As the dust begins to settle after the revised alcohol guidelines were announced last month, we invited a few selected experts for their reflections on the reaction and policy implications. Indeed a subsequent BMJ comment by Professor Theresa Marteau stating the guidelines 'may not reduce consumption directly' sparked further coverage and debate over the role of guidelines beyond informing individual decision making.
James Nicholls, Director of Research and Policy Development, Alcohol Research UK, said:
"The publication of the revised alcohol guidelines has raised a number of interesting and important questions about health advice more broadly. On the one hand, it has triggered some productive discussion about how risk is calculated a communicated - and it would perhaps have been interesting if the consultation included an opportunity to consider the level respondents felt marked an ‘acceptable’ mortality risk. The reaction to the CMO’s call for people to think about cancer every time they approach a drink certainly suggested that risk-tolerance in the general population may be higher than among some public health professionals, for better or worse. On the other hand, questions are starting to emerge about wider knock-on effects. Although construed as advice for personal decision-making, in reality the guidelines will have important implications for issues such as how population-wide levels of ‘risky’ drinking are calculated and how screening and brief advice works in primary care. Both have the potential to influence policy and practice, making the guidelines much more than simple advice for healthy living."
"I wrote a piece for The Conversation arguing that the alcohol guidelines have become an annual dramatic media performance of policy, rather than an actual policy. I felt that the reaction to the guidelines, both in direct responses to my article and in general media coverage, supported my thesis. My point was not that the guidelines were misconceived, although I think they are for a number of reasons, but that they reflect a possibly unconscious but powerful tendency in policy to confuse media (and social media) reaction with more substantive outcomes. That the announcement received blanket media coverage would be seen by some as its own justification because putatively it 'raised awareness', but this, of course, reflects the logic of public relations rather than that of behavioural epidemiology. More importantly, policy that is inflected by the logic of PR displaces and distracts from more substantive policy measures. The more cynical observer might say substituting PR for policy serves the interests of the alcohol industry."
Professor Mark Petticrew, Professor of Public Health Evaluation at the London School of Hygiene and Tropical Medicine, who was on the Guidelines Development Group highlights a previously contentious issue:
"One other aspect of alcohol and health that is discussed in the report of the Guidelines Development Group to the CMOs is labelling. The report notes that “Consistent messages (developed and monitored independently from industry) should appear on all alcohol products again at stipulated sizes, colours and positions to ensure that health messages and guidelines are prominent”.
We already know that the provision of health information on labels is poor - the most recent report produced for the Portman Group by Campden BRI showed that many alcohol container labels do not clearly present the three required elements (i.e., the CMOs’ guidelines, the pregnancy warning and the unit alcohol content). This may be of particular relevance to women: wine is much less likely to include these elements; only 52% of wine labels include this information. We also know that the pregnancy logo is smaller on wine (which is more likely to be drunk by women) than on beer containers (more likely to be drunk by men). Current labelling practice therefore may make it more difficult for women to make informed decisions about their drinking."
William Haydock, Health Programme Advisor for Public Health Dorset & Visiting Fellow at Bournemouth University, openly reflects:
"Much of the commentary on the new drinking guidelines can be seen as a classic example of ‘normative misperception’. If we assume for a moment that many of those commenting on the guidelines are higher risk drinkers – who tend to see their own behaviour as perfectly normal and not worthy of comment – it’s not surprising they might object to being told they’re drinking above recommended limits. And these objections show exactly that misunderstanding of how much most people drink. To note that ‘the drinking habits of the vast majority of Britons are perfectly reasonable’ is true, but misses the point that these guidelines aren’t really aimed at most people, who already drink below both the old and new guidelines. Perhaps this debate is a timely reminder of the importance of behavioural interventions that make people aware of what ‘the norm’ actually is, so they can identify whether or not they're really part of that ‘vast majority’. (Disclaimer: I’m a ‘higher risk’ drinker myself.)"
Finally Nick Heather, Emeritus Professor of Alcohol & Other Drug Studies at Northumbria University, considers the rationale for having recommended guidelines despite much of the hostility towards them:
One of the main objections to ‘official’ drinking guidelines, including the recent CMO guidelines and earlier versions, is that drinkers don’t take any notice of them. This objection is frequently encountered in media comments on the guidelines and in general conversation “down the pub”. It has also been expressed in a scientific article in the journal Addiction by Melanie Lovatt and colleagues. Based on focus groups with drinkers in northern England and Scotland, these researchers found that “Current drinking guidelines were perceived as having little relevance to participants’ drinking behaviours and were generally disregarded”.
This is a statement of the blindingly obvious to anyone with any experience of British drinking culture but it entirely misses the one of the main points about the value of drinking guidelines. Some of the heavy drinkers interviewed by Lovatt et al. will eventually decide they want to reduce the harm they experience from drinking or, at least, cut down their risk of harm. When they do, they will need to know what to aim for – in other words, what level and pattern of drinking constitutes low risk. This is an issue of the self-control of behaviour or, in more scientific parlance, self-regulation as explored by Carver& Scheier. We self-regulate in order to bring our behaviour in line with standards, and clear and explicit standards are necessary to guide behaviour change. If one is aiming at total abstinence it is obvious what the standard should be; when reduced drinking is the objective, however, one needs to know exactly what counts as success – what lawyers call ‘bright lines’. To merely try to ‘drink less’, which would be the aim if drinking guidelines did not exist or were ignored, invites uncertainty and back-sliding and lowers the chances of successful behaviour change. This applies equally to formal treatment or brief interventions and to spontaneous attempts by people to cut down risky or harmful drinking on their own - and this, despite the findings of Lovatt et al., happens all the time and in large numbers in our society.
Beyond this justification for drinking guidelines, it should also be obvious that the public has a right to know the latest scientific evidence on the level and pattern of drinking that increases the risk of harm; imagine the outcry if it were discovered that scientists had kept this information to themselves! As this suggests, scientists have a duty to inform the general public about the latest, reliable evidence on alcohol-related harm. If people wish to ignore this evidence, that is up to them – it is (hopefully) still a free country. But if they are affected personally by the evidence and wish to do something about their drinking, clear guidelines will help them lower the risk of damage from it."
The consultation period runs until 1st April 2016 .