program Plus Life Skills Training evaluation. Drug and Alcohol Review, (26), 585–593.

Hastings, G. & Angus, K. (2009). Under the influence: The damaging effect of alcohol marketing on young people British Medical Association, London.

Home Office 2012, The Government’s Alcohol Strategy, London.

Scottish Government 2009, Changing Scotland’s Relationship with Alcohol: A Framework for Action, Edinburgh.

SHAAP 2007, Price, Policy and Public Health, Edinburgh.

Stockwell, T. et al. 2012, ‘Does minimum pricing reduce alcohol consumption? The experience of a Canadian province’, Addiction, vol. 107, issue 5.

Stothard, B., & Ashton. M. (2000). Education’s Uncertain Saviour. Drug and Alcohol Findings, (3).

University of Sheffield 2012, Model based appraisal of Alcohol Minimum Pricing and Off Licensed Trade Discount Bans in Scotland using the Sheffield Alcohol Policy Model v2 – Second Update, Sheffield.

World Health Organisation 2009, Global health risks, Geneva.

World Health Organisation Europe 2011, European Alcohol Action Plan 2012-2020: Implementing regional and global alcohol strategies, Geneva.

Equality is never given. It is often taken away.

I saw ”The Iron Lady” last week. Aside from being a moving and appropriate portrayal of Alzheimer’s, it reminds you how remarkable Thatcher was. In 1981 she argued:

 “Equality and opportunity cannot exist alongside each other. What is opportunity if your only opportunity is to be equal?”

Typical of the woman but what a pity. She could truly have been remarkable if her own personal experiences hadn’t made her so blinkeredly individualistic. And mental illness is a great leveller.

Muriel Spark had an idea that babies are born knowing everything that goes on in the world but that from the moment they are born the socialisation process constricts them, narrowing their knowledge so that they can be social beings. The end point is where we are deemed to be successful, whether as academics or managers or parents or citizens. But actually we only demonstrate how successfully we have been robbed of our primal knowledge, so that we can conform with expected social behaviours.

Nobody gives equality but more powerful people can take it away from less powerful people.

The current debates in the UK about LGBT marriage are not about a wider, benevolent society granting equality to LGBT people who want to be married; rather, they’re a marker that LGBT people are reclaiming what was taken away from us. I was legally married to my partner Paulo in Brussels but returned to the UK to find that our marriage had been relegated in UK law to the status of ‘civil partners’. And the ignorance and conceit of some people is breathtaking. The Tories in particular have clearly been dragged into the 21^st century by the weight of public opinion but they expect us gays to be grateful for their tolerance.  Take for example, the response that I received from David McCletchey MSP when I asked him to support gay marriage:

“I welcome the establishment of civil partnerships in Scotland which means that civil partners now have the same legal rights and responsibilities as married couples in terms of their relationship with one another.  Accordingly I do not see the need for further change.”

 Either he’s been forced to accept the step towards equality – civil partnerships – that he really doesn’t agree with. And he is convinced of his own benevolence in embracing diversity in this way. And LGBT people should be grateful. Sorry but this one isn’t.

In Thursday’s ‘Guardian’ Susanne Moore criticised the attitude of Louise Mensch, the conservative pseudo-feminist MP whom she typifies as “pulling away from victim and drab feminism in favour of being chic and individually entrepreneurial”.  As Susanne points out, contrary to the individualistic and neo-liberal Mensch, all women do not have the same opportunities. Class is still important and women are more likely to be victims of physical and mental abuse, workplace discrimination and patronising and chauvinistic attitudes, even in places where you’d least expect it. I’ve come across this recently in my work as a member of the European Union’s Civil Society Forum on Drugs where not one women was elected to its “managerial” board. I raised the issue of the importance of having women’s representation but I seemed to be one of the only people  that thought it was really important. Presumably in this, as in so many other contexts, women’s voices will be sought by men on issues which the latter deign to consider pertinent.

 But it’s my contention that all issues are women’s issues and it’s not for men to decide where and when and how they should be represented.  Men don’t give women a voice and power but they can take it away. Straight people don’t give gay people equal rights. White people didn’t give slaves their freedom. They took it away.

