Sunday, 15 July 2012

Alcohol Addiction and Education: Some random thoughts

Over the past weekend I was involved in a twitter conversation and I happen to make the observation that alcohol consumption was linked to price.  The reply which came from people I know to be health professionals left me a little surprised.  The link between alcohol and price was doubted and then a comment was made how will this help the addict?  Further conversation stressed the need for more education.   Clearly there are evidential blind spots in operation here.  Lets deal with price first.  As the alcohol industry will not tire of tell you there is no proof of a causal relationship between alcohol consumption and price.  In this they are correct, but what they won’t say is when looking at wider population effects this is almost impossible to show.  What we have is the very next best thing, a plethora of cross-cultural/international evidence that shows there is a strong relationship with greater levels of alcohol-related harms and low priced alcohol.  Paying a realistic price helps the addict because it means that alcohol is not so ingrained into our culture. 

Secondly the panacea of education that is often beloved of health professionals and certainly the alcohol industry largely because it makes barely a dent in their profits.  I support alcohol education so long as it is delivered in an evidence based way-which unfortunately is rare.  But even when delivered according to the evidence, behavioural change is minimal.  The alcohol industry loves it because it gives the impression of doing something but in reality has a minimal effect.  The result of education is to increase knowledge but the evidence for behaviour change is very weak, indeed sometimes it has shown that it encourages rather discourages experimentation.  So please let us have evidence driven education programmes but accompanied by measures that really will have an impact;-increase in price and reduction of availability.

Especially whenever representatives of the alcohol industry are asked to comment on consumption the spectre of the predominance of the responsible drinker or consumer is raised-ergo people who are not responsible are "spoiling the fun of the majority.”  Alcohol is fun I am a drinker and most of time I consume responsibly but there will be occasions when I don’t but I think elements of “fun for the majority” need to be unpacked.  It may be a bit po-faced but I despair of some of the attitudes that surround drinking.  I have lost count of the number of times I have heard comments along the lines of when I get home “there will be a nice glass of something cold waiting for me.”  Notwithstanding the inherent dangers of using alcohol as a reward (see my last blog-Home drinking: because I am worth it) if the words “glass of something cold” was replaced with “a joint” “ a valium”, “line of coke” “syringe of heroin” it does not quite have the same ring.

This week I read something that threw into sharp relief the dysfunctional culture that surrounds drink.  Devon and Cornwall police returned 27 sixteen year old youths staying as a group without their parents in Newquay who were “running riot” having  smashed up their rented accommodation whilst on drunken sprees with alcohol brought down from Bristol, Birmingham and Guildford respectively.   For some on twitter apparently this was caused by a “lack of alcohol education.”  If ever there is a case of the horse having bolted this is it.  I am less critical of the young people than their parents.  Nice to give someone a rite of passage provided other people pick up the tab.  No doubt most of the parents would regard themselves as responsible I beg to differ, I shudder to think what messages they have been given albeit not consciously concerning how alcohol is fun.  Education has no chance when it is undermined in such a manner by our wider culture.  

Now for some final thoughts about addiction, I welcome more treatment services but I also feel that wider society can help the addict by realising that an addiction is just the extension of an unhealthy habit and “there but for the grace of God go I.”  I have worked with individuals who were addicted to alcohol for many years and understand from talking to many of them that the main challenge they face is relapsing on leaving treatment services.  They will describe putting themselves in situations where eventually they are overwhelmed by cues. (although they are unlikely to use such a word) usually in response to a stressful situation or wishing to test themselves.  A cue is something that they associate with drinking, such as a pub, going back to areas where they drank, the smell of alcohol.  I spoke to someone recently who had been drinking for many years and could provide a thirty year perspective.  The main challenge he now faces is that alcohol is far easier to obtain and cheaper- he stressed the role of supermarkets in making alcohol easily available. 

The addict plays a vital role in helping to persuade ourselves that we are not like him or her for we use alcohol “responsibly”.  I may be making a utopian suggestion here, but if we paid a realistic price for alcohol, accepted some restrictions on its’ availability and examined some of our own beliefs and attitudes to alcohol we might be creating a creating a healthy culture for us all and at the same time making recovery for those who have become addicted to alcohol just a little bit easier.

Dr John Foster is Principal Research Fellow at the University of Greenwich-School of Health and Social Care.   This blog represents my personal opinions and do not represent those of the University of Greenwich.


  1. Good piece John. It is a fundamental challenge to effective alcohol policy that the lay person will assume that 'more education' is what's needed. As you highlight this is contrary to the evidence but does in some ways seem like a rational conclusion to assume. Of course not the only policy issue where the common assumption is quite out of sync with the evidence..

    One other key issue is I feel the false perception of "us" and the seperate "alcoholic others" as the only problem drinkers. Whereas of course we know the spectrum of alcohol misuse runs throughout society and social groups.

    So whilst I don't disagree with you comments on addiction and treatment, I feel they may inadvertently re-enforce this notion to some extent. Namely not everyone with alcohol addiction/in treatment would need abstinence as a goal. Most peoeple with some level of dependence will only have it to a mild severity - so if identified early would need far less intensive interventions/support.

    Nonetheless both those seeking controlled drinking and abstinence goals face the common enemy of the ubiquitous cue to 'enjoy' a drink when we would probably choose not to.

