UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 368-iHouse of COMMONSMINUTES OF EVIDENCETAKEN BEFOREhealth Committee
alcohol
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This is an uncorrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.
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Transcribed by the Official Shorthand Writers to the Houses of Parliament: W B Gurney & Sons LLP, Hope House, Telephone Number: 020 7233 1935 |
Oral Evidence
Taken before the Health Committee
on
Members present
Mr Kevin Barron, in the Chair
Jim Dowd
Sandra Gidley
Stephen Hesford
Dr Doug Naysmith
Mr Lee Scott
Dr Howard Stoate
Dr Richard Taylor
________________
Witnesses: Professor Ian Gilmore, President, Royal College of Physicians and Dr Peter Anderson, Public Health Consultant, gave evidence.
Q1 Chairman: Good morning, gentlemen. Could I welcome you to the first session of our inquiry into alcohol? Would you give us your names and the current position you hold for the record, please?
Professor Gilmore: I am Ian Gilmore; I am President of the
Dr Anderson: My name is Peter Anderson; I am a consultant in public health working as a freelance advisor to the WHO and the European Commission.
Q2 Chairman: Thank you. I think you have both submitted written evidence and we have published the first round of written evidence to this inquiry which will be available. I suppose I ought to declare an interest as well. I have been made an honorary fellow of the Royal College of Physicians and we have also got Dr Richard Taylor who is also a member. My first question is to both of you. I wonder if you could just explain or outline the key harms that result from drinking to excess on a single occasion and drinking to excess regularly.
Professor Gilmore: The harms that result from heavy drinking on a single occasion are really the harms associated with being drunk and losing control, so it is about accidents, violence, unwanted pregnancies, rape and so on. Some people sadly die each year of acute alcohol poisoning. Alcohol is the commonest cause of death in young men from 16 to 24 and that is mainly the result of acute intoxication rather than chronic consumption. The best known ill effect of chronic consumption is sclerosis of the liver; that is the best marker of alcohol misuse. Not every heavy drinker gets sclerosis but it is responsible for something in the region of 8000 deaths a year and it is rising remarkably. Since I qualified as a doctor it has gone up almost ten-fold in younger people (25 to 44); it has virtually doubled in the last decade and at least 70% of liver disease (which is now the fifth commonest cause of death in this country) is due to alcohol.
Dr Anderson: I would say something similar. For the single occasion it is mostly accidents and injuries. In fact the risk of those accidents and injuries increases lineally with the frequency with which someone is drinking heavily on a single occasion and almost exponentially with the amount that someone is drinking on a single occasion. For the chronic conditions there are over 60 or so recognised diseases within the WHO's classification of diseases that are causally related to alcohol. In addition to liver sclerosis there are a wide range of cancers, particularly of the upper part of the throat and the neck as well as with the large bowel, and in women female breast cancer. There is a large range of cardiovascular diseases including hypertension, high blood pressure, certain types of stroke, arrhythmias in the heart. Then there is a whole bag of other diseases that have less importance in terms of public health but are still caused by alcohol. Recently there is a lot of new evidence coming out of alcohol's causal role in communicable diseases, things like tuberculosis and pneumonia.
Q3 Chairman: I assume from what you have both said that in both of these areas alcohol related harm is rising.
Professor Gilmore: Absolutely.
Q4 Chairman: Could you outline how these harms affect different age groups in
the
Professor Gilmore: It is of relatively high importance in the young because of the risks of accidents, but it is not just a problem of young people. In fact one of the difficulties in alcohol health is that the spotlight has been on young people; it is very easy to blame other people but some of the biggest rises in alcohol related health harm are in older people. I think there are 300,000 hospital admissions a year in the elderly related to alcohol. It really goes right across the spectrum; it is not just about young people. Clearly we are concerned about young people because they are tomorrow's health problem, if you will, and we know that early regular exposure to alcohol when young makes people more likely to have dependency and other problems in later life, but it is not just about young people.
Dr Anderson: It is really across the whole age spectrum from the foetus in pregnancy (a woman drinking in pregnancy can cause increased risk of foetal damage) all the way through to old age. As Professor Gilmore has said, the accidents and injuries tend to occur in a younger age whereas the chronic diseases - the cancers, the cardiovascular diseases - tend to occur in older age. The thing with the alcohol harm compared, for example, to the tobacco harm is that to some extent alcohol harm occurs at a slightly younger age than tobacco harm in general. The other main factor is the differences by socio-economic group. There is a lot of evidence that people who are socio-economically disadvantaged are at much greater risk of alcohol related harm even when taking into account differences in drinking patterns and the amount of alcohol consumption. For a given level of alcohol consumption people from lower socio-economic groups tend to get more harm than people from higher socio-economic groups.
Professor Gilmore: You looked at health inequalities recently and alcohol was very much a factor that came up then.
Q5 Dr Stoate: Professor Gilmore, I would like to tease some of these figures out. On the face of it the ONS figures show about 8000 deaths a year from alcohol and yet from the figures you have given us it is rather more alarming than that. What I am afraid of is that it is not given the prominence it deserves amongst the public who say that 8000 deaths is nothing compared to smoking (100,000), obesity (possibly 30,000 or 40,000 deaths a year); alcohol is a pretty small figure. I would like you to expand it a bit for us.
Professor Gilmore: That is a very important question because those 8000 are the ONS figures and that is where alcohol is named on the death certificate as the cause of death. Nearly all of those are alcoholic sclerosis. It does not pick up the accidents, the violence and so on. If you include cases where alcohol is named on the death certificate as a contributory cause then the figures rise to about 15,000 but if you actually take the percentage of oesophageal cancer that can be attributed to alcohol et cetera, using the attributable fraction (which is a well recognised and scientifically reputable way of doing it) the figure comes out between 30,000 and 40,000. If you look at obesity, obesity is probably never named on a death certificate and if you use the same criteria for obesity the figures would not be 30,000 they would probably be about 300,000. That 30,000 is taking the percentage of diabetes, hypertension et cetera related to obesity that contributes to death. I am not doing down the importance of obesity and certainly not of smoking, but smoking probably comes in currently around the 80,000 mark, alcohol 30,000 to 40,000 and obesity about 30,000.
Q6 Dr Stoate: That is much more realistic. My concern as a doctor is that on many death certificates someone might be put down as heart failure, they might be put down as pneumonia, they might have a CVA so how can we get to the true figures because the underlying cause - which may be alcohol or at least largely alcohol - cannot be done at a general practice level because often there is not enough knowledge of what the actual cause of death is.
Professor Gilmore: Absolutely and there is still a stigma around it. I think when a doctor has to write a death certificate and there is a choice of getting round not using an alcohol related term then they are quite tempted to do so for the sake of the family. You are absolutely right, the figures we get are almost significantly underestimates.
Dr Anderson: One way round this is through epidemiology, to look at what Professor Gilmore has alluded to which is attributable fraction. We can very easily calculate the proportion of breast cancer or the proportion of oesophageal cancer that is due to alcohol and then, knowing the number of deaths, one can then work out estimates of the number of deaths that will be occurring. That is when you start getting these higher figures. I think the other important thing is not to always just think of deaths but to think of ill health as well. There is this concept that was developed by the WHO called a disability adjusted life year which is a measure of both ill health (weighted for the severity of ill health) and premature death. If we start looking at this comprehensive assessment of alcohol then its contribution to both ill health and premature death rises much higher than just death itself. Certainly at the European level alcohol at the moment is about third in the ranking after hypertension and tobacco, but all the estimates show that this is likely to increase further.
Q7 Dr Stoate: Why is it then that alcohol is not in the public mind amongst the commonest cause of death because the figures you have both given indicate that it should be?
Professor Gilmore: I keep telling them.
Q8 Jim Dowd: Is there any work being done on the lifestyle of excessive consumers of alcohol? Would they, for example, be more likely to be smokers as well or would they be more likely to be obese? Has any work been done around the lifestyle and the risks they run generally, not just in terms of alcohol?
