Wednesday 21 September 2011

Some real research into alcohol

In August, former British Medical Journal editor Richard Smith discussed an encounter with two sociologists. The topic of discussion was 'binge-drinking' and the role of parents. One of the sociologists was his daughter. She was unsurprisingly against "tough love" from parents. The other was this person:

A much older sociologist at the lunch said that it was fashionable to blame parents for everything and that there wasn’t good evidence of the influence of parenting.

This sentence tells you quite a lot about sociologists. It might help explain why sociology is treated with such disdain by a large section of the public (unfairly, IMHO). It is, I think, blindingly obvious that the people who raise you have a profound influence on your character, prospects and behaviour. If "older sociologists" dispute this it is perhaps because their horizons have never extended much beyond school and university. (There is an amusing video of a sociologist describing her experience of going to Las Vegas after the American Sociological Association accidentally held their annual convention there.)

More importantly, ideological axe-grinders—of whom there are many in sociology—like to blame problems on things that they can change by force of law. Why focus on important but complex issues like parenting and education when you can focus on simple but trivial issues like advertising and pricing?

Activists, neo-prohibitionists and anti-capitalists are much happier blaming the corporations and the institutions, man, than looking at the real factors behind excessive drinking and alcoholism.

I dislike and distrust 'alcohol control' partly because I put a high value on freedom but also because I strongly believe that their broadbrush stategy is ineffective, costly and harmful, since it ignores the real issues. It is a neo-prohibitionist population-level response when it should be a targeted response to the minority who need help.

Considering how implausible it is that corporations could mould minds in ways that friends and family cannot, it is remarkable how entrenched is the view that parenting has only a minor influence on behaviour. Both nature (genetics) and nurture (parenting) have been downplayed in academia since the 1960s to such an extent that when the Joseph Rowntree Foundation (JRF) found that family and friends are the biggest influence on drinking behaviour, they described it as an "inconvenient truth".

JRF have produced successive reports showing the same thing, most recently in June when they reported that "family and friends have a strong influence on teenagers’ drinking patterns, and are stronger influences than some other factors – such as individual well-being, celebrity figures and the media."

Well, duh, you may say. Even so, the temperance lobby managed to harness the findings for their own ends (as the Quaker teetotaller Joseph Rowntree would no doubt have wished). The ubiquitous Don Shenker said...

"Government ministers must also look at some of the causes of why it is so easy for children to obtain alcohol, usually from the home.

"Government should look to see if they've done everything they can to stop the large supermarkets from continuing to heavily promote cheap alcohol which incentivises more alcohol purchases and therefore results in more alcohol being stored in the home, blah, blah, blah..."

Note how he takes a report that discusses a deep-rooted social factor and turns it into an issue about access and pricing. It's no accident that this guy is in the lobbying business. He's good at it.

Since then, the think-tank Demos has produced a report which broadly echoes JRF's findings, but using a more sophisticated methodology and coming to a more sophisticated conclusion. JRF found a link between parent's drinking habits and those of their offspring, whereas Demos found the link with the particular types of parenting. 'Tough love', they say, is the best way to bring up a child. 'Disengaged' is the worse.

None of this should be a great surprise, as one of its authors, Jamie Bartlett, said:

This is quite intuitive. It does not mean parenting is the 'cause' of binge-drinking, as some reports have put it, or that it is the only factor. But it is important.

Note that Bartlett, unlike certain advocacy groups, has the integrity not to shout 'causation' here, even though the associations being reported are stronger than any epidemiological finding you'll read about this month.

The risk of excessive drinking at age 16 is 8.36 (836 per cent) times higher if a child’s parent has a ‘disengaged’ parenting style rather than one of ‘tough love’.

The whole report, which is now available to download, exhibits a degree of academic rigour that is rarely displayed by partisan groups and is frequently absent in the peer-reviewed literature (sadly, these two elements frequently merge together). This is a credit to Demos—and a vindication of think-tanks, which George Monbiot ludicrously believes are "crushing democracy" (because democracy would be so much better served if the people George doesn't like were silenced)—but it is also an indictment of the state of research into this, and other, contentious topics. There is a refreshing absence of an a priori conclusion in this report and, almost uniquely amongst the current literature, there are no policy demands. It's difficult to imagine now, but there was a time when ending an academic study with a political call-to-arms would have been viewed as crass and unprofessional. Demos's report takes us back to those good old days when there was a division between science and politics.

What is striking is how many unspoken facts are laid out openly from the start. Many of them are the kind of things I've been saying on this blog and elsewhere for some time. They are the facts that do not get aired on Panorama or in the newspapers.

