A shoddy attempt to turn Big Alcohol into Big Tobacco

If you were involved in the revision of the UK's alcohol guidelines, you are the last person in the world who should be criticising others for misrepresenting evidence. As I've explained before, the benefits of moderate drinking were subjected to the full 'merchants of doubt' treatment by the Chief Medical Officer's guidelines committee. They blatantly cherry-picked the evidence, relying heavily on the work of one sceptic (Tim Stockwell) while raising a bunch of zombie arguments that have long since been debunked in the literature.

But 'public health' knows no shame and so Mark Petticrew, the activist-academic who helped lead the evidence review - and who told his colleagues what the conclusion was going to be before it had got started - has popped up today with a diatribe dressed as a study, claiming that the drinks industry 'appears to be engaged in the extensive misrepresentation of evidence about the alcohol-related risk of cancer.' 

His evidence for this comes from the tried and tested quack methodology of doing a Google search and, er, misrepresenting the evidence. Written with three colleagues - although I'll just say 'Petticrew' in this blog post for brevity - he breaks the industry's alleged misrepresentations into several categories.

He starts with what turns out to be his strongest evidence. Under 'Denying, disputing or selectively omitting the relationship between alcohol consumption and cancer', he quotes the International Alliance for Responsible Drinking (IARD) and some Canadian organisation who say:

‘Recent research suggests that light to moderate drinking is not significantly associated with an increased risk for total cancer in either men or women.’  International Alliance for Responsible Drinking

'Some studies show a link between alcohol and breast cancer among both pre-menopausal and post-menopausal women. However, no causal relationship has been shown between moderate drinking and breast cancer.’ Éduc’alcool (Quebec)

The first of these quotes, from IARD, cites a BMJ study from 2015. The study actually does show an increase in total cancer risk from moderate drinking for women, but not for men. The IARD quote is badly worded, at best, and is all the stranger because they go on to explain the results of the study correctly in the sentences that follow (Petticrew doesn't quote that bit). The risks are extremely low, amounting to an increased risk of between two to four per cent, but they are not completely absent.

However, there is evidence from other sources that moderate and light drinkers do not have a higher cancer risk. Only last month a large American cohort study found that overall cancer risk was 0.89 (0.82-0.97) for light drinkers and 0.95 (0.85-1.05) for moderate drinkers. This means that light drinkers were significantly less likely to die from cancer in the study period. Nevertheless, the source used by IARD does not accurately reflect the statement quoted by Petticrew so it's 1-0 to him.

The second quote depends on what evidence you consider sufficient for a 'causal relationship'. Epidemiology famously cannot prove causation, but most authorities consider the statistical association to be good enough to infer it in this instance. On that basis, the Quebec organisation could be said to be 'disputing' the evidence, albeit no more than Petticrew and his chums have been disputing the much greater weight of evidence about the benefits of moderate drinking.

This is as good as the study gets as an exposé of industry 'denial'. Everything else in it is drivel, as we shall see. For the most part, Petticrew excoriates the industry for saying things that are patently true.

Under 'Distortion: mentioning some risk of cancer, but obscuring, misrepresenting or obfuscating the nature or size of that risk', he writes

It is commonly stated by these organisations (12/20 SAPROs) that the risk of some common cancers only exists for ‘heavy’, ‘excessive’ or ‘binge’ drinking. For example,

‘Cancer risk associated with the consumption of alcohol is related to patterns of drinking, particularly heavy drinking over extended periods of time.’ Australia, Drinkwise

In what universe is this stating that risk 'only' exists for heavy drinkers? If Drinkwise had meant to say that, they would have done so. As it is, the use of the word 'particularly' clearly implies that there is risk, albeit less risk, for non-heavy drinkers.

Similar statements also appear on the IARD website, such as ‘In general, alcohol-associated cancers have been linked with heavy drinking’ [27].

The scientific evidence suggests that such statements are misleading (Table S1), because the increased risk of some common cancers, such as breast, oesophageal, laryngeal, mouth and throat cancers and cancers of the upper aerodigestive tract, starts at low levels of consumption, even though it is low at those low levels [7,8] (see also Table S3).

Like the Drinkwise quote above, the IARD statement is true. Cancer risk is clearly related to patterns of consumption and heavy drinkers have a greater risk than light drinkers. IARD's report Drinking and Cancer provides five academic references to support this.

It is an indisputable facts that some cancers, such as liver cancer and possibly pancreatic cancer, are only associated with alcohol if you're a heavy drinker. For those cancers which are linked to moderate consumption, risk is significantly greater for heavy drinkers. Neither of the sources quoted above suggest otherwise, and the IARD document explicitly discusses the cancers that are - or might be - linked to light/moderate consumption.

It should also be noted that in the press release for this 'study', Petticrew says:

'It's important to highlight that if people drink within the recommended guidelines they shouldn't be too concerned when it comes to cancer.'

If IARD had said that, he would doubtless condemn them for downplaying the risks or being 'misleading'.

He continues:

Other industry claims (from three organisations) relate to disputation of the mechanisms, or involve claims about the consistency of the evidence, as in these examples:

‘Recent studies indicate a dose-response relationship between alcohol consumption and breast cancer, although this relationship was not evident in some past studies.’ IARD [27].

‘All the studies show that the knowledge about the causes of breast cancer is still very incomplete and as scientists from the National Institute on Alcohol Abuse and Alcoholism in the USA recently pointed out, some other (possible confounding) factors have not been considered in the research relating the consumption of alcoholic beverages to breast cancer.’ Wine Information Council [28].

This is also a feature of SABMiller materials:

‘The mechanism by which alcohol consumption may cause breast cancer is not fully known.... The relationship... is undergoing vigorous research... If and how these two factors may interact and affect risk is not completely known.’

All of these are uncontroversial statements of fact and plenty of non-industry sources echo them.

Here is the American Cancer Society, for example:

Exactly how alcohol affects cancer risk isn’t completely understood. In fact, there might be several different ways it can raise risk, and this might depend on the type of cancer.

And here is Cancer Research UK:

According to Dr Ketan Patel, a Cancer Research UK expert on how alcohol causes cancer: “We don’t really know. We don’t fully understand why alcohol causes some cancers and not others.”

Petticrew says that statements like this are examples of the industry tactic of 'Claiming or implying that, as knowledge of the mechanism is incomplete, the evidence of a causal relationship is not trustworthy'. That's rich coming from him. The alcohol guidelines review repeatedly cast doubt on the benefits of moderate drinking by falsely claiming that there is a 'lack of well evidenced biological processes that could explain the effect' and then presenting this as proof that the benefits do not exist at all.

Petticrew pulls exactly the same trick in his little polemic when discussing non-Hodgkin lymphoma which has been inversely associated with alcohol consumption. Keen to dismiss any benefits from drinking, he quotes an authority saying that 'there is no immediately obvious mode of action that could explain the association.'

But there is a difference between what Petticrew does and what the industry and cancer charities quoted above are doing. They explicitly state that the risks are real but that the causal mechanisms are not fully understood. Petticrew, by contrast, is claiming or implying that, as knowledge of the mechanism is incomplete, the evidence of a causal relationship is not trustworthy.

Petticrew then mentions the Portman Group...

The Portman Group’s response to the consultation on the revised UK guidelines (issued in 2016) includes a section in which the evidence is disputed, referring to protective effects. It refers to the ‘increased risk of a small number of cancer types’ and states: ‘Different levels of alcohol consumption have a range of effects on cancer risk including no impact on the majority of cancers, and in some cases, an inverse relationship.’ [11]. As well as misrepresenting the evidence, this statement is misleading as it confuses the number of different ‘types’ of cancer, with the risk of specific cancers.

Again, everything the Portman Group says here is true. The press release that accompanies Petticrew's article correctly notes that alcohol 'accounts for about 4% of new cancer cases annually in the UK.' There are more than 100 different types of cancer and IARC has established that alcohol consumption could cause seven of them: 'cancers of the oral cavity, pharynx, larynx, oesophagus, colorectum, liver (hepatocellular carcinoma) and female breast.' They also noted that 'an association has been observed between alcohol consumption and cancer of the pancreas'. But that's it.

It is reasonable to describe seven out of 100 as a 'small number' and it is indisputable that alcohol has 'no impact on the majority of cancers'.

