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Evidence for alcohol policy is still uncertain and it’s time to admit it

Public divided over minimum unit pricing.

The government recently attracted criticism after announcing a plan to ban the sale of alcohol at below cost price in England and Wales. The controversy was unsurprising. After all, in the past two years, the coalition has reeled from one alcohol pricing initiative to the next with all the composure of the inveterate binge drinkers they claim to be targeting.

In 2012, they supported a minimum unit price (MUP) of 40-45p, insisting that “all the evidence” backed up this policy, before backtracking in 2013 and blaming “a lack of conclusive evidence”. Now they announce a much lower minimum price (duty plus VAT), claiming this will save public money by reducing alcohol-related crime and ill-health. Health experts have attacked this measure as inadequate, accusing ministers of succumbing to pressure from the drinks industry.

While the drinks industry is undoubtedly a lobbying force, there is more to this issue than a neo-liberal prioritisation of private profit over public health. The crucial tension here is between government for the people and government by the people.

Public opinion matters

Stephen Turner, a social scientist from Florida University, has explored how distinguishing these two concepts can help illuminate conflicts of expertise versus popular will, or paternalism versus representative government. In short, policies which have tangible benefits for the people are not always favoured by majority opinion expressed by the people.

This is pertinent to alcohol policy for two reasons. First, public opinion appears to be either divided over MUP or mainly opposed to it. While the democratic imperative of government by the people doesn’t shape policy in a direct or straightforward way, MPs in a hung Parliament facing an election in 2015 will clearly seek to avoid antagonising any significant portion of the voting public.

Second, governing for the people requires a clear, objective understanding of what is actually in the people’s best interests. A notable problem here is that there is considerable uncertainty about what a moderate, safe or responsible form of drinking actually entails.

Medical advice on acceptable levels of drinking changes over time and varies substantially between countries. The current official advice in the UK is that men should not exceed 21 units per week (3-4 per day) and women 14 units per week (2-3 per day). But this is also challenged by experts who stress that all drinking involves risk. This uncertainty about what is in people’s best interests makes any genuine attempt to govern for the people difficult.

The uncertainty derives largely from difficulties in establishing the cause of alcohol-related harm. With regard to crime, there is clearly an association between drinking and offending – particularly violent offending – but the precise causal connection remains unclear. There is ambiguity in the extent to which intoxicated offending results from the physiological effects of consuming alcohol, the acting out of learned patterns of intoxicated behaviour or something else.

When it comes to health problems, there is more detailed clinical and epidemiological knowledge about the connections of alcohol to harm but it is still not possible, for most conditions, to look at the assembled evidence and discern a form or quantity of drinking that will or won’t result in harm to any individual drinker. And this blurred vision is at the root of the international and historical variation in advice given on moderate drinking. It is also the reason why statements about how much crime and illness would be prevented or public money saved by specific pricing policies are usually questionable.

In his 2008 annual report, then Chief Medical Officer Liam Donaldson promoted an MUP of 50p by asking people to “imagine a country in which nobody is physically or sexually assaulted because of alcohol, nobody dies in an accident caused by alcohol …” It was a wilful act of hyperbole which suggested that MUP could actually eradicate, not reduce, alcohol-related harm. Donaldson’s statements were at the sillier end of the spectrum, but even other projections of harm-reduction that are more carefully calculated encompass some uncertainty.

Confronting uncertainty

The problem is that this uncertainty is rarely acknowledged in public and political discourse. Public health campaigners routinely tell us that the evidence is there and it is overwhelming, as if recognising uncertainty – about harm causation or the realistic capacity of certain policies to reduce it – means losing any sway over public opinion or government policy.

In a recent contribution to Sociologies of Moderation, I argued that the tension between government for the people and government by the people might be better mitigated if uncertainty is confronted rather than circumvented. I suggest two ways of helping achieve this: uncertainty must be acknowledged in order to help create a more transparent debate about alcohol and build greater public trust in science; and wider public debates about alcohol policy need to engage much more extensively with public opinion. This includes public opinion about various policies as well as public views on drinking generally.

I can’t claim to be entirely certain about this, but a more open, inclusive and reasoned dialogue about alcohol and how it should be regulated should result from these measures. Ultimately, this may produce clearer, more coherent alcohol policies.

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