PURITANISM IS A VIRUS – AND IT’S SPREADING!

With minimum unit pricing (MUP) set to be introduced in Scotland in May, the puritans of the health lobby have been emboldened to push this policy out to the rest of the UK. The Welsh Assembly has been debating this issue in recent months and commissioned the Sheffield Alcohol Research Group (SARG) to produce a Welsh version of their model that depicts the effects of MUP at different price levels on consumption, harms and how many lives can be “saved” if MUP is introduced. The SARG research predict 66 lives will be saved a year in Wales if a 50p minimum price is introduced. This assumes that people will respond to the imposition of higher prices in ways that seem implausible to many. One of the persistent criticisms of the SARG model are the assumptions it makes about ‘price elasticities of demand’ – assumptions about how much people will reduce their consumption in response to an increase in price. There are approximately 1,500 alcohol-related deaths a year in Wales so it seems unlikely that it will be possible to measure whether this claim of 66 lives saved annually is fulfilled or not. The media has feigned shock at the claim that 75% of alcohol consumed in Wales is drunk by 22% of the population, who are defined as hazardous or harmful drinkers. And within that number are 3% who are the very heavy drinkers - accounting for 27% of alcohol consumed.  Why this should surprise anyone is beyond me – “Shock, horror – most alcohol is drunk by people who drink the most” is a “dog bites postman moment” and a statement of the blindingly obvious. Let’s put these figures into perspective. About 20% of Welsh adults don’t drink at all. 58% drink at or below the government’s low-risk guideline of 14 units a week (less than a pint of beer a day). So, that’s 78% at no risk or virtually no risk. Only 22% consume more than 14 units a week including 3% “harmful drinkers” – defined as drinking 50+ units a week for men, and 35+ units a week for women. Only in the oddball world of the activist academics of SARG is a person drinking a couple of pints a day classified as a “hazardous drinker”. The focus of harm-prevention really ought to be on the 3% of harmful drinkers, yet the Welsh Government has accepted that minimum pricing won’t help these drinkers, who most likely have an alcohol dependency. MUP is a policy which the Institute for Fiscal Studies has said will raise the price of 70% of off-trade sales. So MUP isn’t targeted at people at greatest risk, but at those who, by the standards recognised by most people, are light to moderate drinkers. MUP isn’t about targeting those most at risk, it’s about denormalising the use of alcohol and pricing it out of reach. The minimum price will only ever go up. Those reading this who are thinking: “Good, about time we bashed Tesco” need to realise three things: Firstly, that denormalising the use of alcohol will affect all sections of the trade. Secondly, making alcohol more expensive in the off-trade may reduce consumption a bit, but it will also reduce consumers’ discretionary spend overall and that is likely to mean less money to spend on going out. The notion that MUP will tip people out of the living room and into the tap room is a health lobby lie. Thirdly, now that the genie of minimum pricing is out of the bottle, how long will it be before government regulators – national or local - apply a higher MUP to the on-trade?

Talking of which: the government in the Isle of Man is now considering introducing MUP. Chief Constable Gary Roberts appeared at the opening of the triennial licensing courts, which sees licensees applying to renew their alcohol permits. Addressing the court, Mr Roberts said a new substance misuse strategy from the government looks likely to introduce a minimum price per unit for alcohol.

He told the licensing bench such a move would “save lives and help the on-licence trade regain its vibrancy.”

The same lies are being perpetrated by health lobby puritans wherever this “silver bullet” policy is proposed. It is always presented as a pub-friendly proposition, when in reality it is the thin end of the wedge. If even a rinky-dink assembly like the Tynwald can introduce this for the off-trade, what odds would you take for it being introduced by the UK Parliament for England – and then spreading to the on-trade, because a city council like Newcastle decides it’s needed to curtail binge drinking in the night-time economy.

For those who think I’m scare-mongering, I have three words: the smoking ban.

BIG TEMPERANCE VS BIG ALCOHOL

The recent announcement of a partnership between Dutch brewing giant Heineken and the Global Fund to Fight AIDS, Tuberculosis and Malaria has drawn a scream of protest from the alcophobe fanatics of Big Temperance. Heineken has agreed to aid the Global Fund by providing its experts on supply chain logistics, to better deliver medicines and health care products to people living in African countries to help the fight against these three major killer diseases.