It is also true that an inverse relationship between alcohol consumption and a few forms of cancer, including renal cancer and non-Hodgkin lymphoma, has been repeatedly found in epidemiological studies. Petticrew asserts that there is a 'lack of evidence for protective effects of alcohol consumption on cancer'. An unbiased reader who reads the meta-analyses (see links in previous sentence) might conclude that he sets the bar of proof higher for evidence that shows benefits than for evidence that shows harm.

The Portman Group is neither 'misrepresenting' nor 'disputing' the evidence. Petticrew chooses not to quote from page 20 of Portman's consultation response in which they explicitly say:

'The relationship between alcohol consumption and increased risk of certain cancers is clear and we believe it is important consumers are aware of this.' 

Moreover, the sentence immediately before the one Petticrew quotes (beginning 'Different levels...') says:

'We fully accept the evidence on the links between alcohol and certain types of cancer.'

Under 'Distraction: focussing discussion away from the independent effects of alcohol in increasing the risk of common cancers', Petticrew cites the following examples of the industry saying things that are 'potentially misleading':

‘Not all heavy drinkers get cancer, as multiple risk factors are involved in the development of cancers including genetics and family history of cancer, age, environmental factors, and behavioural variables, as well as social determinants of health.’ Australia: Drinkwise [26].

‘Alcohol has been identified as a known human carcinogen by IARC, along with over 1,000 others, including solvents and chemical compounds, certain drugs, viral infection, solar radiation from exposure to sunlight, and processed meat.’ IARD [27].

‘For example, the fact that you are female is a risk factor in developing breast cancer. We also know breast cancer is age-related so you’re more likely to develop it as you get older and that you’re more prone to breast cancer if it is part of your family history. These are all factors beyond our control. We also know that risk is related to the ‘hormone environment’ that women experience during the course of early pregnancy, child birth and breastfeeding which all exert a protective effect.’ Drinkaware, UK [32].

These are mundane statements of fact. It seems that Petticrew won't be happy until the alcohol industry's only health message is 'IF YOU DRINK, YOU'LL DIE!!! GET AWAY!!!'

In fact, these 'industry messages' are not very different from that of the Committee on Carcinogenicity, who say:

Drinking alcohol has been shown to increase the risk (or chance) of getting some types of cancer. This does not mean that everyone who drinks alcohol will get cancer, but studies have shown that some cancers are more common in people who drink more alcohol.

The Drinkaware discussion of breast cancer is similar to what you will find on Cancer Research's webpage about breast cancer. Although Petticrew doesn't mention it, the quote he uses is from Professor Paul Wallace, an epidemiologist with an impressive CV in alcohol research, who is Drinkaware's Chief Medical Advisor. The full quote runs as follows:

Professor Wallace says it’s important to put this risk into context. There are many other factors which increase the risk of developing breast cancer. “I often sit down with my patients and explain that there are certain factors we can do nothing about,” he says. “For example, the fact that you are female is a risk factor in developing breast cancer. We also know breast cancer is age-related so you’re more likely to develop it as you get older and that you’re more prone to breast cancer if it is part of your family history. These are all factors beyond our control."

There is a lot that Petticrew could have quoted from that Drinkaware webpage but didn't, presumably because it wouldn't fit his narrative of an industry cover up. For example:

When asked to name the main health effects of drinking too much alcohol, many people will first say liver disease. Others will mention heart disease. Some will name mental health issues. Cancers are often low down on the list.

But they shouldn’t be – especially breast cancer.

It is clear from a number of large scale studies that there is a link between alcohol consumption and cancer. Globally, one in five (21.6%) of all alcohol-related deaths are due to cancer. Breast cancer is the most common cancer among women and second only to lung cancer as a cause of cancer death in women.

Professor Paul Wallace, Drinkaware’s Chief Medical Advisor, believes that more people should know that alcohol can increase women’s risk of getting breast cancer.

I challenge any reasonable person to read this - or, indeed, any Drinkaware literature - and claim that the organisation is trying to downplay or deny the risks of drinking. I was on a Drinkaware panel once. They are basically a temperance group. Only a lunatic could think otherwise.

Petticrew says that there are 'two particularly frequent areas of misinformation', namely breast cancer and colorectal cancer. As evidence, he goes back to the Portman Group...

The Portman Group’s response to the UK guidelines includes a section on breast cancer, in which the evidence is disputed. For example, it states that ‘studies associating moderate alcohol consumption are contradictory’.

Is the evidence 'disputed' by the Portman Group? No, it is not. Here is what the Portman Group actually said in their consultation response:

A percentage (6%) of all breast cancer cases in the UK is attributable to alcohol - the links between alcohol consumption and breast cancer are clear and it is right that consumers are made aware of the risks.

As for the studies being 'contradictory', there is some truth in this, but it is not the Portman Group saying it. The Portman Group were only quoting some (reputable) scientists who said:

'Since studies associating moderate alcohol consumption and breast cancer are contradictory, a woman and her physician should weigh the risks and benefits of moderate alcohol consumption.'

Petticrew misquotes this and wrongly attributes it to Portman, which is sloppy at best. In fact, the point being made by the Portman Group is that risks should be explained in a meaningful way. This is not controversial. Cancer Research UK have made an effort to explain breast cancer risk in absolute, rather than relative, terms. John Holmes made a similar point in a journal article this week.

Nevertheless, Petticrew repeats his false claim about Portman disputing the evidence, saying:

...in disputing the evidence on increased breast cancer risk, the Portman Group document does not reference the IARC reviews, other systematic reviews, nor the Committee on Carcinogenicity review.

Not only is the initial claim a lie, but the claim about references is also a lie. The Portman Group document cites the Committee on Carcinogenicity reports several times and uses it as a source for a table which shows 60,000 breast cancer cases a year, of which Portman says alcohol causes 3,600 (see below).

 
This is a strange way of 'disputing the evidence'.

What is the point of all this flim-flam? Regular readers will have probably guessed. It's all part of creating a narrative of alcohol being the new tobacco and Big Booze being the new Big Tobacco. And he's good the headlines he wanted.

If you want to know why a 'public health' study has been written you have to head straight to the 'discussion' section where it all comes out...

The most obvious parallel is with the global tobacco industry’s decades-long campaign to mislead the public about the risk of cancer, which also used front organisations and CSR activities to mislead the public.

...These findings therefore have significant implications. They provide evidence that the AI [alcohol industry], like the tobacco industry, misleads the public and policy-makers about the cancer risks of their products. Our findings are also a reminder of the risk which accompanies giving to the AI the responsibility of informing the public about alcohol and health.

...some public health bodies, academics and practitioners liaise with the industry bodies included in this study, for example by acting as advisors or trustees, or by collaborating with them in implementation activities. Despite their undoubtedly good intentions, we suggest that it is unethical for them to lend their expertise and legitimacy to industry campaigns which mislead the public about alcohol-related harms.

The AI, unlike the tobacco industry, still has significant access in many countries to government health departments. It is also active in the international policy arena, with, for example, partner or stakeholder status at World Health Organization and United Nations meetings relevant to alcohol, on occasions when the tobacco industry is excluded. This study shows that the AI uses similar tactics to the tobacco industry, to the same ends: to protect its profits, to the detriment of public health.

There you have it. Petticrew is none-too-subtly telling academics to back away from the alcohol industry if they want to keep their reputations intact in the coming war on drink. He is also sending a signal to politicians that industry always lies while anti-alcohol campaigners, such as himself, are trustworthy. And he is telling governments to lock drinks companies out of the political process as has happened with tobacco under the Framework Convention on Tobacco Control.

Petticrew gets to this conclusion by saying things that are not true and denying things that are true. His study uses sleight of hand, evasion and downright misrepresentation to create a false narrative that falls apart as soon as you look at the primary sources. He does precisely what he accuses the industry of doing: selectively quoting from research in order to mislead, lying by omission, and making claims that cannot be supported by the weight of evidence.

For all of Petticrew's bluster, the drinks industry is dominated by massive, blue-chip companies with who would get sued if they lied about the harms of drinking. 'Public health' academics have no such incentive to stay honest.