Professor Gilmore: There is certainly an association between smoking and drinking and there is also an association with obesity. Indeed, when it comes to liver disease there is increasing evidence that obesity and alcohol misuse is a very dangerous combination because they both cause fatty liver and when combined the sum seems to be greater than the individual parts. When it comes to looking at the harm that comes from alcohol, clearly in the studies they are very careful to associate the effects of smoking and so on so that it is not exaggerated. Peter would know more in this area than me.
Dr Anderson: I would not add very much to that, just to emphasise that in the scientific studies you can take into account the relative contributions of other risk factors like tobacco or obesity or other lifestyle issues so that you end up being clear what is the direct component from alcohol after having adjusted the potential impact of the other factors.
Q9 Jim Dowd: I realise this might be something of a generalisation, but would it be fair to say, for example, that excessive drinkers would be more prone to a poor diet?
Dr Anderson: If you are a very heavy drinker and become dependent on alcohol such that alcohol has taken over your life, then yes, that is true. However, I think in terms of the more average excessive drinker it is probably not so true, not.
Q10 Jim Dowd: I remember Dylan Thomas was once asked why he drank so much and he said it was because food made him sick.
Dr Anderson: I think one has to separate people who are very, very severely dependent on alcohol, where alcohol is so affecting their lives that they are not eating properly, from the much broader group of people who could be excessive drinkers but where alcohol has not affected their normal daily functioning.
Q11 Jim Dowd: On the question of units, what is a unit? Is it a glass of wine or a glass of beer or a measure of spirits?
Professor Gilmore: In scientific terms it is eight grams or ten millilitres of pure alcohol and that equates to a half pint of ordinary beer, a small glass of wine (about 110 or 120 millilitres of 10% wine) and a single pub measure of spirits. However, as you know, glasses are getting bigger and drinks are getting stronger. A significant number of pubs and restaurants will offer only 250 millilitre glasses of wine which is one third of a bottle. If it is a 14% red wine that will contain about four units. Equating a glass of wine with a unit causes a lot of people to underestimate their consumption.
Q12 Jim Dowd: When people are drinking and deciding how much they have consumed, it will be done by glass although I do accept the qualifications you have made.
Professor Gilmore: Yes.
Q13 Jim Dowd: If I recall it correctly, it is 21 units per week for men and 14 for women. Is that right?
Professor Gilmore: Those were the levels recommended by the royal colleges in the 1980s. The conservative government in the mid-1990s brought in recommendations of three to four drinks a day for men and two to three drinks a day for women. This was seized on by many as a relaxation of the limits. Then it was pointed out that people should have two alcohol free days a week in which case it comes out to be the same. It has come in for a lot of criticism with the front page of the Times saying these figures were plucked out of the air which is unfair because we know that people vary in their genetics, not everybody who drinks heavily will get liver disease - some might get some other complications - and we are not able to individualise risk yet although we may be able to in ten or 20 years' time. For the moment all we can say is that if you stick within those limits you are very unlikely to suffer physical, mental or social harm.
Q14 Jim Dowd: Would it be fair to say that anybody in excess of that is not a moderate drinker?
Dr Anderson: When you look at alcohol the risks in relation to harm are pretty
well monotonic or linear meaning that the risk starts at zero and it goes
upwards. The more you drink, the greater the risk. There is some new work that
has come out of
Q15 Jim Dowd: Would you describe somebody who has 30 units a week as a moderate drinker or is that veering towards excess?
Professor Gilmore: That would fall into what the scientific literature refers to as "hazardous" which means that you are not necessarily suffering harm but your risks are very significantly increased. Above 50 units for a man and 35 units for a woman we would describe as "harmful"; if you have not already suffered some form of physical or mental harm you are quite likely to do so. The government recently changed those terms - just to keep confusing us - to lower, increasing and higher. As Peter says it is a continuum but, for the sake of classifying people and giving people an idea of where they stand (because people rarely drink two and a half units exactly every week) we have these categories to try to help people understand.
Q16 Dr Taylor: Just to reassure us, do we understand that two units a day is going to be pretty safe really?
Professor Gilmore: There is less than a 1% chance of dying of an alcohol related cause.
Q17 Dr Taylor: Ian, you have already said that the problem affects people of all ages; do you think that the focus of the media attention on binge drinking is tending to eclipse the other sort of problems?
Professor Gilmore: Yes I do. I think the biggest change in drinking habits in this country is buying from supermarkets at heavily discounted prices, drinking relatively quietly at home and developing either dependency or physical problems. I think the anti-social behaviour and the social unrest has been particularly picked on by the media and that has been helpful to one extent in that it has raised the profile of alcohol misuse as a problem, but it should not divert us from the fact that there is an awful lot going on behind closed doors.
Q18 Dr Taylor: Is there evidence that it is young people who are getting these cut price drinks at the supermarkets particularly?
Professor Gilmore: I think people across the age range are availing themselves of alcohol. It has never been cheaper in real terms than it is currently and it has never been more available.
Q19 Dr Taylor: Obviously the alcohol industry is keen to minimise the problem. What are the best sorts of figures, the most striking examples that prove that it is not only a tiny minority of the population that is affected?
Professor Gilmore: There are three million alcohol dependent people in this country and that is a very significant number of people who are dependent on alcohol.
Q20 Dr Taylor: Three million?
Professor Gilmore: Yes, 2.9 million is the figure that is usually quoted.
Q21 Dr Taylor: How does dependency fit in with this 30 units and 50 units a week?
Professor Gilmore: I am not a psychiatrist, I am a physician as you know, but dependency is a form in general terminology of alcoholism; it is people who have to have a drink to prevent either psychological or physical symptoms developing.
Dr Anderson: The evidence is that the more you drink the greater you are at risk of becoming dependent. For young people the earlier the age you start to drink and the more you drink as a teenager or adolescent, the greater the risk as a young adult of becoming dependent.
Q22 Dr Taylor: Peter, can you tell us something about the link between harms caused by alcohol within a population and the overall consumption of that population? I think you have this weird phrase "prevention paradox".
Dr Anderson: It is not my phrase but other people have used it.
Q23 Dr Taylor: Could you explain that to us as well?
Dr Anderson: When you examine different countries and regions within different countries and changes over time there is a very, very high correlation or relationship between the amount that a community or a society or a country drinks and the level of alcohol related harm and the level of alcohol dependence. As a country's consumption goes up, harm goes up; as a country's consumption comes down, harm comes down. The prevention paradox is making the point that although there are people who drink very heavily, in terms of the overall contribution of the size of the problem to a population or to a country it is actually the much larger group of middle to heavy drinkers that are causing more problems than the smaller group of very heavy drinkers.
Q24 Mr
Scott: I have a question for both of you. What
are the causes of the increase in drinking in the
Professor Gilmore: I will go first but Peter is an international expert on the impact
of marketing and advertising. I think the evidence is very strong that the
biggest drivers of increased drinking are the price and the availability. Clearly
there is a cultural aspect of this but there has always been a culture towards
binging in the
Dr Anderson: In terms of the second part of the question, I would agree that you
could say in the last ten to 12 years that government policy has, to some
extent, led to an increase in consumption, particularly by letting alcohol
become much more affordable. The price of alcohol both relative to income and
relative to other goods has dropped considerably in the
Q25 Mr
Scott: Dr Anderson, the growth in off-trade
sales that we have just been referring to has obviously made things a lot worse
because people are now drinking in the comfort of their own homes and maybe the
outcomes of that are not being seen on our streets quite so much. Do you think
that is the major cuase of the growth in alcohol problems in the
Dr Anderson: I could not in confidence answer which has contributed most. Without a doubt it is contributing but I would not like to say it is the greatest contributory cause. What I think it indicates is that if something is going to be done about it that problem also has to be addressed. There is evidence of course that young people will go and get drunk on cheap beer bought in the supermarket and then go out to the pub already intoxicated which then leads to further problems. The message always with alcohol policy is that it has to be comprehensive; you cannot just do one thing, you have to do a combination of things.