This has prompted an Open Letter to the Global Fund from IOGT International and over 70 other alcohol health charities and NGOs, calling for the Fund to immediately end its partnership with Big Alcohol. IOGT International is the International Order of Good Templars by another name – an anti-alcohol group with its roots in the nineteenth century temperance movement. IOGT is also a dominant presence in the UK’s Alcohol Health Alliance and had members on the Public Health England committee that fiddled the revised low-risk alcohol drinking guidelines. These are the people leading the fight against Big Alcohol in Africa.

The crux of their argument is that alcohol (not just alcohol abuse) is a major cause of ill-health and that drinking it makes people disinhibited and therefore more likely to have unprotected sex, leading to more HIV/AIDS infections, so a big conflict of interest, they claim, between the Global Fund and Heineken. But this argument is a mere smokescreen for people who think it more important to stop the spread of alcohol use than the spread of AIDS, TB and malaria.

The Global Fund gets 95 per cent of its revenue from governments – taxpayers - around the world. Only 5 per cent comes from private donations, including companies. They administer a $4 billion annual budget. Any sensible person would welcome the help of a wealthy global brewer. To be sure, this is not entirely an act of selfless philanthropy, Heineken want to sell their products in Africa and to present themselves to African governments’ as good corporate citizens. But there is a powerful reason, from a health perspective, why Heineken and other global drinks’ producers should be encouraged to make their products more widely available in African countries, and at a price local people can afford. That reason can be summed up in one word: moonshine.

Anyone who knows anything about alcohol abuse in Africa will tell you that the problem is not the legal market for well-known brands, which many Africans can’t afford anyway, but the illegal market for moonshine. Every year, countless numbers of Africans risk their health and their lives drinking illegal alcohol. The illicit brewing market in Africa is worth an estimated $3.5bn a year. With names like “Kill me quick”, “The dog that bites” and “Goodbye Mum”, African moonshine has a frightening reputation.

Over the years, thousands of Africans have been killed, blinded or rendered sterile by drinking these lethal concoctions. In one of the worst recorded cases, 128 Kenyans died and a further 400 were harmed after drinking a particularly poisonous batch of illicit booze.

In Libya, where alcohol has been banned since early in Gaddafi’s rule, a bottle of Chivas Regal can cost more than $100, so Libyans drink a local concoction called “bokha”. There was recently a major health crisis related to poisoned bokha. Someone had added methanol to a batch and some 1,500 patients flooded into Tripoli’s hospitals within a few days.

The World Health Organisation says that about half of all the alcohol drunk in sub-Saharan Africa is produced illegally, with 85% of consumption in Kenya and 90% in Tanzania coming from the illicit market.

Barley, the essential ingredient in beer, is still not grown in many parts of Africa. High taxes and poor supply chains have also pushed up the price of legitimate goods. Toxic homebrew plugs the gap in the market. Africa's booming cottage industry is made up of clandestine breweries, where maize and sorghum is fermented, using water that itself is often filthy. The alcohol content is bolstered, using anything from embalming fluid to stolen jet fuel. The resulting grog may sell for as little as 20 US cents a glass. But for the poorest Africans, living on a couple of dollars a day, it is often the only way of blotting out their troubles.

This is the folly of trying to ban legal means of accessing properly produced, quality-controlled beverage alcohol products. All that happens is that the demand is met by illicit supply of poisonous concoctions that can kill or blind people on the spot.

And yet IOGT and its virtue-signalling fellow-travellers are worried about Africans knocking-back a pint of Heineken’s lager!

DRINKING BY NUMBERS

As the ‘public health’ hysteria over alcohol and the clamour for minimum pricing in England continues, it’s useful to get an overview of the issues by looking at some straight statistics. I increasingly think that the Office for National Statistics (ONS) is an oasis of calm objectivity in a sea of opinionated, emotionalised subjectivity emanating from alcophobic activists. So, I’ve been looking at stats published in 2017 by NHS England which are based mainly on ONS data and some from Public Health England.

What do these numbers tell us about alcohol use and abuse and its consequences? First, the much-vexed question of alcohol-related hospital admissions: there were 339 thousand such admissions in England, representing just 2.1% of all hospital admissions - which has changed little in the last 10 years. This statistic is a measure of the number of hospital admissions where an alcohol-related disease, injury or condition was the primary reason for the admission, or where it was a secondary diagnosis related to an external cause, e.g., an alcohol-fuelled fight. This is known as the “narrow measure” of alcohol-related hospital admissions; it is a record of “admission episodes” – not people admitted, which is a much lower figure.