Not for the first time, Petticrew has started with a conclusion and scrambled around for evidence to support it. When he failed to find any evidence, he wrote what he was going to write anyway. If the 'public health' movement had any integrity, the man would be a pariah.

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Responsible drinking

Mark Petticrew is one of the many psychologists who got on the 'public health' gravy train to satisfy his appetite for controlling other people's lives. He was one of the main people responsible for lowering the drinking guidelines last year and when he is not complaining about the free exchange of goods and services, his main schtick is to carry out 'reviews' of voluntary agreements between government and industry.

If it doesn't involve taxing the poor or creating criminal offences, Petticrew isn't interested, and so he invariably concludes that initiatives like the Responsibility Deal don't 'work' whereas heavy-handed and regressive policies do (even when the latter have obviously failed or haven't even been tried).

His findings are therefore highly predictable. Public Health Responsibility Deal on healthy eating? "Could be effective" but needs "food pricing strategies, restrictions on marketing .. and clear penalties". Responsibility Deal for alcohol? Not very effective, needs "law enforcement" to make "alcohol less available and more expensive." Voluntary agreements in general? Can be effective but only when there are "substantial disincentives for non-participation and sanctions for non-compliance", ie. when they are not voluntary. 

You get the picture. For Petticrew, the iron fist is always preferable to the velvet glove. In a new article in the Journal of Public Health, he and a colleague have now moved onto the concept of 'responsible drinking' which he thinks is yet another crafty industry trick.

Industry responsibility messages particularly appear to frame responsibility around the individual drinker, rather than alcohol consumption itself, often focusing on a minority of ‘harmful drinkers’, as opposed to the majority of ‘moderate’ or ‘social’ drinkers, while presenting responsible drinking as a behavioural issue, rather than a health or consumption level issue.

This sentence is close to gibberish for a normal person but it is quite typical of how 'public health' views behaviour. Notice how the 'individual drinker' is separated from 'alcohol consumption' as if there were no connection between the two, as if consumption does not stem from behaviour, as if human agency does not exist and alcohol consumption is just something that happens to people. In the 'public health' view, consumption is not something that the individual chooses, it is something that the government controls by tinkering with prices and regulating advertisements.

The gist of Petticrew's article is that the concept of personal responsibility is used predominantly, if not exclusively, by drinks companies to disguise the fact that it is they, not us, who decide how much we drink...

The term ‘responsible drinking’ was used almost exclusively by industry bodies (AB InBev, Diageo and DrinkIQ), or industry-funded bodies (Portman Group, IARD and ICAP). 

This conclusion is based on a Google binge (sorry, a 'web-based document search') which compared how the term 'responsible drinking' was used by industry groups and neo-temperance groups. Petticrew says that this amounts to 'comparing industry and non-industry sources' but it is nothing of the sort. Lots of 'non-industry sources' use the term 'responsible drinking' but Petticrew doesn't mention them because it would ruin his narrative.

The British government, for example, has long promoted 'responsible drinking' and explained what it means by the phrase:

Through our Public Health Responsibility Deal, companies have agreed to encourage a culture of responsible drinking, which will help people to drink within guidelines.

You can see the same term being used approvingly by all sorts of institutions, including the BBC, the NHS, the police, the Methodist Church and Sheffield University. The term 'moderate drinking', which Petticrew also takes umbrage at, is even more widely used by academics and medics.

It only takes a brief 'web-based document search' to find evidence of this, so who did Petticrew think he was fooling? If his little study shows anything at all, it is that a handful of anti-alcohol groups refuse to use a phrase that is commonly employed by the rest of society, presumably because they don't believe in personal responsibility. It is they who are the aberration. 

The term did not appear to be used in any of the documents sourced from PHE or Alcohol Concern, and was used once by the WHO

So the term 'responsible drinking' doesn't suit the agenda of the 'public health' lobby. So what?

While the meaning of ‘responsible drinking’ in the context of these messages is unclear, as the term is typically not defined

This is not true. The government defines it as drinking within the guidelines (see above) and so does the industry. Here is a typical label on an alcoholic drink in the UK.

It seems pretty obvious that the 'drink responsibly' plea is directly related to the unit recommendations that appear immediately below it. Petticrew admits that the message is sometimes 'presented alongside official guidelines' but complains that the advice 'may conflict with official guidance'. In so far as this is true, it is only because the guidelines were changed by Petticrew and his cronies last year and the drinks companies are still deciding whether or not they should put information on their products that is blatantly untrue (I hope they don't although some are already doing so.)

As the label shows, responsible drinking goes beyond following the guidelines and encompasses not drinking if you are pregnant or driving, but it is quite clear that 'responsible' or 'moderate' drinking is defined by the drinks industry, in part, as drinking within the government's guidelines. Given how low the guidelines were even before Petticrew and the temperance lobby set about them, this is a rather extreme interpretation of responsible drinking. The message to drink responsibly would be perfectly valid if it had no unit-based definition at all.

He concludes:

We conclude that public health practitioners should be aware of the derivation and use of concepts such as ‘responsible’ or ‘moderate’ drinking by industry and industry-funded bodies, as these may exist to promote industry agendas and undermine public health agendas.

Good grief. The paranoia is rampant.

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Mark Petticrew doubles down

Mark Petticrew has been going through the Twitter feed of Drinkaware, presumably because it beats working for a living and because 'public health' is such a shoddy enterprise that it will let him get another peer-reviewed study out of it. In 2017, Petticrew and his colleagues cherry-picked statements by various industry-funded educational organisations to claim that they downplayed, disputed and misrepresented the risks of drinking.

Amongst many other untruths, Petticrew accused Drinkaware of ignoring the link between drinking and breast cancer despite them having a whole webpage dedicated to the subject which downplays nothing and which his article ignored. His hatchet job was criticised for making 'a number of incorrect assertions' by the Portman Group and for being 'wholly unjustified and unprofessional' by Drinkaware's scientific advisors in a slew of responses published in Drug and Alcohol Review.

The latter concluded...

It is vital that Drinkaware’s important public health function is not compromised by unjustified allegations of inaccuracy and by entirely unwarranted attacks on its independence and integrity. We therefore expect Petticrew et al. to address the inaccuracies in their paper, which we have highlighted in this commentary.

Fat chance. In the meantime, the neo-temperance lobby's grudge against Drinkaware has become more intense due to its partnership with Public Health England, and Petticrew is now back for more in the International Journal of Environmental  Research and Public Health.

He wastes no time in repeated his previous slurs...

Drinkaware and other SAPROs ['an acronym Petticrew has made up, standing for 'social aspects/public relations organisations' - CJS] were recently found to be misleading the public on alcohol and cancer risk, including presenting misleading information about the independent effects of alcohol consumption on cancer risk, using similar framings to those developed by the tobacco industry to obscure the evidence on smoking and lung cancer, in some cases not mentioning cancer in general, and breast cancer specifically [19].

The reference cited to support this pack of lies is his own pisspoor study, of course. In his new study, Petticrew doubles down by making similar claims based around the Twitter feeds of three industry-backed alcohol information organisations.

We developed a series of hypotheses a priori based on previous evidence of AI [alcohol industry] strategies and campaigns. If AI-funded bodies are independent of the alcohol industry (as is argued by Drinkaware, see for example [40]), then no clear pattern should be observed, and their tweets should not reflect alcohol industry positions. On the other hand if, as has been noted previously [41], these bodies exist primarily to reflect and defend industry positions, then their Twitter activity should reflect industry arguments, concerns and topics, and should be significantly different from those of non-industry affiliated charities.

The trick employed here is to compare Drinkaware, Drinkwise and Drinkaware Ireland to three hardline, anti-alcohol campaign groups whose mission is totally different: Alcohol Concern, Alcohol Action Ireland, and the Foundation for Alcohol Research and Education (FARE). Petticrew's conceit is to use the neo-temperance lobby as a control group, implicitly portraying them as neutral organisations that are only interested in giving the public an accurate impression of the impact of alcohol consumption on health.

After looking at every tweet sent by these six organisations in 2016, he and his minions conclude:

AI-funded bodies were significantly less likely to tweet about alcohol marketing, advertising and sponsorship; issues related to alcohol pricing, including MUP...

That's because they are not lobby groups.

