Thursday 26 September 2013

Seven supposed myths

I said on Twitter that I'd reply to this post by Dirk Hanson which claims to bust seven alcohol industry 'myths'. It is based on a passage from David Nutt's recent book Drugs Without the Hot Air. I haven't read that book yet but it doesn't surprise me to hear that he spends lots of time preaching against alcohol because that's what he always ends up doing.

Regular readers will know that I have mixed feelings about Professor Nutt. Some of what his says about drugs is sound, but his desire to be seen as the man who evaluates drugs in a cerebral, impartial and evidence-based manner is undermined by his frequent emotional and evidence-free outbursts.

So, the 'myths' are as follows:

1. Consuming Alcohol is Normal

87 per cent of the UK population drink alcohol. Virtually every society in the world has found a way to brew alcohol from some fruit or vegetable for thousands of years. Alcohol is deeply imbedded in all sorts of cultural and religious events from communion to Oktoberfest. It is a versatile drug that enriches people's lives in all sorts of contexts. All this has come about without the help of an alcohol 'industry' or advertising, because people very much enjoy drinking. Alcohol is normal.

It’s normal, so long as you have the “normal” high-activity variant of the ALDH2 enzyme. If you don’t have that form of the enzyme, Nutt reminds his readers, as many Asians and Aleuts do not, then alcohol will affect you quite non-normally through the so-called alcohol flush reaction. Moreover, many cultures and societies unfamiliar with its effects “suffer hugely when new types of alcohol appear, particularly if they are aggressively marketed.”

None of this changes what I have written above. It does not bust a 'myth'. It is, at best, a footnote that applies to some people from Asia and Alaska.

2. Alcohol damage is caused by a small group of deviants: According to Dr. Nutt, statistics show that “millions of people, NOT a tiny minority, suffer harm from their own alcohol consumption, or cause harm to others…. It is the everyday drinking of people who have come to see alcohol as an essential part of life rather than the luxury it used to be, that has created a spike in cancers and stomach problems, and will see liver disease match heart disease as the leading cause of death in the UK by 2020.”

In 2011, 4,765 people in England and Wales died from alcoholic liver disease. Other forms of liver disease (ie. not alcohol-related) killed 7,731 people. Meanwhile, 108,000 died from heart disease. 30,000 died from lung cancer. 11,390 died in accidents. 26,000 died from pneumonia. There is no chance at all that liver disease is going to be the leading cause of death by 2020. It's a ridiculous thing to say.

There has been no "spike" in cancer rates. They have risen steadily "mainly [as a] result of the UK's ageing population."

I was told recently by Nick Sheron that the average weekly alcohol consumption of a patient with alcoholic liver disease is 111 units. Presumably this is based on self-reported figures and is therefore an underestimate. Either way, these are clearly not your average moderate drinkers. David Nutt would have us believe that moderate drinkers are putting their lives at risk, because he believes the hoary old prohibitionist's tales about alcohol being (a) instantly addictive, and (b) toxic at any level. (I do not exaggerate, he said as much here.) In fact, there is a mountain of evidence showing that moderate drinking is healthy. Nutt dismisses this evidence out of hand.

I doubt the industry has ever used the word "deviant", but there is no doubt that there is a small minority of drinkers who drink a vastly disproportionate share of the nation's alcohol. Doctors and policemen see the same faces time and again. A sensible public health movement would target those people rather than the general population.

3. Normal adult non-drinkers do not exist: The alcohol industry is forever reminding politicians of how unpopular alcohol restrictions are to the voting populace. “The existence of non-drinkers obviously threatens this portrayal of society, so the industry tends to dismiss them as having something wrong with them. While some teetotalers are recovering alcoholics, many others have made a positive choice not to drink.” And there are others, I would add, often referred to as “sick” teetotalers, who have quit drinking for medical reasons unrelated to alcoholism.

I've never heard anybody, from the drinks industry or anywhere else, claim that normal adult non-drinkers do not exist. That which can be asserted without evidence can be dismissed without evidence.

4. Ignore alcohol’s harm to the body: Nutt reminds us that “there is no other drug which is so damaging to so many different organ systems in the body…. Most other drugs cause damage primarily in one or two areas—heart problems from cocaine, or urinary tract problems from ketamine. Alcohol is harmful almost everywhere.”

Ignoring something is not a statement and therefore cannot be a myth. Again, I challenge the author to find me an example of anyone in the booze trade who denies that alcohol can be harmful. While he's at it, he might like to ask someone from the anti-smoking lobby if they agree that "there is no other drug that is so damaging to so many different organ systems in the body."

5. Alcohol problems can be solved when everybody works together: “In practice, what the industry means by ‘working together’ is bring in voluntary codes rather than statutory regulation—solving problems through rules that the industry CHOOSES to comply with, rather than laws which they MUST comply with.”

Yes, that's what a voluntary code means. The author has not shown that this collaborative approach is less effective than the confrontational approach.

6. Alcohol marketing is intended to assist consumers in selecting products: Specifically, 800 million British pounds every year for advertising and promotion, according to Nutt. That’s just the kind of civic-minded bunch those alcohol sellers are. The reality, of course is that “marketing communications do have a marked effect on consumption…. All this further entrenches the false division between alcohol and illegal drugs, persuades people that consuming alcohol is safe, and makes realistic discussions of the harm alcohol causes very difficult.”

I genuinely pity people who say things like this. Not only do they dismiss the idea that advertising is about businesses persuading customers to switch to their brand, but they do it with the same sarcasm and superciliousness displayed above. As far as they're concerned, it is self-evident that the industry spends millions of pounds advertising the concept of drink to get people to drink more. Otherwise, what would be the point, eh? It's not like a business can make money out of a static or declining market by stealing sales from its competitors, is it?