Q26 Dr Naysmith: Professor Gilmore, it is quite clear that historical evidence suggests that cultural patterns are very important determinants of drinking patterns. We have already referred to that a bit this morning. It is interesting that for the first 60 years of the 20th century - apart from a little blip - drinking levels were much lower than they were prior to that. There was a famous survey in a 1943, a mass observation which referred to the fact that young people represented the lowest proportion of pub goers, referring to frequent milk bars and coffee shops. Some of us remember those happy days with affection, but it is certainly not true in the way people are behaving now. Later on there was a push by the brewers and so on to counteract what they saw as falling sales. Then there is the fact that women did not used to go into pubs very much 20 or 30 years go. Now they are almost equal numbers with men. All these things are cultural influences. I just want to ask you whether you think that this means that the power of the alcohol industry and its marketing suggests that what the government does in this area is completely irrelevant and does not matter very much.
Professor Gilmore: Clearly changing culture is a very complex issue and it develops
over time. There is no switch that is going to turn us back to milk bars and
coffee bars overnight. However, if you look at the situation where a culture is
relatively stable and the price is modulated then you do change consumption and
you do change harm. For example, social reference pricing or minimum unit
pricing in some areas of
Q27 Dr Naysmith: Dr Anderson, do you have anything to add?
Dr Anderson: I would agree with that. The way you phrased the question gave perhaps a rather pessimistic view. As Ian has said you can counteract even those kinds of changes. If you look at something like drink driving you can show that with a combination of laws and regulations you can make a cultural shift so that whereas before maybe it was perhaps culturally acceptable to drink and drive, it is not culturally acceptable to drink and drive now. That is an illustration which shows that where putting in good legislation and enforcing it shifts people's behaviour and it also shifts their thinking about what they were doing before.
Q28 Sandra Gidley: Dr Anderson, the alcohol industry makes strong claims for the Drink Aware Trust. What are your views of the effectiveness of the Trust?
Dr Anderson: I do not want to answer necessarily specifically about the Trust.
Q29 Sandra Gidley: Please do.
Dr Anderson: There is very good scientific evidence that information campaigns and education campaigns on their own do not change behaviour. These campaigns have to be done in association with policy changes or done to help support policy changes. Just providing information is not going to change people's behaviour. There are some studies that also show that education campaigns funded by the alcohol industry can backfire in the sense that they lead to the people exposed to those campaigns coming up with a much more favourable attitude to the alcohol industry than they did before. That tends to lead to the view that these kinds of industry funded campaigns, if anything, may have a negative effect, ie increasing a positive view or expectancy about the use of alcohol in drinking. In the smoking field there has been a lot more research done on this and it is very clear that tobacco industry funded education campaigns do the opposite; they almost lead to more smoking and they certainly lead to much more favourable views about the tobacco industry. My view is that an education campaign like Drink Aware, funded by the industry, is not likely to do much good anyway in the first place because these campaigns do not. If anything it could lead to a more positive favourable view of the alcohol industry which could then complicate matters when you try to do other policy issues.
Q30 Sandra Gidley: Have there actually been any studies comparing a drink awareness campaign funded by the alcohol industry and one funded by, say, the Department of Health?
Dr Anderson: No. In the tobacco field there have been such studies where they have compared the impact of tobacco industry funded campaigns with campaigns funded by public health bodies. These are the ones that show that the campaigns funded by public health bodies in the tobacco field have some effect, whereas those funded by the tobacco industry do not, but lead to a much more favourable view of the people exposed to the tobacco industry.
Q31 Sandra Gidley: You said the campaigns can end up having a perverse effect.
Dr Anderson: Yes.
Q32 Sandra Gidley: Is that the case if the campaign is targeted at adults or younger people? Is there an age difference in the response to the campaigns?
Dr Anderson: That has not really been studied. The ones that have been studied have tended to be aimed at young people but I do not know if there is a difference by age.
Q33 Sandra Gidley: How should safer drinking, social marketing and other health promotion efforts be funded? Or should we bother?
Dr Anderson: You need to bother. People do need to be informed about these issues. This should surely be done by public health bodies who are able to get the right messages across. The key to these campaigns should be very much focussed on trying to alert public awareness to the size of the problem and what can be done about it. We all know the difficulties sometimes with taxes, that one might be concerned that if you put the tax up people do not like this, but my guess would be that if you did well structured public education campaigns explaining the problem and explaining the reason why, you are more likely to get support for a public policy measure.
Q34 Sandra Gidley: Public health funding is very, very low; this Committee has just done an inquiry into health inequalities. How on earth will one campaign be able to compete with the tide of advertising from the drinks industry?
Dr Anderson: It cannot and that is why you need to control the tide of advertising from the drinks industry, if you like levelling the playing field, so that there is less advertising from the drinks industry thus allowing the potential impact of public health campaigns to increase.
Q35 Sandra Gidley: Should we just take their money and put it in the public health budget?
Dr Anderson: You are taking their money through taxes but there are countries which do earmark a proportion of alcohol taxes for public education campaigns.
Professor Gilmore: Also the industry gets tax relief on their advertising and there is a source of funding which is not being tapped.
Q36 Sandra Gidley: The drinks industry get tax relief on their -----
Professor Gilmore: Professor Noel Olsen, a distinguished public health physician, assures me that companies can write off as reasonable expenses advertising. If one was to abolish tax relief on drinks industry advertising that money could go to public health campaigns run by government.
Q37 Stephen Hesford: What should be the balance between voluntary and statutory controls on alcohol marketing? In terms of making progress with tobacco, the deaths at or about the time the real focus from government started to kick in was about 20,000 deaths a year. If, on your figures that we talked about before, we are at 40,000 for alcohol, is there critical mass that we have not reached from a public policy point of view? Is 40,000 not enough to kick start or really interest the government? Is that an issue? For tobacco there used to be voluntary codes; are we not at that point yet?
Dr Anderson: In the epidemiology I would say that we are at that point. The reason I say that is if we do not just look at deaths but deaths and ill health, alcohol and tobacco are the same. I think one will increasingly see alcohol overtaking tobacco because there is a time lag of the tobacco deaths and they will continue to fall down.
Q38 Stephen Hesford: As usage decreases?
Dr Anderson: Yes. The other important thing of course is that alcohol causes an
enormous amount of harm to people other than the drinker. Just look at
pregnancy problems, look at children being brought up in families where parents
have alcohol related harm, look at accident and injuries that might occur on
the streets, look at the drink driving accidents where an enormous number occur
to people other than the drunk driver. If you want to get a message over to get
more government support for this idea, focus on the harms done to people other
than the drinker. In terms of the self-regulation many different countries
across
Q39 Stephen Hesford: As opposed to the voluntary?
Dr Anderson: Yes, as opposed to voluntary. There is the phrase "Don't ask a bird to clip its wings"; in a way self-regulation to some extent has to go against what the industry itself would like. The evidence is that it just does not have enough teeth unless it is properly backed up by some kind of threat of government statutory regulation or some statutory process that can say, "Okay, unless you really clean your act up here we're going to introduce regulation". The other thing with self-regulation in most countries is that it does not deal with the volume of marketing; it much more deals with the content where the volume also matters. Also self-regulation often does not touch very well on all the different forms of marketing - internet marketing or marketing through SMS messages - and the other point about self-regulation is that when you ask young people what is appealing about an advertisement, for example, they say, "It's elements of humour" and things like that. Self-regulation just does not touch on things like humour at all.
Q40 Stephen Hesford: Using smoking as a parallel again, are we at a point of banning advertising? Where are we in that argument?
Professor Gilmore: Coming to the point of where we are at, it is not just the deaths. If
you think that there are nearly a million alcohol related hospital admissions a
year, you convert the 75%-plus of presentations after
Dr Anderson: The other good thing about the French advertising, for example, is that it tells you what you can do and not what you cannot do. Something that tells you what you can do is so much easier to enforce and monitor because it is much clearer.