...physical health harms, including cancers, heart disease, dementia and diabetes; and fertility and pregnancy

Petticrew et al. count 23 Drinkaware tweets which warned of these 'physical harms' (excluding cancer) (2.8% of the total) whereas the now-defunct Alcohol Concern had 29 (4%). Not much of a difference, really, and they overlook the 101 tweets Drinkaware sent about 'drinking too much' - many of which would have been related to physical harms - compared to just 13 from Alcohol Concern (1.8%).

Alcohol Concern tweeted more about cancer (54 times) than did Drinkaware (27 times), but that is largely because Alcohol Concern liked being able to scare women with the claim that there is no safe level of drinking (for breast cancer) and were obsessed with treating alcohol like cigarettes, for which the cancer link was seen as a useful tool.

Alcohol industry-funded bodies were significantly more likely to tweet about drinking too much, cutting down, children and underage drinking, teens/parents, staying safe while drinking, alcohol units and guidelines, calories/obesity, and alcohol-free or low alcohol drinks. They are also more likely to tweet about drink driving.

So what? These are perfectly valid things for an educational charity to be tweeting about. While the temperance groups are banging on about advertising and minimum pricing, the alcohol awareness groups are giving people practical information and advice on a range of issues. That is what they're supposed to be doing. If there is a problem here, it does not lie with Drinkaware. 

AI-funded bodies do not appear to use Twitter to raise awareness about pregnancy and fertility.

That's an easy thing to check, so let's have a look at the year in question, shall we?

Alcohol & your baby: Info & advice for women who are pregnant or breastfeeding https://t.co/1ZviK6O2N0 #infographic pic.twitter.com/5GiLF5Fb7y

— drinkaware (@Drinkaware) February 3, 2016

Official #alcoholguidelines are now that pregnant women should not drink any alcohol at all: https://t.co/pIKETfnjDc

— drinkaware (@Drinkaware) January 8, 2016

So that's a lie, then. In fact, Petticrew's own data show that Drinkaware tweeted about alcohol and pregnancy more times than Alcohol Concern did. 

Overall, these suggest that there is a difference between the stated visions, values and missions of the AI-funded bodies, and their actual activities.

No. There is a difference between the missions of 'AI-funded bodies' and the missions of anti-alcohol groups. The former are there to educate people and give accurate, practical advice. The latter are there to create hysteria and lobby for illiberal legislation, rather like Mark Petticrew.

There's nothing else to say about this pitiful study so I will leave you with a quote from it which highlights the state 'public health' academia is in today.

[Social media] has also been identified as a potentially rich data source for health research, with a recent systematic review identifying 137 research articles using Twitter, 108 of which involved the analysis of tweets, primarily in the form of content analysis.

Move over John Snow and Louis Pasteur.

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Anti-alcohol cranks call for academic censorship

The psychologist Mark Petticrew has got it into his head that the rather dull health information charity DrinkAware is covertly promoting binge-drinking and drinking while pregnant while also downplaying the risks of alcohol. He has been banging this drum for four years now, producing several studies based on cherry-picking and misrepresentation. Most recently, he resorted to trawling through DrinkAware's Twitter feed crying 'bias' whenever a tweet wasn't as overtly anti-alcohol as those sent by temperance groups. 

The mini-literature he has built up serves no purpose other than to sustain his theory that everything the alcohol industry touches (for it is they who fund DrinkAware) is evil. It is all rather pathetic, but nothing is too trivial to be turned into a peer-reviewed study in the world of 'public health'.

This little saga has reached a new low with two of Petticrew's fellow cultists publishing their own 'study' defending their mate and condemning DrinkAware for having the temerity to respond to his daft accusations. Drinkaware and two other organisations had responded to the first of his articles in the journal that published it, pointing out some of the many inaccuracies and sleight of hand. Incidentally, that article was titled 'How alcohol industry organisations mislead the public about alcohol and cancer' because this is gotcha journalism we're dealing with, not serious academia.

The new study is one of most petty pieces of navel-gazing I've ever come across in a journal. They looked at three of Petticrew's articles and eight of the responses from DrinkAware and the other 'social aspects organisations' (SAOs) he attacked. They then look at four replies from Petticrew and his colleagues.

Why? Essentially to adjudicate. They decide that Petticrew was basically right and the SAOs were basically wrong. Crucially, they enshrine their biased opinion in a peer-reviewed publication that campaigners can wave around.

To make this sound slightly more like an academic exercise and less like score-settling, they describe their methodology as follows:

The analysis began with the first author, who was not immersed in the scientific literature in question, identifying the series of claims and counterclaims before the second author applied his reading of the debates

The second author is Jim McCambridge, a bona fide fanatic who is obsessed with the alcohol industry and is about as far from a disinterested third party as can be imagined. 

The two authors go through the accusations and rebuttals as if they were having an argument on a message board, shouting 'straw man' at the SAOs and accusing them of not responding to the main point. 

...there is a refusal to engage with the arguments made by Petticrew et al.

.. This response largely ignores Petticrew et al.’s attention to context and audience

.. The responses by SAOs raise narrow questions of content accuracy, rather than engaging with the overall findings of the articles

And so on and so forth. It is rather tedious and childish.

It is only when you get to the discussion section that the purpose of the study becomes clear. Aside from establishing that their pal is right and his opponents are wrong, their real beef is with industry-funded organisations being allowed to respond in journals at all. 

We argue that these controversies are scientific in location only, being published in peer-reviewed journals.

.. The forum is important. These replies become scientific artefacts, legitimated by publication in the scientific literature, a resource to be used in subsequent disputes as we see in the later responses of both Drinkaware and Éduc’alcool. In the future, it will be possible to write, “previous papers by Petticrew and colleagues have been heavily criticized,” attaching several references to add credibility to such claims, just as Sim et al. (2019) use Larsen et al. (2018). 

It is not hard to see an element of projection here. This should have been a blog post, not a study. The only reason it has been published as a study is so it looks respectable and can be cited.  

It is key to remember here that whereas the audience for a genuine scientific controversy includes other scientists in the field, the audiences for a counterfeit scientific controversy are people outside the field (e.g., the public, policy makers, journalists). These audiences cannot be expected to possess the tacit knowledge, obtained by socialization in the research community, that would allow them to discriminate between sources and to identify genuine disputes between scientists. 

The responses from the SAOs were all published in the Journal on Studies of Alcohol and Drugs or in Drug and Alcohol Review. These are the journals Petticrew published his studies attacking the SAOs in the first place (which is obviously why the responses were published in them). The Journal on Studies of Alcohol and Drugs is where this study has been published. If the readers of these relatively obscure journals don't have the "tacit knowledge, obtained by socialization in the research community" then who does? 

The editor of this journal obviously doesn't think it is a 'counterfeit scientific controversy' and he probably doesn't want to get sued, which might have been the SAO's second option. So he gave the SAOs the right to reply. Given the severity of the accusations and the shaky grounds on which Petticrew made them, it was the least he could do.

The arrogance of the authors is extraordinary. How dare they decide what is real controversy and a fake one? Who are they to decide who has the ability to understand a simple back-and-forth in relation to studies that are so basic that none of them involved more than scrolling through a website?

The replies, printed in peer-reviewed journals, thus operate as public relations exercises given legitimacy by being located within the scientific literature

You can probably guess what comes next. That's right, it's a none-too-subtle call for censorship. 

It is appropriate for journals to consider why they publish this kind of content, which adds to the burden of doing work in this area, manufacturing doubt about (and distracting attention from) important scientific issues, in part by facilitating attacks on published research and researchers. These organizations can write what they like on their websites, but why should journals publish such harmful material?

"Harmful material"! These people are dangerous cranks. Write that up and turn it into a 'study'.

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Temperance academics get triggered

Has Mark Petticrew finally been driven completely mad by the existence of the alcohol industry? He and his fellow clowns at LSHTM have written countless articles about the booze industry and the organisations it funds, always looking for the worst interpretation and often cherry-picking relentlessly to get the conclusion they want (see various old posts for examples).

