Friday, 24 July 2015

The middle class drink epidemic

 With alcohol consumption falling every year for over a decade it is becoming increasingly difficult to sustain the myth that Britain is in the grips of a drinking epidemic, but where there’s a will there’s a way. One method is to focus on whichever group is drinking the most. Even though everybody is drinking less, some people are bound to be drinking more than others and that means scary headlines. Inconveniently for the doom-mongerers, the people who are drinking the most happen to be the middle-aged and middle class. It would be a better story if the heaviest drinkers were the tired, the poor and the huddled masses yearning to breathe free, but the evidence clearly shows that they are the white collar professionals. In Britain, people in the top social class consume an average of 15 units of alcohol per week while people in the lowest social class only consume 10.

And so, after an admittedly slow news day, several national newspapers have led with the story - such as it is - of reasonably wealthy people drinking bottles of wine. Or, as the Daily Mail’s front page put it, the ‘Middle Class Drink Epidemic’. ‘Successful middle classes suffering crisis in alcohol abuse’ was The Times’ front page headline while The Telegraph led with ‘Middle classes most at risk from drinking’.

The hook for all this is a study (in reality, a glorified survey) published in BMJ Open which found that successful, wealthy, middle class people over the age of 50 are more likely to exceed the government’s drinking guidelines than their peers. At this point it is customary to point out that you can exceed the guidelines by drinking a glass, or a glass and a half, of wine a day (for women and men respectively), and that the guidelines themselves were ‘plucked out of the air’ in the 1980s. But even if you take the guidelines seriously, exceeding them does not make you a ‘harmful drinker’ or a ‘problem drinker’, as The Times claims in its report. It makes you a mere ‘hazardous drinker’ which is below both in the ladder of risk.

Getting technical definitions wrong is the least of the problems with the reporting of this story. It is simply wrong to claim, as The Telegraph does, that middle class people are ‘most at risk from drinking’. As a class, it is true that they drink the most, but they do not suffer the greatest alcohol-related harm, not by a long shot. The harm disproportionately falls on lower socio-economic groups and they tend to drink the least.

This is what public health researchers call the Alcohol Harm Paradox. Public health researchers call everything a paradox when reality doesn’t bend to accommodate their theories and so, if boozing fails to kill affluent people despite their supposedly hazardous rates of consumption, it doesn’t demonstrate that the guidelines are worthless - heaven forfend! - it is merely a ‘paradox’ that requires more research (ie. more funding).

Alcohol Research UK published a rather inconclusive study about the paradox earlier this year and I’m told that there is more to come. I hope they get to the bottom of it, but I would be surprised if it comes down to much more than two basic problems:

Firstly, the definition of hazardous and harmful drinking is too broad to accurately capture people who are at serious risk of coming to grief. According to the government, there are over 10,000,000 hazardous drinkers and yet there are only 6,000 alcohol-related deaths each year. An annual death rate of 0.06 per cent does not represent much of a hazard.

Secondly, you cannot assume that an arbitrarily defined group of people is going to produce more death and disease than another group merely because their group average exceeds an arbitrary guideline. Why? Because averages tell you nothing about individuals. Yes, people on low incomes drink less than middle class people on average. They don’t have much money and alcohol is a heavily-taxed luxury, but within this group are some people who not only drink very heavily but also have a propensity for other risk-taking behaviours. It should therefore not be surprising that a disproportionate number of alcohol-related hospital admissions and deaths arise in the group that drinks the least. The fact that lots of other poor people bring the group average down by drinking moderately or abstaining is neither here nor there to the low income alcoholic.

We can discuss the reasons why some people at the bottom of the socio-economic ladder turn to drink - and, indeed, why some people who turn to drink end up at the bottom of the socio-economic ladder - but that is not really the point here. The point is that middle class people are not the most at risk from alcohol-related harm, despite drinking more, as a group, on average. Rates of alcohol-related mortality are many times higher in the lowest socio-economic group than in the highest.

It takes a certain amount of self-delusion to look at a group of unusually healthy people and conclude that they are suffering from an ‘epidemic’, and yet the report in The Times includes this timeless gem from a spokesman for Age UK:

‘Because this group is typically healthier than other parts of the older population, they might not realise that what they are doing is putting their health in danger.’

In other words, they might be the healthiest people but according to our calculations they shouldn’t be and so we’re going to pretend that they’re not.

To be fair, Age UK are only taking their cue from the authors of the BMJ Open study who apparently saw no paradox at all when they wrote that the ‘problem of harmful drinking’ is concentrated amongst ‘people in better health’. We are through the looking-glass here, are we not?

Imagine if the results had been different. Imagine that the people (ie. group) who were most likely to be ‘harmful drinkers’ were found to be in the worst health. In those circumstances, it would surely have been reported as proof that exceeding the drinking guidelines is very bad for you. Instead, the study showed the opposite but the band played on regardless.

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