Q41 Stephen Hesford: In simple terms, from a medical perspective and a risk of harm perspective, are you saying that we are past the point where the voluntary route is effective or useful?
Dr Anderson: If you want to make the parallel with tobacco then definitely yes.
Q42 Dr Naysmith: I want to go onto the international experience a bit, but just before I do, Dr Anderson, I would like to ask you about something else which came out of this Committee's tobacco inquiry. The tobacco industry maintained for a long time under questioning that they were not promoting tobacco use they were just bringing about brand switching and that sort of thing. In the drinks industry clearly a promotion is a promotion is a promotion and it encourages people to drink. Is there anything similar in your experience in the alcohol industry?
Dr Anderson: In a way there are many parallels - although the alcohol industry will not like me saying this - between that industry and the tobacco industry in the way that they are trying to counteract the evidence about both the harm and the policy interventions. All of the scientific research, for example, on marketing shows that it is not about brand switching, it is actually about increasing the likelihood that young people will start to drink or, if they are already drinking, they will drink more.
Q43 Dr Naysmith: One of the arguments that is sometimes used is that in many other European countries this country seems to drink much less than they do. Does that mean that we are worrying unnecessarily?
Dr Anderson: If you look across at the European Union, for example, that is not
the case. If you look from the top to the bottom the
Q44 Dr Naysmith: Before certain legislation was introduced we used to talk about introducing the continental culture of drinking in this country. It has not quite happened like that. Are there differences in cultural patterns of drinking that are of significance between different European countries?
Dr Anderson: There are certainly differences in cultural styles of drinking and
cultural patterns of drinking. One of the important things in Europe is that
there has been much homogenisation of these different drinking styles and
different drinking patterns so that countries that before were predominantly
wine drinking countries are now much more beer drinking countries. You can get
the same phenomenon of young people going out on the streets and getting drunk
in Spain; it is perhaps not as bad as in the UK but it certainly happens in
Spain. One of the other problems is that the research has been a much more
northern European thing. We know much more about the problems in northern
Europe whereas in southern
Professor Gilmore: I would agree with what has been said.
Q45 Stephen Hesford: What can we learn from your international review of the effectiveness of different interventions to tackle alcohol harm?
Dr Anderson: We can learn that there is overwhelming evidence for what kind of policy options work. How you implement those will vary from country to country or culture to culture. What we know is that price is very, very important. If the price of alcohol goes down, consumption and harm go up and vice versa. We know that price matters. We know that the availability matters. In general the more available alcohol is in terms of the number of outlets, the density of outlets and the days and hours of sale, the more consumption and harm there is. The converse is that availability is restricted and there is less harm. We also know that marketing has an impact. It is smaller than the impact of price and availability but there is an impact there. We need to continue to be tough on drink driving and I think there is still clear room for improvement in the UK to bring the legal blood alcohol level down to the European average which is 0.5 instead of 0.8. Enforcement is important on that but the experience is that every country that has brought their level down always gets more savings of lives. Finally, the other very important area is the work done by the healthcare system and service. There are a lot of people who do have hazardous and harmful patterns of drinking for whom some early identification and brief advice from a GP or a practice nurse or someone else is effective in helping them change their drinking.
Professor Gilmore: That is a really important point. We are not dealing with problems that are insoluble. Policies will make a difference on the population but there are also things that will help individuals. There is a wealth of evidence that early identification of people who are creeping into problem drinking and brief advice actually works. It is a sustained benefit; it is more effective than nicotine replacement therapy and nicotine counselling and a lot of situations where expensive preventative medications are used for blood lipids and the like. So it is not a hopeless situation and indeed even for heavily dependent drinkers specialised treatment services, that are sadly very patchy around the country, are effective. There are solutions to this problem; we are not just preaching doom and gloom.
Q46 Stephen Hesford: In terms of your average GP, is your average GP equipped to deal with this?
Professor Gilmore: Probably not. It has been calculated that there are probably about 350 patients in an average GP list with drink problems and as many as 98% of those may be actually undetected. I think there are a lot of things that could be done around quality outcome frameworks and the like that would encourage better early detection and brief advice done at a general practice level or referral onto more specialised services.
Q47 Stephen Hesford: Are there any PCTs or areas of the country that have grown up with better services that could be used as examples?
Professor Gilmore: There are big differences. I think the Audit Commission looked at how PCTs were responding to alcohol misuse and there was a wide range of abilities and levels which they were at.
Q48 Dr Stoate: You have covered most of what I wanted to ask, but you mentioned all the things, Dr Anderson, that seem to work quite well - interventions that are effective - but are there any things that you think are not effective, perhaps things that we should be switching away from, things that are a waste of time?
Dr Anderson: The whole area of extrication is a difficult one is a difficult one. We have to be very careful about this because people need to be informed and educated about this issue. There is so much research that shows that education on its own does not change young people or people's behaviour. This means that we should not not stop giving education but we should be careful not to think that education is going to solve this problem because it will not. We need to package that in a much broader policy. When you say, "What shall we do about alcohol?" you do not say, "We need more education"; we say, "Well, we need more of these policy things supported by education".
Q49 Dr Stoate: With tobacco, for example, we spent years going round schools with horrible pictures of lungs and stuff saying to the kids, "This is what happens if you smoke". Was that more effective than the alcohol education or was there no benefit there either?
Dr Anderson: There is some evidence that the tobacco education is slightly more effective than the alcohol education but not a great amount. People were really aware of the risks from the Royal College of Physicians' report and things like that and when people understood that these risks were going to affect them then people changed and the whole issue around the environmental impact of smoking pushed it forward. That is why I think with alcohol that the more we can get over this understanding that alcohol does not just affect the drinker but it also affects people surrounding the drinker, a sort of collateral harm if you like. It is like the environmental tobacco smoke but I do not know what word to use for alcohol but it is that kind of idea.
Q50 Dr Stoate: Doctors were at the forefront of being advocates against smoking and stopping smoking but healthcare professionals seem to find it more difficult to disassociate their own behaviour and attitudes towards alcohol from their clinical practice. I think that the medical profession has a responsibility to take a stronger line and become stronger advocates, not advocating prohibition but moderate drinking and harm reduction and taking a lead in this area. In my own clinical practice I tend to use a bit of shock. If I seem somebody with a very raised gamma GT or somebody with a scan showing a fatty liver or somebody who quite clearly is drinking in the order of 80 or 90 units a week, I normally tell them that that is the slippery slope to sclerosis which is irreversible and of which they will die in short order. Is that a reasonable approach or perhaps not?
Professor Gilmore: I think it is factually absolutely correct and I think it does have an effect. Doctors are still listened to by their patients in the majority of cases; I think we are still influential with the individual patient and with society. Yes, I think you are absolutely right to lay it down on the line.
Dr Anderson: I used to be a GP in
Professor Gilmore: There is evidence that engaging with the patient in discussion is more effective than preaching.
Q51 Sandra Gidley: I wonder if you would both like to comment on the focus and effectiveness of government initiatives so far. What have they done well and what is not so good?
Professor Gilmore: In 2004 in building up towards the alcohol harm reduction strategy
for
Dr Anderson: In international circles the alcohol harm reduction strategy was seen as the bad example of what not to do in terms of government policy in European and international circles. Many people have critiqued it from a public health point of view because that strategy really lacked approaches for which there was evidence that something really would come out of it, for example controls on price or regulation of availability or regulation of marketing in an effective way. People who critiqued that from a public health point of view - which includes myself - were very nervous that it put far too much emphasis on things like education and information approaches and far too much focus on self-regulation by the alcohol industry. As a sort of relative outsider here, I think one does observe now that some things are changing, but again people in the European circles are very cautious and nervous about what is going to happen here because the perception is that there is the kind of government view of really going to do something that is going to make a proper impact in terms of reducing early and ill health.