Their latest, published in Lancet Gastroenterology & Hepatology is the weirdest yet. It is based on a short statement from the (industry-funded) Portman Group in response to the news that alcohol-specific deaths rose again in 2021, following a sharp rise in the first year of COVID-19. The full statement reads as follows:

 

In response to the release of the Alcohol-specific deaths in the UK ONS report for 2021, Matt Lambert, CEO of the Portman Group – the alcohol social responsibility body and marketing regulator said:

“Today’s figures show an increase in alcohol-specific deaths on top of last year’s increase, every death is a tragedy for the people concerned and their family and friends. The longer-term impact of pandemic drinking for a small group of drinkers continues and there is increasing evidence that targeted, health focused action is needed for those drinking at the highest harm level.”

 

That's it. That's all they said. I don't know what it was about this bland, 61 word quote that triggered Petticrew and his colleagues but boy did it trigger them. Their article can only be described as a rant. Having quoted the offending press release, they give it the Cathy Newman treatment ('so what you're saying is...').

 

In other words, a large and increasingly globally consolidated industry, which expends a substantial amount on marketing, and whose existence depends on its ability to sell alcohol, is telling a good news story about wider declines in alcohol consumption it claims partial responsibility for...

 

In what universe is the Portman Group statement "telling a good news story"?? 

 

...and implying that its heaviest consumers, whose consumption is increasing, are doing so because they are irresponsible and need targeted, medical help.

Perhaps I don't have the antennae for subliminal messaging that Petticrew has, but I don't infer anything about irresponsibility in that statement. The only thing that vaguely resembles his characterisation is the fact that the Portman Group said "health focused action is needed for those drinking at the highest harm level". 

 

It is widely acknowledged that a lack of face-to-face treatment was a factor in alcohol-related deaths rising during the lockdowns. The British Liver Trust said that: "Stress, loneliness and the lack of access to alcohol support services have resulted in many people drinking more alcohol and putting their livers at risk." If too few people are getting what Petticrew rightly describes as "targeted, medical help", the obvious solution is for more people to get it.

 

Being 'public health' academics rather than medics, Petticrew et al. aren't interested in treatment at all. They're only interested in ineffective, willy-waving, population-level policies.

 

The evidence suggests this narrative masks two crucial realities: the industry's long-standing obstruction of evidence-based means to reduce alcohol harm, and its disproportionate reliance on the heaviest consumers for a large proportion of overall revenue.

They then blether on about minimum pricing (which didn't work) and alcohol advertising bans (which don't work). They conclude...

A different account of the recent alcohol trends can therefore be told. The industry lauds a responsible majority for decreasing consumption, and seeks to claim a role in this decline.

 

It hasn't, has it? Why would anyone try to take credit for decreasing alcohol consumption during the pandemic when we know it was accompanied by a rise in alcohol-specific deaths? The question the 'public health' lobby have to answer is why that decline in consumption didn't lead to a decline in deaths.

 

These claims ignore the inconvenient fact that it is disproportionately reliant on the heaviest consumers.

 

Name me an industry that isn't. This is basically a tautology.

 

These record alcohol deaths are a reflection of greater alcohol sales among individuals at the greatest risk, facilitated by the obstruction of evidence-based policy.

 

As I have explained elsewhere, the rise in deaths occurred at a time when there was far less alcohol advertising than usual, when most alcohol outlets were closed and - in Scotland and Wales - where minimum pricing was in effect. For months on end, the temperance lobby got most of what it wanted. The results were... not great. Since the marketing and retail environment moved in the direction 'public health' ideologues have always desired, it might be worth them asking what went wrong.

 

Through these efforts in pursuit of profit at any cost, the industry has played an outsized part in shaping our current reality, in which the UK faces record increases in alcohol-related liver disease and a health system in crisis.

 

Really? You wouldn't say it was the pandemic and lockdowns that caused the number of deaths to shoot up after being more or less flat for a decade? You don't think there might have been psychological factors at work that undermine your child-like view of the issue?

 Nah, let's blame the pursuit of profit.

We can choose between accepting the industry's own reports of its motivations and good works, or acknowledging its pursuit of profits and reliance on the heaviest consumers and consumers at high risk. The UK is in need of a new alcohol policy to reduce alcohol-specific and alcohol-related mortality. For it to be effective and equitable, the industry and the organisations it funds can have no part in writing it. The UK public deserve nothing less.

 

There endeth the lesson.

Remember that this diatribe was inspired by a two-sentence comment from the Portman Group saying that it was sad so many people were drinking themselves to death and pointing out that treatment works. Is this how academic publishing works in 'public health'? Is any head-banging fanatic who gets triggered by a statement from an industry-linked body that doesn't say "It's all our fault, we're going to disband" allowed to vent spleen in a peer-reviewed journal? Does Lancet Gastroenterology & Hepatology always print communiques from the green ink brigade or does it sometimes publish stuff about gastroenterology and hepatology? 

 

It just bizarre.

As a chaser, Petticrew and friends also mention several industry-funded initiatives to reduce harmful drinking and dismisses them all in a sciency way.

...corporate social responsibility initiatives like the UK Responsibility Deal (which an independent evaluation found to not be effective⁵), funding DrinkAware (which independent research has shown communicates misinformation on alcohol-related harms⁶); and supporting community alcohol partnerships (for which there is little evidence of effectiveness⁷).

 

Reference 5 is one of Petticrew's studies. Reference 6 is one of Petticrew's studies. And reference 7 is - you guessed it! - one of Petticrew's studies. How very independent!

 

According to an independent evaluation (i.e. me), these people are fruitcakes.

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The story of the new alcohol guidelines

I've been reading the minutes of the meetings held by the committee that reviewed the alcohol guidelines recently. You may recall that this was the first full review since 1995 and led to the Chief Medical Officer (CMO), Sally Davies, lowering the recommendations for men from 21 to 14 units a week. The female guidelines were left at 14 units. She also claimed that the health benefits derived from moderate drinking were an ‘old wives’ tale’ and claimed that there was ‘no safe level of alcohol’.

The most striking difference between the 1995 review and the 2016 review is the make-up of the panels. Whereas the 1995 committee was dominated by civil servants who had no obvious prejudices for or against alcohol, the meetings held from March 2013 to discuss alcohol guidance were dominated by activist academics and temperance campaigners.

The Institute of Alcohol Studies (IAS), a small but hardline anti-alcohol organisation, was heavily represented on the committee. The IAS was formed in the 1980s as a direct successor to the UK Temperance Alliance which, in turn, had been formed out of the ashes of the UK Alliance for the Suppression of the Traffic of All Intoxicating Liquors, a prohibitionist pressure group. The IAS receives 99 per cent of its income from the Alliance House Foundation whose official charitable objective is ‘to spread the principles of total abstinence from alcoholic drinks’. Its director, Katherine Brown, was on the CMO’s panel, as was its ‘expert adviser’ Gerard Hastings, although he failed to disclose his IAS role in his declaration of interests.

The IAS’s scientific adviser Petra Meier was also on the committee and was joined by her Sheffield University colleague John Holmes. Holmes and Meier are both strong advocates for minimum pricing and helped develop a computer model which has been repeatedly used to promote minimum pricing by producing estimates of the number of lives that will supposedly be saved by the policy.

Another staunch anti-alcohol campaigner, Ian Gilmore (chairman of the Alcohol Health Alliance, of which the IAS is a key member), was unable to attend the first meeting but was involved thereafter. Gilmore has campaigned for many years for higher alcohol taxes, minimum pricing and a total ban on alcohol advertising.

Other members of the committee may have been less strident than Gilmore and the IAS but there was no doubt where their biases lay. Mark Bellis wrote an article for the British Medical Journal in 2011 complaining that existing alcohol guidance was too generous and ‘read more like an alcohol promotion slogan’. Mark Petticrew and Theresa Marteau are both strong advocates of a range of heavily interventionist ‘public health’ policies, including sugar taxes, plain packaging and minimum pricing.

Of those who attended the initial meetings in 2013, only three did not explicitly advocate stricter alcohol control: the health economist Martin Buxton, the health sociologist Sally Macintyre, and the epidemiologist Valerie Beral. The latter appears to have been selected because of her research linking alcohol to breast cancer, which would become a crucial element in the ‘no safe level’ narrative.

The minutes of a meeting in June 2013 indicate that the path towards dismissing the benefits of moderate alcohol consumption was mapped out from an early stage. Mark Petticrew told his new colleagues: ‘The beneficial effects of alcohol consumption, where they are evidenced, are limited to a low consumption level of half a drink per day.’ Moreover, he said, ‘The population cohort who experiences any beneficial health effect from alcohol is very small. Given these limitations, there is an argument that beneficial effects could be considered not to be relevant in the context of an overall population message, advice or guidance.’