The so-called “broad measure” records 1.1 million admissions, but includes primary diagnoses plus admissions where an alcohol-related condition was a secondary diagnosis, i.e., not the reason for the admission. The important distinction between the two measures is that the narrow measure is a count of actual admissions to hospital for an alcohol-related cause, whereas the broad measure includes that count, but provides further information about alcohol-related conditions that a patient may have had in addition to the reason for their admission. This provides an indication of the health burden that alcohol misuse has across the whole population. Newspaper headlines often confuse the two to create alarmist headlines.

So, 2.1% of hospital admissions caused by alcohol misuse isn’t a crisis, it isn’t growing like topsy, and it won’t bankrupt the NHS.

In 2015 there were 6,813 deaths that were related to the consumption of alcohol, 65% of which were for alcoholic liver disease (4,428). Alcoholic liver disease sufferers drink at the very top end of the harmful drinkers’ spectrum. Harmful drinkers are classified as men drinking over 50 units a week, or women drinking over 35 units a week. Most of those dying from alcoholic liver disease drink around 200 units of alcohol a week or more – the equivalent of a bottle of scotch a day. Every one of these deaths is an avoidable tragedy, but just over 25 million adults in England drink alcohol at least once a week, so harmful drinking and deaths from it arise from the product being abused by a very small minority.

The number of adults in England who report drinking alcohol in the previous week has fallen from 64% in 2006 to 57% in 2016 – a fall of nearly 11%. The UK ranks 19^th out of 31 countries in terms of annual alcohol consumption per head at just over 9 litres. 

THE ARCHITECTURE OF CHOICE

Old ideas are sometimes relaunched by employing a new language to disguise or mystify what they’re about. And so it is with puritanism. There’s no doubt that we’re seeing a resurgence of puritanism in a variety of disguised forms. The essence of puritanism is that pleasure is bad for you. Since many of our pleasures involve consuming things, this translates into consumption is bad for you. The locus of puritanical concern has, of course, been alcohol, and latterly processed foods with a high content of salt and sugar. And sugary drinks have also featured recently, with the introduction of a sugar tax looming many producers are reformulating their products – Irn Bru and Ribena seem to be getting a lot of attention on Twitter!

So, what’s behind this? What the New Puritans of Public Health want is to alter “the architecture of choice”, to nudge or coerce consumers into making ‘healthy choices’. The argument goes like this: people make free choices about whether to buy products in a market place, but are these choices really free? If products like alcohol, fizzy drinks and highly processed foods are everywhere available, then people are exercising their freedom to choose in an ‘intoxogenic’ and ‘obesogenic’ environment. In other words, free choice is exercised within a deterministic framework which the person making the choice cannot influence. And anyway, the argument goes, cunning marketing and advertising makes people buy things they don’t need by persuading them to want them!

I sometimes think that public health puritans live in a parallel universe. What they term the intoxogenic and obesogenic environment is merely the retail distribution system by another name. And since all of us are born into a society that existed before we did, and will exist after we’re gone, all choice is exercised within a deterministic framework.

So, how do public health puritans plan to alter the architecture of choice? Taking alcohol as an example, their measures include raising alcohol duty by more than inflation every year and introducing minimum unit pricing (MUP) – these are measures which reduce affordability, or “economic availability” as they often call it. In addition, they propose changes to the way in which the retail distribution system handles the product. This has been tried elsewhere, for example, in Australia you can’t buy alcohol from supermarkets, only from separate liquor stores. The same applies in Canada where most liquor stores are owned and operated by the government. Effectively the off-trade is a nationalised industry. In Scotland, where MUP will be introduced on the 1^st May, there are demands being made to have separate alcohol aisles and checkouts for alcohol in supermarkets.

All these attempts at reconstructing the architecture of choice either make people poorer by raising prices, or they make shopping a more inconvenient and miserable experience. The likely effect will be to drive such sales online. So, changing the architecture of choice really means taking choice away or making it more expensive and more inconvenient. All in the name of healthy choices.

At some point I think there will be a consumer rebellion against this. The Institute for Fiscal Studies estimates that MUP at 50p in Scotland will have a dramatic impact on prices. Some cider products will rise in price by as much as 90% and 70% of the alcohol units bought in the off-trade will see prices rise.

Will these price rises tip people out of the living room and into the tap room? The Scottish Licensed Trade Association certainly think so. They’ve been campaigning for government price intervention in the off-trade since the abolition of resale price maintenance in 1964. But it is simplistic to think that the price of alcohol is the only, or even the main thing that determines peoples’ decisions about whether to stay in or go out, and that the supermarket is the enemy of the on-trade. This is just crude Tesco-bashing and it ignores the fact that society has changed beyond recognition from the mid-1960s. Satellite TV, Netflix, computer games, the huge development of fast-food home delivery – all these things have transformed the home into a place to escape to, not from. It’s easy to get caught up in fighting yesterday’s battles whilst turning a blind eye to the complexities of the modern world.