Recovering communities

I was really excited and honoured recently to chair a side event on Recovery at this year’s Commission on Narcotic Drugs in Vienna. I’ve been learning a lot in the past few months through my involvement as a volunteer with Wired In. I’ve had opportunities to listen to the experiences and challenges of people who are recovering not only from addiction problems but from many difficult life experiences. They want and are planning to manage their recovery, not passive recipients of drug treatment, rather, mapping out positive life futures. Drug treatment and other social services and stronger communities can support this, they can’t deliver it. It seems fundamental but it is revolutionary and it’s about hope not hopelessness. It requires a systemic rethink, based on listening to and trusting communities and learning from people in recovery.

The Wired In website – www.wiredin.co.uk – supports an increasingly empowered community of people in recovery, supporting each other, exchanging ideas, challenging the traditional way drug and alcohol treatment services have been provided, emphasising that people with drug and alcohol problems are the experts who are best placed to map out and manage their recovery. Many people in recovery are talking about how drugs and alcohol had always been the focus of their lives and how that’s changing so that their focus is becoming not just about what treatment they get; rather, it’s about how they become integrated into their communities, how their communities change to support that and how they contribute as full members of their communities. And this movement is growing within communities and across countries.

When we think about the problems that people have with drugs and alcohol, we know that problematic drug and alcohol use almost always comes with a whole lot of accompaniments – family breakdowns, abuse, violence, housing difficulties, involvement with criminals and the criminal justice system, financial problems and poverty, social exclusion. We all need support in recovering from that. We all need to recover from the challenges we experience as we go through life. I was in Glasgow last week. I always visit this city with somewhat mixed emotions; I haven’t been there very often recently. I grew up there and have very fond memories of visits to the Kelvin Hall at Christmas and to the Citizens Theatre where I remember a memorable Hamlet set in a mental hospital. However, I also remember when I was very young being frightened of a very drunk man slavering up against our car window. I also remember the sectarianism, which sadly continues to this day – bombs to Celtic supporters! – so that it wouldn’t be unusual for me, even at the age of 48, to be asked which school I went to. (St. Patrick’s it was – no hiding one’s religion and cultural background with that one.)  I can appreciate Glasgow’s incredible architecture and history and the great wit and culture of its people. However, we’re never just professionals or academics or just private individuals, nor are we ever only addicts; as individuals, we’re part of communities and as individuals and as communities we need to and can recover together from all the difficulties we encounter. I guess Glasgow makes me reflect and reframe; thus my ambivalence towards the place.

Following on from this, there seems to me to be a huge and continuing gap between how we frame the context within which drug and alcohol addictions and other social problems occur and the policy responses to it. The UK Employment Minister, Chris Grayling, was on the Today programme on Radio 4 this morning talking about the government’s plans to introduce a payment by results scheme for services delivered for people with drug and alcohol problems. Regardless of whether the government’s motivation is essentially ideological and about cost-cutting, it’s undoubtedly correct that there needs to be more emphasis on delivery of outcomes from treatment. However, recovery communities need to be trusted and supported to grow and they need to be engaged fully in a process to define what successful outcomes look like and to plan how people can be supported to achieve them. Within a new framework, clinicians need to be less arrogant and politicians less ideological and simplistic to recognise that addiction is a chronic long term health condition and that treatment can only ever contribute to delivering recovery, it can’t deliver it – individuals supported within and working as part of communities do that. Just as the law on its own can’t prevent drug problems – for example, drug use patterns in San Francisco and Amsterdam, with strikingly different legal arrangements, are remarkably similar, indicating perhaps the irrelevance of drug laws to people’s behaviours – neither can treatment on its own. And moreover, just as a treatment service which opts to work with complex drug or alcohol users rather than “cherry picking” more likely “successes”, should not be automatically deemed as failing, coming off drugs and alcohol on its own should not be deemed to be a success. Nor indeed should being employed. You can be employed and still be poor, unfulfilled, unloved and unappreciated, lonely and isolated.