These bald assertions were based on private meetings held between Petticrew and two alcohol researchers, Jurgen Rehm and Tim Stockwell, a fortnight earlier. As a result of this information, the minutes of the 25 June meeting state that the group ‘agreed that a key message from the Rehm/Stockwell discussion is that the evidence shows that any amount of alcohol increases the risk of cancer. Therefore it cannot be said that there is such thing as a “safe” limit.’

Here were the two central messages that would be transmitted, almost word for word, to the British public two and half years later — that the benefits of moderate consumption had been much exaggerated and there is no safe level of drinking. This new narrative appears to have arisen from nothing more than a private meeting with two researchers. Rehm has strong views on alcohol policy (he advises governments to ‘treat alcohol like tobacco’) and he is a respected alcohol researcher but his views, as ventriloquised by Petticrew, bear little relationship to what he told the BBC after the guidelines were announced. On BBC Radio 4’s More or Less programme, he made it clear that there was good evidence that moderate alcohol consumption reduced the risk of heart disease and other diseases. Rehm’s own research concluded that the protective effect of alcohol on heart disease was ‘hard to deny’ and not just for those who consume ‘half a drink a day’, as Petticrew claimed, but for larger quantities too. Rehm’s 2012 systematic review found that heart disease risk was at its lowest for men drinking around four units a day, with a lower optimal level for women.

While Rehm’s views may have been misreported by Petticrew, those of Tim Stockwell were not. Stockwell is the world’s most persistent and prominent critic of the evidence showing that moderate alcohol consumption saves lives. His various letters, editorials and studies casting doubt on the benefits of drinking were given a hugely disproportionate prominence in the 2016 guidance. It is telling that Petticrew’s first act was to approach Stockwell and allow his controversial opinion to frame the debate.

The other striking difference between the 1995 review and the 2016 review is the range of evidence put before the respective committees. Whereas the 1995 panel received dozens of submissions, the minutes of a March 2013 meeting show Sally Davies’s team explicitly rejecting a call for evidence, preferring instead to rely on their own wisdom. Several new reports were commissioned, but all were co-authored by members of the committee.

Most of these were commissioned from the Centre for Public Health at Liverpool John Moores University and co-written by Mark Bellis. One of them, entitled ‘A summary of the evidence of the health and social impacts of alcohol consumption’, did its utmost to cast doubt on the benefits of alcohol consumption.

Sceptics such as Stockwell often claim that non-drinkers have a lower life expectancy than moderate drinkers because many of them are unhealthy former drinkers. Despite many studies showing that moderate drinkers also live longer than lifetime abstainers, this zombie argument continues to be made and it reappeared in Bellis’s report for the committee. He was, however, forced to admit that studies which have controlled for this potential confounder still found a protective effect. The draft document concedes: ‘A few meta-analyses have sought to account for such bias, and based on the extent to which this misclassification error can be accounted for, compared with lifetime abstainers a protective association appears to remain for type-2 diabetes, ischaemic heart disease, and ischaemic stroke.’

This was undoubtedly true. The Liverpool report included a summary of epidemiological studies showing that risk from several major diseases is lowest for people drinking between 1.5 and 8.5 units a day and that risk only reverts to that of an abstainer at a level of at least 4 units a day (or 28 units a week). The authors did not dwell on this evidence. Instead, they immediately suggested that there were ‘further reasons to suggest that the beneficial effects of alcohol consumption may currently be overestimated’, a vague claim for which the only citation was an opinion piece by Tim Stockwell.

The Liverpool document has since been made available to the public but the published version has been edited to further obfuscate the benefits of drinking. Whereas it previously acknowledged the evidence that moderate drinking reduces the risk of type-2 diabetes, ischaemic stroke and heart disease, it now only mentions heart disease and Stockwell’s opinion is given added prominence. The passage quoted above has been replaced by the following: ‘A few meta-analyses have sought to account for such bias; for example a recent meta-analysis, which reported that light to moderate alcohol consumption was associated with a reduced risk of cardiovascular outcomes, included lifetime abstainers as a reference category in sensitivity analyses. However, Stockwell et al question the robustness of the conclusions generated from this literature…’

By November 2013, Mark Petticrew had already drafted the committee’s conclusions. He acknowledged that many studies have found a ‘J-shaped relationship between alcohol consumption and total mortality’ but after considering evidence from Liverpool John Moores University and his conversations with Rehm and Stockwell (no other evidence was mentioned) he claimed that the ‘estimates of the size of this protective [effect] are likely to be biased’. Petticrew had no such concerns about flaws in the epidemiology of cancer, however: ‘For cancers there is clear and consistent evidence of a linear relationship. Alcohol is carcinogenic with no safe lower limit.’

The draft guidelines concluded that the benefits of alcohol consumption, such as they were, mainly affected people over the age of 50 and only related to heart disease. The latter is untrue (the evidence before the committee clearly showed a protective effect for other diseases) and the former is largely irrelevant (heart disease is rare among people under 50). Despite portraying the benefits as only applying to older people, Petticrew advised against telling them to drink alcohol. ‘Discussion at previous meetings,’ he wrote, ‘was along the lines of: if someone >65 is not currently drinking, then the evidence is not strong enough to recommend them to start; however if they are currently drinking more than the lower limit, then they should reduce their consumption.’

It was becoming clear that the bar for what constituted good evidence was being set much higher for benefits than it was for risks. The idea that the government should recommend moderate alcohol consumption to people who did not drink was regarded as unthinkable, regardless of the health benefits.

When a second draft of the guidelines was written at the end of January 2014, an even harder line was taken and a new argument had been found. Having whittled away the benefits of drinking until they applied only at a low level to a single disease among one section of the population, Petticrew explained that heart disease in Britain was not the killer it once was and, therefore, ‘irrespective of whether any protective effect is real or artefactual, any positive impact on total mortality is likely to decline as mortality from IHD [ischaemic heart disease] continues to decline’. No one seems to have raised the possibility that heart disease rates have declined in the last 50 years partly as a result of rising alcohol consumption, nor was it pointed out that heart disease — declining though it may be — still kills more people than all the ‘alcohol-related’ cancers combined.

At this stage, however, there was little to suggest that the male drinking guidelines would be reduced to bring them in line with those of women. The Liverpool report had shown clear differences in risk for men and women, and a presentation viewed by the committee on 10 September 2013 showed different J-curves for both sexes. The draft conclusions of November 2013 noted that alcohol’s ‘cardioprotective effect on total mortality is observed at a much lower level of consumption for women’ and almost every country in the world has higher guidelines for men.

This began to change after the committee, via Public Health England (PHE), commissioned some computer modelling to help formulate the final guidelines. In the minutes of a September 2014 meeting it was noted that ‘the PHE tender exercise had resulted in just one bid and that the bidder would be interviewed in early October to explore their proposals’. We must presume that the lone bidder was Petra Meier and John Holmes’s team at Sheffield University since it was they who won the contract.

It remains puzzling why a theoretical model was deemed necessary when so much epidemiological data exists to show the effect on morbidity and mortality from different levels of alcohol consumption. We may never know how the model was put together — the published Sheffield report does not provide enough data to allow independent replication — but one thing is clear: its risk curves bear no relationship to any risk curves in the published epidemiological literature. Whereas observational epidemiology shows lower rates of mortality for people drinking up to 4-8 units per day, the Sheffield model suggests that drinkers’ mortality risk is lower than abstainers only at very low intakes and exceeds that of abstainers at around two units per day. Moreover, while epidemiological studies find that men can drink more than women before assuming the same risk as a teetotaller, the Sheffield report finds similar limits for both sexes.

It is not even clear what the Sheffield report is measuring. The key criterion for gauging a safe drinking level is the risk of death, ie mortality risk, but the Sheffield report instead focuses on mortality from ‘chronic alcohol-related causes’. It is obvious that non-drinkers are less likely to die from alcohol-related causes, but it tells us nothing about overall mortality.

