Trends in alcohol consumption and deaths – Must what comes down go back up?

This guest post by John Holmes orginally appeared on his personal blog, APE: Alcohol Policy and Epidemiology and has been reproduced with his permission. The piece represents his views only and not those of the Sheffield Alcohol Research Group.

In April, a BMJ analysis piece by Nick Sheron and Ian Gilmore argued that the recent downward trend in alcohol-related deaths in England and Wales was most likely caused by economic factors.  In particular, it pointed to the global recession and the alcohol duty escalator which, between 2008 and 2013, raised alcohol taxes by 2% above inflation each year.  Sheron and Gilmore’s main concern was that the combination of subsequent duty cuts and the UK’s economic recovery mean “the relentless rise [in alcohol-related deaths which preceded the downturn] is likely to resume as incomes outstrip rises in taxation”.

Support for this gloomy outlook followed in May when NHS Health Scotland’s MESAS project published its annual summary of alcohol sales data.  The headline figures for England and Wales showed that the amount of pure alcohol sold per adult increased slightly in 2015 from 9.0 to 9.1 litres after declining from 2005 to 2013 and holding steady in 2014.  Whether alcohol sales will continue to rise and trigger increases in alcohol-related mortality is unclear but, at first glance, Sheron and Gilmore seem to be on firm ground with their predictions.  However, I am unconvinced for two reasons.

First, although there is ample evidence that economic factors influence alcohol consumption and related harm, other factors also seem to be playing an important role in today’s alcohol market.  Most notably, the UK’s steady decline in youth drinking predates both the recession and the duty escalator and shows no signs of abating as economic trends reverse.  Instead, a wide range of hypotheses with little connection to economic factors have been proposed to explain why today’s youth are turning their backs on alcohol.  These include increased health consciousness, the rise of the internet, better enforcement around underage sales, changes in parental attitudes and practices, increased educational pressures, a desire for more diverse life experiences and migration from abstemious societies.  Notably, several of these hypotheses do not exclusively apply to young people and may also explain declines in consumption among older populations.  So yes, an improving economy and tax cuts may lead drinkers to consume more than would they would otherwise have been the case, and we should not be blasé about the consequences.  However, it is also possible that economic forces will not be sufficient to outweigh other countervailing forces pushing alcohol trends in the opposite direction.

Second, Sheron and Gilmore’s prediction rests heavily on the total consumption or population model of alcohol policy.  This model has been around for decades and comes in both refined and crude forms, but the heart of the argument (i.e. the crude version) is that when average levels of alcohol consumption in a population go up, alcohol-related harm in that population also tends to go up.  Superficially, this proposition is unproblematic and the general tendency has ample supporting evidence.  However, things can get messy when the average consumption trend is made up of lots of sub-trends going in opposite directions – and that is what has been happening in the UK in recent years.  Alongside sharp declines in youth drinking, we have also seen continuing increases in middle-aged women’s drinking, declines in male drinking, increases in female abstinence and an increasing share of the country’s alcohol consumption being accounted for by older age groups.  And that’s just the alcohol consumption trends.  Throw in migration from countries with different drinking cultures, a collapsing pub sector, an ageing population and attempts to diversify major sectors of the drinks market and claims that changes in a simple average will produce predictable outcomes starts to look somewhat shaky.

None of this is to say that we should be unconcerned about increases in the affordability of alcohol, particularly at the lower end of the market.  Alcohol Focus Scotland recently showed that it is still possible to buy cider for 18p per unit, lager for 26p per unit and vodka for 36p per unit in Scotland.  That means a woman can give herself a one-in-five chance of dying from alcohol and still have change from £10 each week. Meanwhile, researchers in Australia found that, like the UK, cheap alcohol in their country is disproportionately purchased by the heaviest drinkers on the lowest incomes who are at greatest risk of harm from their drinking.  So the economics of alcohol remains an important area for policy debate.  However, when considering where things are going in the future, we should be cautious in assuming that an economic recovery and tax cuts will see a decade of consumption declines revert to the post-war norm of increasing alcohol problems.  It may happen, but there are good reasons to hedge our bets and give greater attention to what is going on under the bonnet of our drinking trends to understand what the future may hold.

Comments

[Cjsnowdon]

A prudent note of caution about making predictions based on dogma from Dr Holmes.

Gilmore and Sheron's article was an obvious attempt to uphold two articles of faith in the 'public health' lobby. First, that consumption is overwhelmingly dictated by price. Second, that alcohol-related harm and mortality are directly tied to per capita consumption.

They do this by using graphs that appear to show both alcohol consumption and alcohol-related mortality peaking in 2008 and conclude that 'the trends in alcohol related deaths coincide with trends in consumption of cider, wine, and to some extent white spirits and strong lager, and are consistent with the population consumption theory'. But their figures for alcohol consumption are for total volume sold, not per capita (ie. they do not take the growing population into account).

Per capita figures are, of course, the appropriate measure but using them would mean having to admit that alcohol consumption fell between 2004-08 when there was no alcohol duty escalator and alcohol was becoming increasingly affordable. This basic mistake should have been picked up in peer review.

Some of us are still waiting for the 20% decline in alcohol-related deaths that should accompany the 20% decline in alcohol consumption under the whole population theory that Gilmore and Sheron openly endorse. Alcohol-related deaths per 100,000 people are only fractionally down on the number recorded when consumption was at its peak in 2004, to say nothing of alcohol-related hospital admissions which have risen. Indeed, it is interesting that Gilmore and Sheron DO say nothing about hospital admissions - a first for them? - presumably because they, too, do not fit the theory.