Q52 Sandra Gidley: Marks out of ten for the government so far?
Dr Anderson: Based on the alcohol harm reduction strategy, maybe one. If you
compare it with what else is going on in
Q53 Sandra Gidley: Professor Gilmore, are you feeling any more generous?
Professor Gilmore: I am feeling more optimistic about the last year or so with a lot of initiatives looking at young people, accepting now that price is an important factor. I think at the moment the end of term report is "Could do better, a lot better".
Q54 Chairman: Professor Gilmore, from what you have said about the CMO's annual report you were not very happy with ministerial reaction to it on this issue of unit pricing when it was published. Would you agree with that? Were you happy with ministerial response to it, Dr Anderson?
Dr Anderson: I was not party to all of that close information so I do not know, but in terms of the kind of proposals that have been put forward for a discussion on minimum price this, from a health point of view, is a very important potential approach. The very powerful thing about minimum price is that it targets those people who are heavy drinkers, who have problems with drinking, whereas the lighter people drinking at lower risk levels are hardly affected by the impact of minimum pricing. So it is actually a very effective targeted strategy that deals much more with the problem without affecting the number of people who are lighter drinkers.
Professor Gilmore: I did not like the implication that it would impinge on a lot of responsible moderate drinkers when in fact the evidence says that it would very little impact on moderate drinkers and really, as Peter says, it would be targeted.
Q55 Dr Taylor: You have given us an awful lot to think about and you have said that it is a time for action. If it was left to each one of you, what would be the three most important things to do straight away to reduce alcohol related harm? If you could summarise those three it would help us tremendously in writing our report.
Professor Gilmore: I would go for minimum unit price, allow those granting licences to take the public health into account and I would enforce separate areas in supermarkets with separate tills.
Dr Anderson: In addition to minimum price I think one needs to adjust the tax structure to reduce harm. There is an awful lot of information as to how you do that intelligently and it can be done.
Q56 Dr Taylor: Where would we find that sort of information?
Dr Anderson: The Treasury will have that information because they have a lot of information about the changes in consumption for different beverage categories when the price changes. There is also a lot of information about which types of drinking people would be affected. I would very much restrict the marketing of alcohol. Maybe it is not possible to make a ban on alcohol advertising, but certainly something that is modelled on a law that says no advertising on television and really deals with the content and shift away from this idea of what you are not allowed to do to what you can do and make that very restrictive in terms of simply giving information about the product and not using all the kind of glamour and sex to market things. The third thing I would do is that I would really try to make a major investment in helping family doctors and nurses do more to help people who are at risk in drinking. This would do two things. It would help the patients enormously but it would also get the doctors to be more motivated and sensitised about this issue to then help the whole population do something about it.
Q57 Chairman: You may be aware that this Committee has been in
Dr Anderson: I think you need to consider what jurisdictional powers local communities can have. If you look globally on alcohol policy issues there is more and more responsibility given to local communities because it is local communities that know about the issue and suffer the potential harm and it is much easier to build coalitions to do things. Local community interventions can be very good, but that means the ability to give the jurisdictional responsibility to local communities, to make these individual decisions separately or in addition so they can have stronger things than what might be national legislation and that could be tougher things on licensing for example.
Q58 Jim Dowd: Professor Gilmore, you mentioned that there is a certain ambivalence within the medical profession when they look at their own behaviour, but is the principal difficulty that everybody knows that physically at least one cigarette is bad for you but nobody is saying that one alcoholic drink occasionally is bad for you. Is the problem not where the margin is set?
Professor Gilmore: Absolutely and I sometimes wish my clinical interest were in smoking because it has no redeeming features whereas in the individual's case an occasional drink or drinking in moderation does not pose a significant risk to health, although Peter is absolutely right that in population terms there is a linear relationship between any consumption and harm. Given the fact that most of us in most of things we do accept a degree of risk then moderate drinking in most people's views is a reasonable risk to take. Yes, I have never campaigned for the abolition of alcohol or prohibition in some way and I know I would not have my views falling on sympathetic ears if I were.
Q59 Jim Dowd: In both your responses earlier to Sandra's questions on the drink responsibly campaigns by the drinks companies, do you regard them as (a) ineffective, (b) counter-productive or (c) total hypocrisy?
Dr Anderson: All three.
Q60 Jim Dowd: They cannot be ineffective and counter-productive.
Dr Anderson: It can be ineffective in terms of leading to the change that we would like to see which is reduced harm. We would say that it is likely to be ineffective in terms of reducing harm. It is counter-productive in the sense that it leads to a more positive view about the alcohol industry serving the drinks which tends to then make people feel a bit easier about drinking. In a way it is hypocritical because if you were an industry wanting to be serious about reducing harm then you would have to be serious about agreeing to certain things that would reduce harm, for example supporting something like minimum pricing or, for example, being really serious about regulating your own advertising.
Q61 Jim Dowd: I want to look at this minimum pricing a bit further. The alcohol consumption levels per capita now are just below what they were at the start of the 20th century, although they are moving towards the same kind of point. The lows during the 20th century of course were during the war years. Some people spent as much as a sixth of their total disposal income on alcohol in those days; that figure has now plummeted because of pricing. What kind of level of increase in minimum pricing would be necessary to alter that behaviour? How do you respond to the suspicion that the pricing mechanism has a deep class bias in it insofar as it assumes that the problem is with those on lower incomes, whereas if you can afford it then it will not be a problem at all?
Dr Anderson: If you increase the price collectively everyone changes their drinking. There are going to be a very small number of very rich people it is not going to worry, but in general everyone changes their drinking. There are studies to show how different groups of people change their drinking in terms of either drinking less or switching to different beverage categories. There is that data on which you can make estimates of the impact of a change in price. There is a group at Sheffield University that has done work for the Department of Health in terms of modelling what might happen if you set different minimum price levels or if you set different taxation levels and that can give you quite powerful information of the consequences of changes to very heavy drinkers or light drinkers, reductions in crimes, reductions in hospital admissions or premature death. There are good ways of being able to say, "What is the likely impact if we do this option or do that option?" so no-one is working completely in the dark. You can try to make these things that are more targeted on reducing the problem which is what one wants to do rather than necessarily affecting a broad group of lighter drinkers.
Professor Gilmore: The chief medical officer's report points out that a minimum unit price of 50 pence would not affect 85%-plus of products sold in pubs, clubs and restaurants.
Q62 Jim Dowd: That is 50% compared to what at the moment?
Professor Gilmore: Fifty pence.
Q63 Jim Dowd: What is it at the moment?
Professor Gilmore: There is no minimum unit price at the moment. If you go out and buy three litres of 8.4% white cider for £2.99 you are getting more than your weekly safe limit in one bottle. That is as cheap as you can get it, about 10 pence a unit.
Q64 Jim Dowd: So we are talking about an increase at the margin of 400%.
Professor Gilmore: So that bottle of white cider would go up 400% but a pint of beer in a pub would not change at all.
Chairman: Could I thank both of you very much indeed for coming along and helping us with this inquiry.
Witnesses: Professor
Martin Plant, Professor of Addiction Studies, University of the West of
England, Dr James Nicholls, Senior
Lecturer,
Q65 Chairman: Gentlemen, could I welcome all three of you to this second part of our first evidence session of our inquiry in alcohol. I wonder if, for the record, I could ask you to give us your names and the current position you hold.
Professor Plant: I am Martin Plant. I am Professor of Addiction Studies and Director
of the Alcohol and Health Research Unit at the University of the West of
Dr Nicholls: I am James Nicholls. I am Senior Lecturer in the School of
Historical and Cultural Studies at
Dr Kneale: I am James Kneale, Lecturer in Geography at
Q66 Chairman: Thank you. The received wisdom about the drinking culture in the United Kingdom seems to be firstly that we have always been a country of heavy drinkers and secondly that there is a pronounced difference between the drinking cultures of northern European countries, like the UK, and southern European countries. Do you think that these assumptions are correct?