I believe that there’s a very positive debate currently going on in the general public about how we re-build our communities and develop community solutions across all areas of our lives, rather than simply pathologising and blaming individuals for problems such as drug and alcohol misuse (or indeed unemployment) and penalising them. Wired In is one example of a network that is demonstrating the high aspirations of people in recovery, celebrating achievements and showing the way forward. But our politicians still have a long way to go to appreciate and embrace the full meaning of recovery, rather than just using the word as a rhetorical tool.

LGBT Pride and Prejudice

I greatly respect and usually agree with Evan Harris and I know that he has actively championed measures to make LGBT (lesbian, gay, bisexual and transgender) people less unequal.  However, I’m afraid that he (http://www.guardian.co.uk/science/political-science/2011/jan/25/political-science-evan-harris-advisory-committees)  and other “liberal” commentators are wrong when they take issue with the appointment of Hans-Christian Raabe to the Advisory Council on the Misuse of Drugs (ACMD) on the basis of his not being clinically qualified (which I find odd, as a practising GP he must bring useful perspectives), but don’t consider that his and his colleagues’ odious and highly unscientific views about LGBT people are relevant.

Evan and others are colluding with a position where it is acceptable to hold and express repellent views about the LGBT minority which they would find unacceptable, were they to be expressed about other groups, such as women (even at Sky, ask Andy Gray) or black people (ask any non-Daily Mail reader).

Previously, when discussing drug classification, the ACMD considered at length its role in giving out public signals, especially to young people, about harms of different drugs and usually concluded that it was important to take this into consideration. Well, with this appointment and many of the arguments being voiced about it LGBT young people and others are being sent a clear signal. Imagine, if you can, an argument being made that it didn’t matter whether a fellow committee member had linked black people with paedophiles, it’s the committee member’s professional experience that counts, anything else is irrelevant. It simply wouldn’t happen if suggested links with paedophilia had informed prejudiced public discourses about black people, as they have done for many years in relation to gay men.

Of course, Melanie Phillips has waded in to express her concern about the ‘demonised’ Christian community, echoing previously voiced concerns by Dr. Raabe himself (http://www.dailymail.co.uk/debate/article-1349951/Gayness-mandatory-schools-Gay-victims-prejudice-new-McCarthyites.html).  This woman has the uncanny ability to articulate the polar opposite of what I usually believe, despite her alleged concern about many of the same issues which worry me, issues that affect young people and communities, including drugs and alcohol, violence, bullying, anti-social behaviour, community engagement and responsibility.

Many of my family and friends would consider themselves to be Christians but they would hold no truck with the homophobic bigots who have colonised Christian public discourse. Melanie, however, trades on being extreme and controversial; it sells papers. But promotion of such views also damages people’s lives and leads to bullying and in still too many cases, depression, self harm and suicide.  However, though unacceptable, in a way it’s easier to deal with than the acceptance and normalisation by usually unprejudiced people of the bigoted positions of others.

I was in a seminar last week where someone was sounding off about what she perceived as the unacceptability of discussion of religion in social situations nowadays. Without any irony, she suggested that religion had become “The love that dare not speak its name”. I wish Oscar Wilde were here to respond to such rubbish. Every day LGBT people and women are treated to bigoted argumentations based on asserted religious beliefs about how we should conduct our lives and what rights we should or shouldn’t have.

And to get back to the ACMD, ideally, it should be a committee with the best representation of scientists, researchers and professionals for it to give good advice about drugs, with a public health focus. Dr Raabe has co-authored a vile paper that asserted:  

“Any attempts to legalise gay marriage should be aware of the link between homosexuality and paedophilia. While the majority of homosexuals are not involved in paedophilia, it is of grave concern that there is a disproportionately greater number of homosexuals among paedophiles and an overlap between the gay movement and the movement to  make paedophilia acceptable.” http://www.catholiceducation.org/articles/homosexuality/ho0095.html

Being a member of the Advisory Council on the Misuse of Drugs is an important public office. It should not be acceptable to hold such an office and to express and publish offensive statements against LGBT people or any other minority group.