I wonder if these bien pensants believe that businesses advertise products like margarine and washing powder in order to get people to buy more and more margarine and washing powder until their shelves are rammed with the stuff. Or would they concede that the intention is to get people to switch from Persil to Daz and from Flora to I Can't Believe It's Not Butter?

That's how advertising works most of the time. The exception is with brand new product categories where the advertising of one brand helps raise awareness of the product more generally and therefore lifts overall sales. E-cigarette advertising today is a good example of this. Alcohol is the opposite. It's been around forever.

Moreover, there is not a "false division between alcohol and illegal drugs". There is a very clear division. Alcohol is legal and drugs aren't. I would personally like to legalise drugs and Nutt, from what I can gather, would like to ban alcohol. Nevertheless, that is not currently the situation and it is perfectly consistent to allow the advertising of legal products but not illegal products.

Incidentally, the alcohol market in Britain has a turnover of about £40 billion so a marketing budget of £0.8 billion is hardly excessive.

7. Education about responsible use is the best approach: “It is useful for the drinks industry,” Nutt explains, “to emphasize the value of education, because it takes the focus off regulation…. There is also extensive evidence gathered by the WHO from around the world, showing that merely providing information and education without bringing in other policy measures doesn’t change people’s drinking behavior.”

I'm always amused by the way people in public health believe that commercial advertising is incredibly effective in controlling people's thoughts and actions, but their own health campaigns are utterly useless.

The success of an educational campaign should not be measured by how much it changes behaviour, but by how well-informed it leaves people. A well-informed population in a free society can do what it wants, regardless of whether it displeases people like Prof Nutt. People might decide to drink within the arbitrary, evidence-free limits set by public health mandarins (and most do) or they may decide that those limits are too low for their tastes and ignore them (as I do).

Who knows why alcohol consumption has fallen so much in Britain since 2002? Perhaps educational campaigns had some effect. It's hard to say. Certainly, it had nothing to do with advertising, of which there has continued to be plenty, nor did it have anything to do with availability, which has increased.


Carl V Phillips said...

Add to your list of things to not like about Nutt, his recent claims that smokeless tobacco is 17% as harmful as smoking. Of course the main problem with that it that it is that more than an order of magnitude higher than the actual scientific estimate. But also consider the utterly silly claim precision: No, not 15%, not 20%, but 17%.

Will Haydock said...

Hi Chris. Two points.

1. Advertising
Although some claims can be simplistic in viewing advertising as mind-control, as you know I think you go too far in the opposite direction when in fact the reality is somewhere in between.

We know that culture contributes to people's desires, and advertising contributes to that. Plenty of ads are not about brand switching, and this is particularly the case when you think of household budgets as a whole. People balance spending on one margarine brand not just against another, but also against butter, and as part of an overall budget that will affect what sort of other products they buy. I'm not sure how much of a Jam fan you are, but it is a big decision whether to cut down on beer or the kids' new gear - or for that matter any other spend. There is no fixed demand for alcohol that different brands/products are competing for.

Also, I think public health people have a point when they view marketing campaigns as pissing in the wind against the budgets of major alcohol producers.

However, I do quite like your idea of an informed, choosing public (it's perfectly acceptable to know the risks of consuming alcohol and then go ahead anyway) but advertising doesn't aim to provide 'perfect information' so much as a 'buzz' around the product. Then we get into a discussion of pesky concepts like rationality, desire etc.

2. On 'working together' you're being a bit facetious, though you're quite right that on what's actually written there the 'myth' is not busted. There is a genuine debate to be had on this, and also voluntary codes are not the only way of 'working together'; you could work with all partners round the table and come up with an alternative such as mandatory codes. (Of course, the responsibility deal for whatever reason doesn't actually feature all stakeholders, so...)

Fredrik Eich said...

I see you have a phd in looking at binge drinking.
The amount of binge drinking I have done in my life I think I deserve one too.
Problem is the University of Pubs doesn't hand them out. ;-)

Christopher Snowdon said...


Thanks for your comments. Of course I accept that margarine competes with butter but I would see both as being in the same product category of dairy spreads. Similarly, cider competes against beer in the alcohol category.

"There is no fixed demand for alcohol that different brands/products are competing for."

That's just an assertion, isn't it? I mean, sure, alcohol consumption goes up and down but is that led by advertising? I really doubt it. As I said in the post, consumption's been going down for the last ten years - has advertising also been falling? Spirits consumption has been falling for 150 years but spirits are still quite heavily advertised. Wine, on the other hand, has been the big growth segment in the last 30 years and it is advertised very little.

The public health lobby needs many economics lessons, but there are two things it particularly needs to get its head around. 1. The alcohol industry is not a monolithic entity but is made of fierce rivals. 2. These firms can easily make more money in a declining or static market.

Ian said...

Dr. Nutt's book is well worth the read. I don't think that you have captured his position on banning alcohol quite clearly. From the book: "I drink myself and enjoy it." and "Banning alcohol outright would be an extreme and probably counterproductive measure"

As an emergency physician, I certainly do see the same faces time and again, but I see far too many new faces from alcohol too, the drunk and now raped grad party girl, the two workers who went off the road on their way home after stopping at the pub, new atrial fibrillation from overdoing it on the weekend. I've worked in many different emergency departments over the years, even in heavy IVDU areas, but it's always alcohol that keeps me busy during the night shift.

Bald headed John said...

then maybe you should be pleased that some people are keeping you in employment, yes?