On alcohol consumption, for example:

In strictly medical terms, binge-drinking in the UK – as measured as more than twice the recommended daily allowance of alcohol consumed in a single episode – has been falling for at least five years in a row, and is not significantly higher than in other European countries.

Indeed it has. And, as I have said before, alcohol consumption in Britain today is unexceptional both in historical terms and in relation to other wealthy nations...

UK per capita alcohol consumption is unremarkable by comparison with other countries of a comparable size and income level, and well below historic levels in the eighteenth or very early twentieth century. Moreover, the majority of the population either do not drink, or do it within the government’s lower risk limit.

There are a couple of points with which I disagree. For example...

Unfortunately, there has been a marked increase in the number of people who are unconcerned by the long-term health effects of their behaviour – and even their immediate personal safety.

I have not heard this claim before and I am not at all convinced that it is true. The reference they give does not seem to support the assertion that people are less concerned about their health and safety than previous generations. There may be research elsewhere showing this, but my own, admittedly jaded and anecdotal, view is that the people are more obsessed with long-term health and safety than ever before.

I also think the following statistic could have been treated with greater scepticism: 

There has been a steady increase in reported alcohol-related hospital admissions over the last decade. In 2009/10 there were 1.1 million admissions related to alcohol, which was an increase of 12 per cent on the previous year and around double the number in 2002/03, when there were 510,200 admissions. However, it is to be noted that the majority of alcohol-related admissions were older people, likely to be suffering from long-term alcohol misuse.

It is certainly true that the majority were old, and often very old, people. Whether they were suffering from long-term alcohol misuse is more questionable. As this eye-opening article by Nigel Hawkes explained, 'alcohol-related' hospital admissions are estimates of the crudest variety. Admissions figures are added up and then large percentages are hived off and designated 'alcohol-related'. More than half of the so-called 'alcohol-related admissions' are for hypertension and heart palpitations, and the definition of 'alcohol-related' has been expanded to such an extent in the last decade that I see the figures as being essentially useless. What we are seeing is an increase in old people going to hospital for various reasons. Tellingly, the proportion of admissions that are 'alcohol-related' has barely changed over this period. The very fact that alcohol-related hospital admissions have doubled in a decade, at a time when alcohol consumption has been falling should make us ask serious questions about the reliability of these data.

What, then, is the problem with British drinking habits? It is not one of overall alcohol consumption in the general population, but of the behavior of a minority.

However, the last decade has seen changes to the way people drink. A small, but possibly growing, number of young adults in the UK is drinking to extreme excess, often in an intentionally reckless and very public way, putting themselves and others at risk of harm – and causing considerable social and financial cost.

How much this has changed in the last decade, it is difficult to say. As the authors indicate, it is not clear whether the number of people drinking to "extreme excess" has risen at all. There is more than a hint that our recent obsession with 'binge-drinking' falls under that most useful of sociological terms, the moral panic.

With more people going to university, more disposable income, people marrying later and having children later, there are very plausible socio-economic reasons for drinking and 'binge-drinking' to be on the rise. Alcohol consumption is undoubtedly higher now than it was fifty years ago, though not higher than 100 years ago. There is also evidence of greater drunkenness than in most other countries.

The UK consumption average for a single drinking episode is the highest in Europe, and the drinkers in the UK have the fourth highest average number of drinks per day overall.

I suspect it was always thus. Northern European drinking habits and all that. But, again, this is not a question of overall alcohol consumption so much as patterns of alcohol consumption. It would be helpful if we could ditch the silly term 'binge-drinking' and return to calling it drunkenness. Or at least tipsiness, for that is all you need to be to meet the ludicrous modern definition of 'binge-drinking'.

That being the case, we believe the task at hand, and the proportionate and liberal response to binge-drinking, is to help create an environment in which people are free to drink alcohol – but behave in a responsible manner when they do.

But what, if anything, can be done? I have always maintained that pricing has the least effect on the people who most need to be targeted. (Exhibit one: the homeless.) This seems to be borne out by the data.

One study by the Centre for Economics and Business Research (CEBR) found that heavy drinkers are in fact likely to be the least responsive to changes in price, meaning a minimum unit price of 50 pence per unit would reduce alcohol consumption by harmful drinkers by a very small amount: around two pints of beer per week.

Sin taxes are highly regressive. It is always fascinating to see supposed left-wingers supporting regressive taxation when 'vices' are concerned, despite conclusive evidence that they widen inequality and exacerbate poverty.