Professor Plant: Yes. First of all records and criticisms of the British style of
drinking go back for centuries. Binge drinking is not the new British disease,
it is actually a very old one. Recent research that has been carried out
comparing both drinking by young people and drinking by adults in
Dr Nicholls: There is certainly a history of certain patterns in the consumption
in
Dr Kneale: I would agree with James, but also I would clarify that one of the
reasons that Britain does seem to have a problem is that we tend to focus on
drink as a problem of public order rather than as a question of public health. Clearly
the two are closely connected here and we do have to consider them together. However,
I think most of the concern and most of the records about alcohol as a problem
in
Q67 Chairman: Is it that is just a bit colder up here.
Dr Kneale: No, although the Victorians did select that in select committees,
that in
Dr Nicholls: I think it is also important to bear in mind that levels of
consumption have gone up and have gone down as well and that has been in
response to a number of factors. Arguably the most driving factor in terms of
consumption going up and down has been relative prosperity, whether people had
the money to buy alcohol or not. It is important to bear in mind that in
Q68 Dr Stoate: We have been told this morning that alcohol consumption has probably, broadly speaking, fallen steadily from 1700 to 1960, although it has gone back up since then. First of all, how do we know that? Given that people do a lot of informal drinking - they brew their own, they avoid tax, they have moon shining - how do we know what the figures are?
Dr Kneale: Consumption figures in the
Q69 Dr Stoate: We do not know how much of that was illegally produced or not recorded.
Dr Kneale: People have tried to estimate some of those things but actually what is most interesting about the historic panics we have had about alcohol is that they have usually followed periods of free trade legislation which have been designed to get rid of smuggling, for example the gin trouble in the 18th century but also in the early 19th century, opening beer houses was designed to make the running of the alcohol industry more legitimate effectively. Usually we have a fairly good sense - apart from, I think, with things like spirits and wine in the 18th century - of how much was being smuggled and it probably was not very much.
Q70 Dr Stoate: We have also been told this morning that the drinking of alcohol is closely related to prosperity and yet surely prosperity has not been falling from 1700 to 1960, so how come that works?
Dr Kneale: This is the interesting question which is where we are now. If we have seen a similar rise in consumption to the ones that we saw in the 1830s and the 1870s, what happened there is that an initial excitement - which I think was probably down to people's rising wages and real disposable income - got translated into celebration (because in those times if you wished to celebrate you could not guarantee that you would have the money to save for a rainy day so you spent it) and you spent it on things like alcohol. What happened shortly after each of those spikes in the 19th century is that the money goes so in the 1840s people are hard up again or in the 1880s people start to spend their alcohol money on other things, they start to calm down and sober up. So the fall at the beginning of the 20th century is when we see things like holidays available for every family, people spending money on things like cigarettes unfortunately. There were rival attractions. It is not just prosperity, it is changing habits.
Q71 Dr Stoate: That makes sense certainly, but how have the harms of alcohol changed over that time? We are quite interested to hear about these. Obviously we know that consumption is going up rapidly at the moment and we know there are changing patterns of harm, but can you tell us a bit more about how the pattern of harm has changed?
Dr Kneale: I have to admit that I am not strong on the history of alcohol related harms. Most of what I concentrated on - partly because I know the epidemiologists and the other public health specialists you have heard from already are much more knowledgeable about this - are questions of consumption.
Dr Nicholls: We are also dealing with how those harms are recorded and which harms become part of public record. If you look at the literature about the 18th century gin craze you would assume that the harms were to do with public order but they were also to do with damage to the economy, there were a lot of concerns over the economic impact of gin drinking particularly around parental drinking and the impact on unborn children of mothers drinking. There was a perception clearly of harm being passed onto the unborn child and to children in the 18th century, however again it is very difficult to ascertain for certain what the motivation behind identifying those harms was and there were certainly some people saying at the time, "How would a doctor know what the impact on a poor mother was of gin when they would not even attend them giving birth?" We have to be quite careful in saying that we can say for certain what the actual harms were. It is interesting to look at what the perceived harms were. I think that is also important and it does tell us something about the social impact of alcohol, to see what concerns it triggers.
Q72 Stephen Hesford: Just to pick up on what Dr Kneale was saying about the drop in consumption towards the end of the 19th century, there was a big temperance movement around that time; did that have any effect?
Dr Kneale: It did. It became a very complicated movement and a very divided
one, but I think generally over the 19th century the idea that
alcohol carried all kinds of social but also moral hazards as well as health
hazards became firmly entrenched. People tend to assume that temperance failed
because prohibition was not established in
Dr Nicholls: I think it is also an example of where you can look at legislations having an impact on alcohol consumption. There was a select committee in 1834 (which was reported quite heavily in the press at the time and described as the Drunken Committee) which looked at alcohol related issues. Its recommendations at the time were ignored but what it recommended were things like the opening up of public parks, public libraries, the provision of alternative leisure activities for the poor which actually became part of government policy later in the 19th century and it has been argued by some people that it was those provisional alternative recreational opportunities that actually had the biggest impact on the decline in alcohol consumption in the later 19th century and the early 20th century. So I think there is something to be said for the argument not so much the kind of banner waving temperance movement that had an impact but more the impact of the temperance movement on those areas of policy that are not necessarily directed related to alcohol consumption but related to creating a culture in which there are alternatives to drinking.
Q73 Stephen Hesford: Somehow creating some kind of alternative culture.
Dr Nicholls: Yes, and suggesting that there were other things for people to do with their spare time and with their money than simply to go to the pub and to get drunk.
Q74 Stephen Hesford: Does that have any relevance to today?
Dr Nicholls: I think it is difficult because part of the problem today is that we have a limitless palette of alternative leisure activities. I suppose one of the more worrisome features of contemporary society is that one of the alternative leisure activities that young people in particular will undertake as an alternative to drinking alcohol is to take other drugs. There is a wider increasing drug use generally and I think the simple notion that you can create counter attractions nowadays is not as clear as it would have been in the 19th century. There are plenty of counter attractions but that is not to say that we cannot try to engage in a debate about where alcohol sits in our leisure activity and what kinds of drinking and what patterns of levels of drinking are acceptable within that.
Q75 Dr Naysmith: Dr Kneale, I think you are arguing that consumer tastes and cultural factors are the most important influences on alcohol consumption. That might suggest to some people perhaps that the government cannot do very much to change alcohol consumption, yet the government's interventions to restrict alcohol during the First World War did appear to have an effect. How helpful have government interventions been to reduce alcohol consumption historically?
Dr Kneale: I think the most successful interventions have been those which have followed the path of events anyway. During the First World War there was very, very strong government control of production and consumption of alcohol, effectively nationalisation in some areas of outlets. That worked very well but it was at a time when alcohol consumption was declining and really it worked partly because some of the pubs that were opened up in places like Carlisle were very modern establishments which focussed on things like selling food, which tried to encourage people to sit down, to drink slowly and so on. All of those things were things which were happening outside those areas as well, so it was really effective because it tapped into people's desire for more modern, fashionable, clean, efficient environments. Things like the drink driving legislation succeeded extraordinarily well; that is probably the most successful piece of 20th century legislation in terms of alcohol partly because it really hit the public mood. The way people responded to it was to decide that drink driving was dangerous, unjust and a kind of moral failing and it matched people's ideas.
Q76 Dr Naysmith: What do you think we could do now that would work, similar to some of these historical pluses, if any?
Dr Kneale: That is a difficult question. I do not want to suggest that governments cannot lead and only have to follow because I think that policy does obviously affect this. Some of the things we heard about this morning in terms of changing prices, while I am not 100% sure that they would affect the middle drinkers - the people who drink wine at home because they can afford it - I think that some of the other things that were in the Scottish proposals are quite interesting, things like stopping three for two offers and so. I think the general sense that alcohol is cheap is something that has to be changed and there are various policy initiatives to do that. I think that would probably help.