Moreover, the team stripped out all health benefits from drinking with the exception of heart disease. In their response to a comment from the peer-reviewer (who, interestingly, said ‘I predict that there will be very little, if any, change to the guidelines’), the team stressed that ‘excepting cardioprotective effects, the report focuses exclusively on the negative consequences of drinking’. This was certainly true and, like Petticrew and Bellis, the Sheffield team went out of their way to cast doubt on the cardiovascular benefits. In the space of two sentences, they described the protective effect on the heart as ‘disputed’, ‘overestimated’ and suggested that the scientific consensus was moving towards the view that the benefits barely existed at all. This passage contains ten references, half of which were articles or op-eds written by Tim Stockwell.

In short, the Sheffield team produced a theoretical model that was entirely divorced from the epidemiological evidence. The model appeared to show that a ‘safe’ level of drinking — if defined as carrying no more risk than abstaining from drink — was significantly lower than had been reported in a large body of epidemiological research. The model also deviated from observational epidemiology by showing this ‘safe’ level to be similar for men and women alike. Indeed, it actually reported a higher level for women. When a computer model clashes with observed reality so conspicuously, it is time to bin the model. Instead, the CMO’s committee binned the real world evidence and used the model as the basis of its recommendations.

By April 2015, the only question was how to sell the new advice to the public. Having failed to completely erase the health benefits of drinking, the group were concerned about the public being encouraged to drink even small quantities of alcohol. The group emphasised that there was ‘now no justifiable case to recommend that anyone should choose to start drinking alcohol in the interests of their health’. Their message to those who already drank below the current lower risk limit was that ‘should they wish to reduce their frequency or levels of drinking, [they] need have no health concerns in doing so’. Whatever the evidence might say, there was no doubt that the committee favoured total abstinence: ‘The message is quite clear that any level of drinking can be harmful to health’.

The statistician David Speigelhalter, who acted as an adviser to the committee in the latter stages, told them that ‘a message that “there is no safe lower limit” would risk being at odds with public opinion’, but it barely seemed to matter if the public found the new guidelines credible or realistic. A telling comment in one set of minutes indicates that the real intention was to influence policy: ‘It would be important to bear in mind that, while guidelines might have limited influence on behaviour, they could be influential as a basis for government policies, which could in turn help to alter norms.’

The new guidelines were announced on 8 January 2016. The committee had made every effort to downplay the benefits of moderate drinking, and Sally Davies delivered the final blow by dismissing those benefits as ‘an old wives’ tale’ on the Today programme. Nearly three years after cramming her committee with temperance campaigners and ‘public health’ activists, Davies went further than even Tim Stockwell could ever have hoped when he had that first chat with Mark Petticrew in June 2013. The job was done.

Cross-posted from Spectator Health

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The drinking guidelines were set by temperance zealots

First published by Spectator Health in February 2016 


I've been reading the minutes of the meetings held by the committee that reviewed the alcohol guidelines recently. You may recall that this was the first full review since 1995 and led to the Chief Medical Officer (CMO), Sally Davies, lowering the recommendations for men from 21 to 14 units a week. The female guidelines were left at 14 units. She also claimed that the health benefits derived from moderate drinking were an ‘old wives’ tale’ and claimed that there was ‘no safe level of alcohol’.

The most striking difference between the 1995 review and the 2016 review is the make-up of the panels. Whereas the 1995 committee was dominated by civil servants who had no obvious prejudices for or against alcohol, the meetings held from March 2013 to discuss alcohol guidance were dominated by activist academics and temperance campaigners.

The Institute of Alcohol Studies (IAS), a small but hardline anti-alcohol organisation, was heavily represented on the committee. The IAS was formed in the 1980s as a direct successor to the UK Temperance Alliance which, in turn, had been formed out of the ashes of the UK Alliance for the Suppression of the Traffic of All Intoxicating Liquors, a prohibitionist pressure group. The IAS receives 99 per cent of its income from the Alliance House Foundation whose official charitable objective is ‘to spread the principles of total abstinence from alcoholic drinks’. Its director, Katherine Brown, was on the CMO’s panel, as was its ‘expert adviser’ Gerard Hastings, although he failed to disclose his IAS role in his declaration of interests.

The IAS’s scientific adviser Petra Meier was also on the committee and was joined by her Sheffield University colleague John Holmes. Holmes and Meier are both strong advocates for minimum pricing and helped develop a computer model which has been repeatedly used to promote minimum pricing by producing estimates of the number of lives that will supposedly be saved by the policy.

Another staunch anti-alcohol campaigner, Ian Gilmore (chairman of the Alcohol Health Alliance, of which the IAS is a key member), was unable to attend the first meeting but was involved thereafter. Gilmore has campaigned for many years for higher alcohol taxes, minimum pricing and a total ban on alcohol advertising.

Other members of the committee may have been less strident than Gilmore and the IAS but there was no doubt where their biases lay. Mark Bellis wrote an article for the British Medical Journal in 2011 complaining that existing alcohol guidance was too generous and ‘read more like an alcohol promotion slogan’. Mark Petticrew and Theresa Marteau are both strong advocates of a range of heavily interventionist ‘public health’ policies, including sugar taxes, plain packaging and minimum pricing.

Of those who attended the initial meetings in 2013, only three did not explicitly advocate stricter alcohol control: the health economist Martin Buxton, the health sociologist Sally Macintyre, and the epidemiologist Valerie Beral. The latter appears to have been selected because of her research linking alcohol to breast cancer, which would become a crucial element in the ‘no safe level’ narrative.

The minutes of a meeting in June 2013 indicate that the path towards dismissing the benefits of moderate alcohol consumption was mapped out from an early stage. Mark Petticrew told his new colleagues: ‘The beneficial effects of alcohol consumption, where they are evidenced, are limited to a low consumption level of half a drink per day.’ Moreover, he said, ‘The population cohort who experiences any beneficial health effect from alcohol is very small. Given these limitations, there is an argument that beneficial effects could be considered not to be relevant in the context of an overall population message, advice or guidance.’

These bald assertions were based on private meetings held between Petticrew and two alcohol researchers, Jurgen Rehm and Tim Stockwell, a fortnight earlier. As a result of this information, the minutes of the 25 June meeting state that the group ‘agreed that a key message from the Rehm/Stockwell discussion is that the evidence shows that any amount of alcohol increases the risk of cancer. Therefore it cannot be said that there is such thing as a “safe” limit.’

Here were the two central messages that would be transmitted, almost word for word, to the British public two and half years later — that the benefits of moderate consumption had been much exaggerated and there is no safe level of drinking. This new narrative appears to have arisen from nothing more than a private meeting with two researchers. Rehm has strong views on alcohol policy (he advises governments to ‘treat alcohol like tobacco’) and he is a respected alcohol researcher but his views, as ventriloquised by Petticrew, bear little relationship to what he told the BBC after the guidelines were announced. On BBC Radio 4’s More or Less programme, he made it clear that there was good evidence that moderate alcohol consumption reduced the risk of heart disease and other diseases. Rehm’s own research concluded that the protective effect of alcohol on heart disease was ‘hard to deny’ and not just for those who consume ‘half a drink a day’, as Petticrew claimed, but for larger quantities too. Rehm’s 2012 systematic review found that heart disease risk was at its lowest for men drinking around four units a day, with a lower optimal level for women.

While Rehm’s views may have been misreported by Petticrew, those of Tim Stockwell were not. Stockwell is the world’s most persistent and prominent critic of the evidence showing that moderate alcohol consumption saves lives. His various letters, editorials and studies casting doubt on the benefits of drinking were given a hugely disproportionate prominence in the 2016 guidance. It is telling that Petticrew’s first act was to approach Stockwell and allow his controversial opinion to frame the debate.

The other striking difference between the 1995 review and the 2016 review is the range of evidence put before the respective committees. Whereas the 1995 panel received dozens of submissions, the minutes of a March 2013 meeting show Sally Davies’s team explicitly rejecting a call for evidence, preferring instead to rely on their own wisdom. Several new reports were commissioned, but all were co-authored by members of the committee.

Most of these were commissioned from the Centre for Public Health at Liverpool John Moores University and co-written by Mark Bellis. One of them, entitled ‘A summary of the evidence of the health and social impacts of alcohol consumption’, did its utmost to cast doubt on the benefits of alcohol consumption.