The distributional impacts of minimum pricing are heavily contested, and have been questioned by a recent report by the CEBR, which argues that minimum pricing is a regressive measure because people on lower incomes typically pay more as a proportion of their income on alcohol, and will therefore be the most affected.

And if pricing really made a difference, we would expect countries which have the highest alcohol taxes—such as the UK—to have the lowest rates of binge-drinking.

The evidence on how minimum pricing would affect binge-drinking is not conclusive. Countries where excise tax on alcohol is very high also have very high levels of consumption.

In other words, the real-life evidence suggests that minimum pricing would be a futile and counterproductive endeavour. The real drivers of hazardous drinking are not price or advertising, but factors which are beyond the reach of government, and therefore of little interest to those who demand remedial legislation.

It appears that although not the only determinant of drinking behaviour among young people, parenting can and does have a dramatic effect on it. Good parenting has positive effects on young people’s drinking behaviour and there is indirect evidence that it builds the kinds of personal qualities and relationships that guard against risky behaviour in general. If there is an optimal parenting style for reducing the risks of early and excessive binge-drinking, it is the tough love, authoritative style cited above.

There is more to this report than a message of 'blame the parents'. It is rather more nuanced than that—go read the rest to see why—but nurture is clearly very important and should not be a surprise to those of us who are not "older sociologists".

Insofar as alcohol is a problem in society, it is a problem of public order and—for a small minority—an issue of addiction and health. In my experience, people who behave like idiots when drunk are idiots when sober. Drunkenness may bring this to the fore, but it is the underlying lack of respect and self-restraint that is the real problem. The nanny state panders to, and encourages, the irresponsibility and indiscipline that is at the heart of the problem. Don't blame the drug (alcohol) for these people. Blame them and, if you wish, blame their parents. As Frank Zappa once said: "A drug is not bad. A drug is a chemical compound. The problem comes in when people who take drugs treat them like a license to behave like an asshole."

Britain has more than its fair share of assholes (these are now my views, not those of Demos, BTW). From my travels to other countries, I regard this as an incontrovertible fact. You can argue about why this is so until the cows come home. As the wildly differing reactions to the London riots demonstrated, your opinion will probably be coloured by your political views. Whatever they are, you would probably agree that the causes are complex and deep-rooted. The temperance lobby, however, portray the problem as simple, political and easy to remedy through legislation. Most of what is written about alcohol is designed to further this legislative agenda, whether on the Alcohol Concern website or in the pages of The Lancet. Politically motivated junk science takes us further from the truth and further from real answers. Demos has produced a report which looks at the issue more thoughtfully and, though it will probably be ignored by the public health lobby, it is a valuable contribution to serious discussion.


Mark Wadsworth said...

I've been doing real research into alcohol for nearly thirty years, and on the basis of first hand experience, can confirm that it's still bloody great.

Can I get funding somehow to continue my monitoring programme?

Richard H. said...

Great post Chris. I am a 58yr old male born and raised in the U.S. I have been a working professional in the field of alcohol and drug addiction for the past 28yrs. Prior to that I spent approx. 15yrs in "intensive" personal "field work" concerning alcohol and drugs.
Although my experience is entirely in the U.S. I would guess it is fairly similar in the U.K.
and that is this: despite all the years of research, all the plethora of testing, medications, treatment modalities, educational programs etc. the facts have remained fairly stable (contrary to what the nannies say) that somewhere between 18 to 23% of the population has a definitive alcohol problem. Which of course means that roughly 80% of the population uses alcohol responsibly (and a percentage of that 80% does not drink at all).
So all the tax hikes, price hikes, increases in legal sanctions, etc. only serve to wrongfully punish those people who use alcohol responsibly and does precious little, if anything to those who abuse it.
And, ignoring or minimizing parenting, education and upbringing in general is a collosal mistake and I would bet, as you suggested, serves other purposes.

Anonymous said...

In the mid 60's when I was a teenager and at work I used to go out every Friday and Saturday night to parties and pubs with friends and we ALL got 'drunk'.
Was that binge drinking ?
Times have not changed one bit as in the 80's my kids did the exact same and now my Grandkids are doing the self same thing that their parents and Grandparents did when they were in their teens.

dearieme said...

"It is, I think, blindingly obvious that the people who raise you have a profound influence on your character, prospects and behaviour". But it's blindingly obvious that the sun goes round the earth. If memory serves there is American evidence that is interpreted as implying that children tend to be much more influenced by their "peers" than by their parents. It's my instinct that it might well be wrong, but I have no evidence to put against it - and it would be consistent with the "Mass Society"/conformist aspects of American life that so often strike foreigners.