I am aware of the problem of pre-loading, but I think this is more a product of later closing than cheap supermarket booze. And there is a new enemy on the horizon – one that threatens both sides of the trade: a puritanical public health lobby that is happy to drive a wedge between the on-trade and the off-trade. We can speculate whether MUP will or will not shift drinking back towards the pub and the bar, but we will know for certain whether this is the case in Scotland within the next 12 months.

STRAIGHT STATISTICS MATTER

In my last article I launched the CPL Nanny State Annual Awards for Fake News and Phoney Statistics. Several people contacted me and asked was this tongue-in-cheek, and did misleading statistics really matter, given the environment in which we live where information on social media sites like Twitter have a shelf-life attuned to the concentration span of a mouse. The answer is that whilst our awards night will be light-hearted and enjoyable, the impact of fake news and phoney statistics can be very serious indeed.

As an example, take the now-infamous quote from Professor Dame Sally Davies, England’s Chief Medical Officer of Health: “There is no safe level of alcohol consumption.” And to illustrate the point she asks women to consider: “Do I want that glass of wine or do I want to raise my own risk of breast cancer?” Notwithstanding the fact that she meant to say: “Do I want that glass of wine or do I want to avoid raising my risk of breast cancer?” it is the alarmist and misleading nature of the warning that is so damaging.

I am very sensitive to the emotional nature of anything connected with cancer, because it touches the lives of almost every family in the country, including my own. But let me explain why Professor Davies’ quotes are so misleading and why they raise women drinkers’ concerns unjustifiably.

Firstly, the implication is that one glass of wine a day will raise a female drinkers risk of breast cancer, and to most people that means raising their risk of dying from it because in the popular imagination cancer = death. The good news is that If you are a middle-aged woman you have just a 0.3% chance of contracting and then dying from breast cancer over the next decade. And this chance is the same whether you drink alcohol or not. There is slightly more chance that as a light-to-moderate drinker your eventual and inevitable death will be from breast cancer, but only because light-to-moderate drinkers are much less likely to die prematurely from heart disease, and you must die from something, eventually.

An analysis of various causes of death of middle-aged and elderly Americans (Thun et al 1997) found that, of the 251,420 women in the study, 0.3% of the non-drinkers and very light drinkers died from breast cancer, over the 10 years of the study’s duration. And the same percentage applied to the moderate to heavy drinkers. These were women drinking 1 to 4 standard drinks a day. In America a ‘standard drink’ is about 14 grams of undiluted alcohol, so approximately 1.4 units. So, a woman drinking 1 to 4 standard drinks is drinking between 1.4 to 5.6 units of alcohol a day and has the same chance of contracting and dying from breast cancer as that of a non-drinker.

In a smaller mortality study (35,000 women, Fuchs et al 1995) the chance of death from breast cancer during the 12-year follow-up period was 0.4%, and this was identical for non-to-light drinkers and moderate-to-heavy drinkers. And again, crucially, there was a much higher chance of death from cardiovascular disease among the non-drinkers.

Reading all this confused me somewhat. I was sure that there were numerous population studies that showed drinkers had a one percentile higher chance of getting breast cancer (from just under 10% lifetime risk to just over 10%), and there are, but these are studies of “incidence” (how many women are diagnosed) not studies of mortality (how many women die). So, women who drink alcohol have a slightly higher chance of being diagnosed with breast cancer, but if they are, they have slightly less chance of dying from it. That didn’t seem to make sense. So, I did a bit more research. It turns out that around 90% of women who are diagnosed with breast cancer don’t die from it, partly because medical science cures many of them, but also because many of the diagnoses are incorrect. Research also shows that women who drink alcohol are more likely to screen more for breast cancer than non-drinkers (Mu and Mukamal 2016), so you would expect them to be disproportionately represented in the diagnostic figures arising from screening activity. So, the link between drinking and the incidence of breast cancer is a statistical correlation, not a causal link – it is, in fact a self-fulfilling prophecy.

So, here’s what Professor Dame Sally Davies should have said: “When asking ‘do I want that glass of wine, or should I not drink at all’, women should balance a slightly elevated risk of getting breast cancer, which may be explained by the fact that drinkers are more likely to screen for it, with the actual elevated risk of cardiovascular disease associated with not drinking at all.”

This is why straight statistics matter.