  2. Thanks James

    I agree with your comments re abstinence and am about to start some work locally concerning evaluation of SBI and am particularly interested in considering those who dont have abstinence as a goal. What I did not say is that often individuals stop drinking problematically (possibly become controlled drinkers)without contacting treatment services. This is of course a different debate. The aim of this blog is to write in an thought-provoking but accessible manner and I hope this aim is being acheived.

  3. I really enjoyed reading your post John which I am in general agreement with. James kind of touched on this but there is emerging evidence of screening (e.g. completing a modified AUDIT questionnaire about alcohol consumption) having an impact on behaviour change. In public health terms, I wonder could this be considered an intervention in its own right for people drinking at increasing and higher levels of risk?

    1. Thanks Paul

      There is now a body of evidence emerging as to the impact of screening and brief intervention. If you are not already familiar with it see the SIPS study. Google this and alcohol findings and you should find this. Get back to me if you have problems accessing it. I am about to conduct and evaluation into SBI in an accident and emergency in the Greenwich area.
      Perhaps in another blog I might look at treatments briefly but it wont be popular with the treatment community which has had major problems with the idea that some of their work when evaluated often does not produce cost effective outcomes but that is another debate.

    2. Impressive stuff as usual, John - I agree that price is a big factor but the problem with making alcohol expensive or hard to get is people will find alternative means of boozing eg going to Calais shops or even making moonshine and drinking at speakeasys like in the prohibition era.
      (David Ogden)

    3. Thanks Dave.

      You may have a point though time will tell. There has been a history of buying alcohol duty free for somewhile though this has become less popular as supermarket prices have been comparatively low. However this may change and the Shepherd Neame brewery in Kent have expressed concerns.
      Often quoted is the experience of Russia where consumption slowly crept up again following an initial fall in response to a price rise. However there was already a culture in place in Russia of home brewing alcohol (known generally as unrecorded consumption as tax is not paid.) Currently there is not a culture of this in the UK though there are parts of the country where stills have been found- generally associated with Eastern European migrant communities and there have been some sales of illicit vodka in off licences.

      If the recession is prolonged we may see a big change in UK culture but currently unrecorded or duty free consumption is small.

  4. I have to wonder whether someone hasn’t created a ‘neo-temperance toolkit’ that gives them the formula and content of their anti-alcohol propaganda, because all the elements were there: the ritual denunciation of the drinks’ industry as one-dimensional capitalist villains who cynically favour alcohol education because it doesn’t work; the usual tired arguments about raising price and reducing availability were rehearsed; a lurid tale of alcohol-fuelled teenagers running amok (“I blame the parents”); the comparison made between alcohol and drugs; and finally a reminder of the slippery slope “addiction is really just an extension of a bad habit and ‘there but for the grace of God go I.’

    Let me start with his comments about the impact of education. The gist of it is he doesn’t think alcohol education has much of an impact on the drinking culture, it doesn’t work; unlike propaganda.

    Indeed, he goes further and suggests that education might actually backfire because it “encourages rather than discourages experimentation” (with alcohol).

    More to the point, there is evidence that alcohol education does work. For the past eight years Diageo has sponsored “Smashed”, an interactive theatre education workshop, which educated young people about the risks of underage drinking. Following the 2012 tour, 98 per cent of participating students said they understood alcohol misuse can damage their health; 96 per cent said they understood it can affect relationships with friends and family; 98 per cent said they understood the relationship between drinking and accidents. “Smashed” has so far reached 195,000 young people in 1,100 schools and will be touring again in 2013.

    Furthermore, the latest NHSIC report on smoking, drinking and drug use in England in 2011 has shown that:

    • The proportion of pupils who drank in the last week has fallen by eight per cent since 2010 and by 54 per cent since 2001
    • The mean weekly amount drunk by pupils that did drink fell by 20 per cent since last year
    • The number of pupils who have never had a drink has risen by 40 per cent since 2001

    Foster also addresses the relationship between consumption and price: “As the alcohol industry will not tire of telling you there is no proof of a causal relationship between alcohol consumption and price….” Well, actually the alcohol industry makes no such claim, and if it did it would be wrong. Why does Dr Foster think the industry is campaigning for a reduction in VAT to five per cent in pubs, and an end to the alcohol duty escalator? It is precisely because we do understand that demand for alcohol products, like the demand for any other product, responds to increases in price.

    The issue is not whether price rises would lead to a fall in alcohol consumption, but whether there is a causal relationship between the fall in consumption per head across a whole population, and a reduction in alcohol-related harms. The ‘whole population’ approach, of which he is an advocate, is a theory in desperate search of evidence. The last six years has seen the ground move beneath it. An 11 per cent fall in alcohol consumption whilst alcohol-related harms continue to rise – the opposite of what those seeking to suppress the mass market in alcohol believed would happen.

    And then he goes on to make the comparison between someone who is looking forward to going home “where there will be a nice glass of something cold for me” and consumption of illegal drugs. He suggests that if “glass of something cold” was replaced with a “line of coke” or “syringe of heroin” it wouldn’t have quite the same ring to it.

    We all make our pitch to consumers in the same market-place of ideas. This creates individual choice. I suspect Dr Foster doesn’t like the idea of education or advertising because he believes that if you give people a choice they’ll make the wrong one! They can resist anything except temptation. For you, the difference between ‘responsible drinkers’ and ‘alcohol addicts’ is just a matter of how far down the slippery slope they are.