Q77 Stephen Hesford: There is some confusion about the relationship between alcohol price, income and consumption. What is the historical evidence about that?
Dr Kneale: In the past people were probably more sensitive to questions of price partly because incomes were lower but partly because alcohol was a larger part of the household budget for that reason.
Q78 Stephen Hesford: This idea of spending one sixth of your income and that sort of idea?
Dr Kneale: Yes. That figure is now something like 5% or under 5% of the household budget so it is a much smaller amount and is therefore is less significant to people. If we are concerned about fairly affluent drinkers who drink wine at home I cannot see that the minimum price would affect their alcohol budget very strongly so I do not think they would be as sensitive to changes in price. There are a series of examples in the late 20th century where people faced with falling incomes and rising prices chose to drink more extensive drinks, particularly in the 1980s the fashion for strong continental lagers meant that some young men in particular wished to spend more money on strong beers rather than accepting the economic facts and spending less.
Q79 Stephen Hesford: Is that a kind of designer label for beer?
Dr Kneale: Yes, it is about taste and about particular kinds of brands.
Q80 Mr Scott: If you could chose the most effective solutions to alcohol related harm, given historical and cultural influences what would they be?
Dr Nicholls: I think that the way licensing functions is not a decisive factor but I think it is an important one. As has already been pointed out, historically a lot of the periods where you have had spikes in consumption or spikes in concern over anti-social behaviour have tended to follow free trade and laissez-faire approaches to licensing whereby the assumption has been that the right to sell alcohol is a natural right which the government, on a kind of capricious whim, puts some controls onto rather than seeing the right to sell alcohol as being something that should, by definition, be regulated by the state and which is a kind of gift to the individual retailer. Where you have had periods when you have had a free market approach to licensing you tend to get an expansion in the number of outlets, you tend to get an expansion in the consumption. I think that one of the things that happened with the 2003 Licensing Act is that a lot of people focussed on the 24 hour licensing issue. One of the more important features of it was the way the licensing control shifted from magistrates to local authorities which was interesting in principle in terms of giving some popular control over licensing but the regulations that were placed on licensing authorities in terms of the considerations they could give to rejecting licence applications was so strict that it became very difficult for licensing authorities to find grounds for the refusal of licensing applications. Being clearer and more robust in terms of licensing regulations and making it clearer that there are certain rules by which you have to abide in order to acquire a licence has some historical evidence to show that that has had an impact on alcohol related harm. I think focussing on licensing is a very important issue.
Professor Plant: My answer relates to price. There is a scientific consensus of
which bits have been described over the years starting with the government's
own think tank report in 1979 which is classified under the Official Secrets
Act. I have a copy on my shelf because it was leaked, published by the
Dr Kneale: I would agree with Martin that these epidemiological studies do show very important benefits and good consequences of changing price, but the rise in drinking over the last 30 or 40 years is largely something to do with the rising popularity of wine, the importance of off sales, probably supermarkets and that kind of bulk purchasing. It seems to me that while the proposals to do with the minimum unit price will affect off sales more than they would on sales, I really think that supermarkets and off licences probably need more attention, more regulation in some way. I am not entirely sure what that would be, but that seems to me to be the area that needs focussing on.
Q81 Dr Taylor: Professor Plant, you have given us this very stark press release about the study comparing different countries with binge drinking and you tell us that we are the third highest: "Once more UK teenagers reported high levels of binge drinking, intoxication and alcohol-related individual, relationship, sexual and delinquency problems", ranking third just after Bulgaria and the Isle of Man. Why is the teenage drinking culture in this country different from others?
Professor Plant: We started this series of surveys in 1995; these are surveys of 15
and 16 year olds across Europe ranging from Greenland in the West to
Q82 Dr Taylor: So they are attracted to it because of the risks associated with it.
Professor Plant: It all goes as a package deal. There has been a huge change since
the mid-1990s with alcohol consumption amongst young women. When I started
alcohol research in
Q83 Dr Taylor: Absolutely. You would say that young women are being specifically targeted.
Professor Plant: Yes, there is no doubt about this. This is reflected by the fact that the biggest changes in the kinds of things people are drinking. There is a very big increase in wine consumption which largely, although not exclusively, involves young women.
Q84 Dr Taylor: At the age of 17 when driving becomes allowable, does this have an effect? Does it reduce at the age of 17? We have been told that drink driving really is now not culturally acceptable. Has this had any measurable effect?
Professor Plant: Drink driving is far less commonplace than it used to be but there is some evidence of an increase in drink driving amongst young women, still at a very low level compared with what we saw before the legislation. In general people separate out their drinking and driving but we still have hundreds of deaths every year caused by this unfortunately.
Q85 Dr Taylor: So you cannot say that the 16 year olds are experimenting and then when they become a little bit older they lessen the binges.
Professor Plant: Not any more. Teenagers in the
Q86 Dr Taylor: Where are these drinkers getting their alcohol from? Is it getting easier for them to get it in pubs or are they getting the cheap stuff from the supermarkets?
Professor Plant: In the teenagers' survey, because that is related to 15 and 16 year olds, only a minority appear to be drinking in bars and clubs, although some of them are. It is certainly easier for a 16 year old girl to pretend she is 20 than for most 16 year old boys, I think. Teenagers generally drink the cheapest stuff they can get, not alcopops but cheap cider or cheap wine and the obvious source of very, very cheap alcohol at the moment are the supermarkets who are sometimes selling alcohol as a deliberate loss leader. In my own local supermarket, Sainsbury, last time I was there they had two separate alcohol promotions that involved offering people drinks even though almost everybody had driven to get there. There is alcohol at the end of almost every aisle.
Q87 Dr Taylor: You cannot walk into a supermarket without seeing the masses of piles boxes on the way in.
Professor Plant: That is correct.
Q88 Dr Taylor: So you think the pubs are really controlling the under age drinking reasonably well expect the girls who can make themselves look 35 and not 15.
Professor Plant: It varies. There has been some good evidence in places such as Newcastle have had more female bouncers that is an improvement because they are more able to search young women, they are more able to safeguard young women and if young women are getting into problems or feel threatened in any way they are more likely to approach a female bouncer than males who are often seen as rather predatory.
Q89 Dr Taylor: Do female bouncers exist?
Professor Plant: Yes, they do.
Jim Dowd: It is a different world, is it not, Richard.
Q90 Chairman: The licensees are responsible for selling on alcohol to people who may have had too much. What is the difficulty in doing that in a local village pub as opposed to a night club?
Professor Plant: They do it very well in
Q91 Chairman: But it is part of the licence as I understand it.
Professor Plant: Yes, it is a legal obligation which is widely ignored.
Dr Stoate: Even worse than that, I was refused service in
Jim Dowd: But you were drunk as well!
Q92 Dr Stoate: That is not the issue. The issue was that it was extremely well policed and I have to say I was impressed.
Dr Nicholls: There are all sorts of other reasons why the licensees of smaller establishments may want to retain control in terms of the way people drinking in their establishment behave. In some of the larger superbars you have very large numbers of staff who are not necessarily well trained, who are not necessarily very well paid and who have no particular investment in policing behaviour in what is quite a dangerous environment for them. If the behaviour becomes antisocial they have bouncers on the door and they can simply chuck the problem out onto the street where it becomes a police issue. So there is not really that intrinsic motivation for the licensee and for the employees to maintain order in that kind of way. I think that is also another issue that has arisen, particularly from the rise of a particular model of bar which is the bar that is enormous, it is policed by bouncers who occupy an semi-formal world anyway in terms of their status as law enforcement officers. I think there is an issue there about distinguishing between the different types of establishments. One of the problems in the way this has been approached historically is that people look at the issue of drink retailers being fairly homogenous and there are a lot of differentiating factors between different types of establishments which are really important and need to be addressed if you are going to identify the problems, the issues that need dealing with and the issues that possibly do not need dealing with.