Sceptics such as Stockwell often claim that non-drinkers have a lower life expectancy than moderate drinkers because many of them are unhealthy former drinkers. Despite many studies showing that moderate drinkers also live longer than lifetime abstainers, this zombie argument continues to be made and it reappeared in Bellis’s report for the committee. He was, however, forced to admit that studies which have controlled for this potential confounder still found a protective effect. The draft document concedes: ‘A few meta-analyses have sought to account for such bias, and based on the extent to which this misclassification error can be accounted for, compared with lifetime abstainers a protective association appears to remain for type-2 diabetes, ischaemic heart disease, and ischaemic stroke.’

This was undoubtedly true. The Liverpool report included a summary of epidemiological studies showing that risk from several major diseases is lowest for people drinking between 1.5 and 8.5 units a day and that risk only reverts to that of an abstainer at a level of at least 4 units a day (or 28 units a week). The authors did not dwell on this evidence. Instead, they immediately suggested that there were ‘further reasons to suggest that the beneficial effects of alcohol consumption may currently be overestimated’, a vague claim for which the only citation was an opinion piece by Tim Stockwell.

The Liverpool document has since been made available to the public but the published version has been edited to further obfuscate the benefits of drinking. Whereas it previously acknowledged the evidence that moderate drinking reduces the risk of type-2 diabetes, ischaemic stroke and heart disease, it now only mentions heart disease and Stockwell’s opinion is given added prominence. The passage quoted above has been replaced by the following: ‘A few meta-analyses have sought to account for such bias; for example a recent meta-analysis, which reported that light to moderate alcohol consumption was associated with a reduced risk of cardiovascular outcomes, included lifetime abstainers as a reference category in sensitivity analyses. However, Stockwell et al question the robustness of the conclusions generated from this literature…’

By November 2013, Mark Petticrew had already drafted the committee’s conclusions. He acknowledged that many studies have found a ‘J-shaped relationship between alcohol consumption and total mortality’ but after considering evidence from Liverpool John Moores University and his conversations with Rehm and Stockwell (no other evidence was mentioned) he claimed that the ‘estimates of the size of this protective [effect] are likely to be biased’. Petticrew had no such concerns about flaws in the epidemiology of cancer, however: ‘For cancers there is clear and consistent evidence of a linear relationship. Alcohol is carcinogenic with no safe lower limit.’

The draft guidelines concluded that the benefits of alcohol consumption, such as they were, mainly affected people over the age of 50 and only related to heart disease. The latter is untrue (the evidence before the committee clearly showed a protective effect for other diseases) and the former is largely irrelevant (heart disease is rare among people under 50). Despite portraying the benefits as only applying to older people, Petticrew advised against telling them to drink alcohol. ‘Discussion at previous meetings,’ he wrote, ‘was along the lines of: if someone >65 is not currently drinking, then the evidence is not strong enough to recommend them to start; however if they are currently drinking more than the lower limit, then they should reduce their consumption.’

It was becoming clear that the bar for what constituted good evidence was being set much higher for benefits than it was for risks. The idea that the government should recommend moderate alcohol consumption to people who did not drink was regarded as unthinkable, regardless of the health benefits.

When a second draft of the guidelines was written at the end of January 2014, an even harder line was taken and a new argument had been found. Having whittled away the benefits of drinking until they applied only at a low level to a single disease among one section of the population, Petticrew explained that heart disease in Britain was not the killer it once was and, therefore, ‘irrespective of whether any protective effect is real or artefactual, any positive impact on total mortality is likely to decline as mortality from IHD [ischaemic heart disease] continues to decline’. No one seems to have raised the possibility that heart disease rates have declined in the last 50 years partly as a result of rising alcohol consumption, nor was it pointed out that heart disease — declining though it may be — still kills more people than all the ‘alcohol-related’ cancers combined.

At this stage, however, there was little to suggest that the male drinking guidelines would be reduced to bring them in line with those of women. The Liverpool report had shown clear differences in risk for men and women, and a presentation viewed by the committee on 10 September 2013 showed different J-curves for both sexes. The draft conclusions of November 2013 noted that alcohol’s ‘cardioprotective effect on total mortality is observed at a much lower level of consumption for women’ and almost every country in the world has higher guidelines for men.

This began to change after the committee, via Public Health England (PHE), commissioned some computer modelling to help formulate the final guidelines. In the minutes of a September 2014 meeting it was noted that ‘the PHE tender exercise had resulted in just one bid and that the bidder would be interviewed in early October to explore their proposals’. We must presume that the lone bidder was Petra Meier and John Holmes’s team at Sheffield University since it was they who won the contract.

It remains puzzling why a theoretical model was deemed necessary when so much epidemiological data exists to show the effect on morbidity and mortality from different levels of alcohol consumption. We may never know how the model was put together — the published Sheffield report does not provide enough data to allow independent replication — but one thing is clear: its risk curves bear no relationship to any risk curves in the published epidemiological literature. Whereas observational epidemiology shows lower rates of mortality for people drinking up to 4-8 units per day, the Sheffield model suggests that drinkers’ mortality risk is lower than abstainers only at very low intakes and exceeds that of abstainers at around two units per day. Moreover, while epidemiological studies find that men can drink more than women before assuming the same risk as a teetotaller, the Sheffield report finds similar limits for both sexes.

It is not even clear what the Sheffield report is measuring. The key criterion for gauging a safe drinking level is the risk of death, ie mortality risk, but the Sheffield report instead focuses on mortality from ‘chronic alcohol-related causes’. It is obvious that non-drinkers are less likely to die from alcohol-related causes, but it tells us nothing about overall mortality.

Moreover, the team stripped out all health benefits from drinking with the exception of heart disease. In their response to a comment from the peer-reviewer (who, interestingly, said ‘I predict that there will be very little, if any, change to the guidelines’), the team stressed that ‘excepting cardioprotective effects, the report focuses exclusively on the negative consequences of drinking’. This was certainly true and, like Petticrew and Bellis, the Sheffield team went out of their way to cast doubt on the cardiovascular benefits. In the space of two sentences, they described the protective effect on the heart as ‘disputed’, ‘overestimated’ and suggested that the scientific consensus was moving towards the view that the benefits barely existed at all. This passage contains ten references, half of which were articles or op-eds written by Tim Stockwell.

In short, the Sheffield team produced a theoretical model that was entirely divorced from the epidemiological evidence. The model appeared to show that a ‘safe’ level of drinking — if defined as carrying no more risk than abstaining from drink — was significantly lower than had been reported in a large body of epidemiological research. The model also deviated from observational epidemiology by showing this ‘safe’ level to be similar for men and women alike. Indeed, it actually reported a higher level for women. When a computer model clashes with observed reality so conspicuously, it is time to bin the model. Instead, the CMO’s committee binned the real world evidence and used the model as the basis of its recommendations.

By April 2015, the only question was how to sell the new advice to the public. Having failed to completely erase the health benefits of drinking, the group were concerned about the public being encouraged to drink even small quantities of alcohol. The group emphasised that there was ‘now no justifiable case to recommend that anyone should choose to start drinking alcohol in the interests of their health’. Their message to those who already drank below the current lower risk limit was that ‘should they wish to reduce their frequency or levels of drinking, [they] need have no health concerns in doing so’. Whatever the evidence might say, there was no doubt that the committee favoured total abstinence: ‘The message is quite clear that any level of drinking can be harmful to health’.

The statistician David Speigelhalter, who acted as an adviser to the committee in the latter stages, told them that ‘a message that “there is no safe lower limit” would risk being at odds with public opinion’, but it barely seemed to matter if the public found the new guidelines credible or realistic. A telling comment in one set of minutes indicates that the real intention was to influence policy: ‘It would be important to bear in mind that, while guidelines might have limited influence on behaviour, they could be influential as a basis for government policies, which could in turn help to alter norms.’

The new guidelines were announced on 8 January 2016. The committee had made every effort to downplay the benefits of moderate drinking, and Sally Davies delivered the final blow by dismissing those benefits as ‘an old wives’ tale’ on the Today programme. Nearly three years after cramming her committee with temperance campaigners and ‘public health’ activists, Davies went further than even Tim Stockwell could ever have hoped when he had that first chat with Mark Petticrew in June 2013. The job was done.

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