Professor Plant: There were some parliamentary inquiries into pubs and trouble in the 19th century. One of my colleagues discovered this and it is interesting when we talk about vertical drinking now in thinking about Weatherspoons and some of their places, the term they used then was perpendicular drinking. It would be worth looking at this because those inquiries took some amazingly detailed evidence about even whether the shape of the bar makes a difference to the level of trouble and harm.
Dr Nicholls: There was also a mass observation, a fantastic piece of research
which involved people in Liverpool where they had perpendicular drinking in the
1940s and bars in
Q93 Jim Dowd: Did they drink faster standing up?
Dr Nicholls: Standing up they drank a lot faster, yes.
Professor Plant: We produced a review recently called Bad Bars and my favourite study is an American one which shows that the speed of the drinking in a bar is inversely related to the speed of the country music being played on the juke box.
Q94 Chairman: It was also about the time on the clock because at about
Dr Nicholls: That was one of the reasons for the introduction of 24 hour licensing.
Q95 Sandra Gidley: Professor Plant, I want to pick up on an answer you gave to Dr Taylor. You said that when young people drink they are much more likely to use drugs.
Professor Plant: The heavier drinkers.
Q96 Sandra Gidley: We hear quite often that cannabis is a gateway drug. Is it actually the case that alcohol is the real gateway drug?
Professor Plant: Yes. In fact there have been a lot of studies for a long time which show that if you look at the heaviest drinkers, heaviest drug users, heaviest smokers, usually they begin their career of experimentation with what is most readily available, which is usually alcohol. The ESPAD study has a lot of fairly complicated findings but most of these teenagers reported that the first drug they ever tried was alcohol followed closely by tobacco. Very often glues and solvents are on the list as well because they are much easier to get at. A lot of British teenagers see drugs like cannabis as fairly easy to obtain although drug use across the European teenage group, including ours, has gone down quite a bit over the period since 1995 when we have been running these surveys.
Q97 Sandra
Gidley: Coming back to the survey, the EU
data shows that around a quarter of deaths in young mean and a sixth in young
women are alcohol related. That seems quite a lot. Is that the same pattern for
the
Professor Plant: I forget the figures but what our ESPAD survey showed was that even in a representative group of normal teenagers, 26% reported having had an alcohol injury or accident in the previous year and a third reported being admitted to hospital (usually, again, that was because they had hurt themselves rather than because they had a chronic illness). It is not difficult to find teenagers who have damaged themselves somehow, usually through drinking a lot on a Friday night or a Saturday night.
Q98 Sandra Gidley: When it comes to deaths from alcohol, is that usually ----
Professor Plant: Fortunately there are not too many of those amongst the younger group. We did a study years ago looking at primary school children and very few of those come to grief unless it is through some kind of overdose which could just as well be alcohol or Domestos. Amongst teenagers road traffic accidents combined with alcohol is a big part of the sum total.
Q99 Sandra Gidley: Other than early mortality, are there any other effects of our current teenage drinking patterns?
Professor Plant: The kind of adverse consequences that teenagers report are having had unplanned sex that they have subsequently regretted, having had unprotected sex, been in fights or arguments fuelled by their own drinking and damaging their relationships with friends or parents. Those are the most common.
Q100 Sandra
Gidley: Is that the same in the
Professor Plant: I am afraid the
Q101 Sandra Gidley: So it is more of the same or is there a different distribution?
Professor Plant: It is more of the same. In fact there are huge difference across
Europe from very levels of almost everything in
Q102 Jim Dowd: Just to follow up that point, to most people who do not follow motor cycle racing the Isle of Man seems like an odd kind of oasis of calm in the world and yet it appears in this study with astonishing regularity as having problems with alcohol and certainly illicit drugs. Do you have any insight into this?
Professor Plant: The
Q103 Jim Dowd: It is a large village really.
Professor Plant: With very limited social amenities.
Q104 Jim
Dowd: The problem of binge drinking in the
Professor Plant: Some of the most visible problems are in towns and city centres,
but in ESPAD we have looked at whether rural areas have different patterns of
teenage drinking, smoking or drug use from other places and the only difference
we have found is that teenagers in towns are more likely to use ecstasy. Teenagers
in the country are just as much likely to drink heavily; they may be going into
the nearest larger place to do it at the weekend. What we do know is that
teenagers across the country are typically getting alcohol from supermarkets
and beginning their evening drinking cheaply at their house or somebody else's.
The Canadians call this "pre-drinking"; in
Dr Nicholls: I think one of the issues is that if all you do is look at newspaper reports and news reports on binge drinking you would think that the issue is young men and women in city centre high streets punching each other or staggering round drunk. That is partly because of the way that it is reported and you do not tend to get binge drinking stories with a photo of a supermarket shelf; it is just not an interesting photograph. I think that the perception of where binge drinking happens or the harms that are associated with it or who is responsible for those harms is driven largely by people's perception that is based on the way it is represented in the media.
Q105 Jim
Dowd: Journalists reporting on excessive
drinking I think is a rather difficult relationship. On
Professor Plant: Scandinavian countries, because they have adopted a fairly
restricted alcohol policy, have kept their consumption down and their
mortality, their health damage and, to some extent, their criminal justice
problems are lower than in the
Q106 Jim Dowd: Is that because of the price or is that just what is done?
Professor Plant: Traditionally it was the price but actually the Scandinavian's tendency to use taxation to keep the problems down has worked reasonably well.
Q107 Chairman: Are some of these issues about reported problems with young binge drinkers, town centres versus rural areas, to do with the way that planning laws have been forcing entertainment into town and city centres to keep them alive and, as a consequence, they are the ones who are spilling out at two o'clock in the morning having had quite an alcohol fuelled few hours?
Dr Nicholls: One of the most significant historical shifts that occurred in the 1990s was that for the first time municipal local authorities, rather than seeing drinking as a leisure activity which they were responsible for regulating with more or less strength, they started to see the promotion of the night time economy as being central to their economic planning. That is a genuinely significant historical change. The question of the extent to which that has actually impacted on consumption is slightly more difficult again because I think the focus tends to be very much on what is a very visible problem of city centres. There are other issues beneath the radar as it were, but I think certainly in terms of the perception of the problem in terms of antisocial behaviour, and in terms of creating a culture in which the social norms and expectations that young people are immersed into when they are very young is that they see images all around of slightly older people getting drunk in a particular kind of a way. There is a real shift there historically, a kind of understandable one in some ways in that the local planning authorities in the early 1990s were faced with a bit of a conundrum as to what to do with their city centres and it did appear that if you could go down the path of the continental café (if you look at Barcelona you can say that Barcelona managed to regenerate itself and it has a 24 hour night life, a vibrant nightlife and so on) it is kind of understandable in a way that that decision was made but that was combined at the same time with the entry into the market of very powerful multinational retail operations who were opening a lot of these establishments. So you had a kind of relaxation of licensing controls combined with the entry into the market of very powerful retailers and I think the unexpected consequence is what we see now in our high streets.
Dr Kneale: At the same time people were increasingly drinking from
supermarkets. They might have been pre-loading and going out to these sorts of
city centre places but I think in 1975 90% of all beer consumed in
Dr Nicholls: If you look at the most recent statistics at the Office of National Statistics from last year you look at where people report having had their most heavy drinking occasion in the last week and in most cases, over the age of 25, it is at home. That is where the heavy drinking is taking place. Even for people between the age of 18 and 25 it is still a significant proportion who are drinking at home. Given that this is self-reported the free drinking is liable possibly not to get recorded on that because you may start drinking at home but then perceive yourself as having your most heavy drinking occasion in a pub. I think that is another thing to look at in terms of the distinction between home drinking and drinking in pubs.
Chairman: Could I thank all three of you very much indeed for coming to help us. Could I also thank you for the written evidence that has been sent which has been published. I do not know when this inquiry is going to end or in what state it will be, but hopefully it will be as sober as when it started. Thank you very much indeed.