As Alcohol consumption falls: Need for a more nuanced understanding. –What does this mean for the Pub?

Recently I wrote that that I felt no matter how influential the public health community became it would always be a secondary consideration for policy makers because of the centrality of alcohol in the UK.  There are now some seismic shifts taking place that suggest this may in time be no longer the case.  The impetus for these changes is largely economic and I suspect the recent public health debate around alcohol is in reality something of a side show.  In retrospect historians may conclude that behaving as they did in the 1990s and early 2000s by promoting cheap alcohol alongside a message that alcohol equated to fun that different facets of the alcohol industry had begun to kill the goose that laid the golden egg.   Policy makers slowly began to perceive that certain aspects of the alcohol culture had become problematic and had to be addressed.

Readers who are familiar with my writings will know that I come from a perspective that public health considerations have to be regarded as equally important as commercial ones.  I make no apologies for this as I feel that the much demonised public sector have been left to mop up the excesses of UK alcohol culture, mainly in the form of the police and medical professions.    The need to reduce the level of alcohol related harm will remain paramount for at least another 20 years but thereafter I suspect the situation may change because slowly alcohol may take a less prominent role in many people’s lives.  I am beginning to question the need for minimum unit pricing as I think there is little doubt that consumption is falling overall.   However I think it is important to understand that this not a uniform across all age groups   

 I will largely confine my comments to the 18-65 age group, though even the most cursory of glances will confirm that much of the spending that drives the UK economy is driven by wealthy pensioners.  Much of this spending is by virtue of generous public  and private sector pension schemes and the historical accident of being able to make obscene profits merely by buying and living in property.  These opportunities will be denied to future generations.

Alcohol consumption for those 40-50 is largely stable.  There are people in this age group who have reduced their drinking but equally this is the group that seem to be most resistant to public health messages.  Many have lived through years of plenty and see little reason to change their behaviour. They have also been the group who have lived through a time when the alcohol industry was able to provide an unequivocal message that alcohol was intrinsic to having fun.  It is not very scientific but my recent experience of a night out may be illustrative.  My wife and I went out to a local restaurant; the majority of people there had more than a little grey hair.  The amount of alcohol being consumed by both genders was very noticeable.  Initially I ordered a bottle of wine and the waitress only bought one glass (for my wife).   Clearly this was something the waitress was used to doing and in fairness there was no embarrassment when I asked for another glass.  However it is indicative of the predominant culture at the restaurant and I saw no reason to think this was exceptional.  I suspect that some had been drinking before going out but that is for another day.  In short this is a group that will continue to sustain the current pub/restaurant model probably for another decade as they have disposable income and are part of a culture where excessive alcohol consumption is the norm.  However I feel it would be dangerous for pubs and restaurants to believe that younger generations will behave in the same way.

I am aware that some of these comments are generalisations and there will be exceptions that prove the rule but they contain more than an element of truth.  There is now a group of adults 30-40 who probably would have been inculcated with the message “alcohol is fun” and I expect would like to behave in the way described in the previous paragraph.  However this is the group who are truly facing the consequences of the money for UK PLC having run out.   Many are on low wages, short-term contracts, high rents and unlike previous generations unable to join the great property owning democracy.   Also there appears to be a marked reluctance to make provision for the future.    I may be wrong but I suspect in time one of the areas of their lives that will become of less importance, because it will be regarded as unaffordable, will be regular trips to the pub or restaurant.

The 18-30 age group present an even greater challenge for publicans and restaurateurs.  Despite what some of media would have us believe alcohol consumption in this group has been on a significant downward trend for a number of years.  Some writers have dubbed this group “The New Puritans.”   This is a bit misleading as they have not stopped drinking but often regard alcohol as less central to a night out than previous generations.  There may be many reasons for this, the distractions are greater- most notably the internet and social networks, money is tight, possibly the behaviours they have witnessed on the part of their elders they now regard as embarrassing rather than fun. 

There is another possibility, -that what is offered by the pub and restaurant may alienate some of this group.  Research now suggests that one of the reasons driving pre-loading is that pubs and restaurants do not provide an atmosphere interviewees regard as conducive to socialising.   It is also noteworthy that whilst pubs have become less appealing to this group drinking coffee and expensive afternoon teas have become increasingly popular.    I am now in mid fifties and I despair at the amount of pubs that have now been converted to gastropubs.   I want a pub to be somewhere I can have a drink without feeling at least a subtle pressure to eat a full priced meal.  This appears to be the dominant commercial model and I suspect there may be an important demographic who are alienated by these developments and importantly they have not been habitual pub users for over 30 years.

I make no apologies for wishing to see alcohol consumption on a downward trend but I think the amount of drinking taking place at home needs to be addressed.  My focus would be on reducing discount offers, and alcohol advertising and promotions but I would like to see the pub thrive.   It strikes me that there is an over-reliance on generations 40+ to sustain the current pub/restaurant model and this is short-termism.  To be brutal, the money will run out and in time this group will die out.  One possible reaction is to regard the current behaviour of young people as a statistical blip and they will in time return to the “alcohol is fun” fold.   They may, but this is a high-risk strategy and I am sure the alcohol industry does not need me to remind them of the importance of hooking them when young.  If this behaviour is maintained it is likely to be long term and possibly cross-generational. 

Thus far much research has focused upon cost as a prime driver of diminishing alcohol consumption.  It is clearly important and I would like to see measures that reduced the price gap between pubs and supermarkets but I also feel it is important for pubs and restaurants to consider that they may now offer a service some young people no longer want and possibly now find alienating.  I suspect if the fall in alcohol consumption in young people continues and is reflected in life-long behaviour then arguments concerning minimum unit pricing will be seen as diverting but of largely symbolic importance compared to wider cultural and economic changes.

PS:  On completion of this blog BBC news announced that it was highly likely that the proposals to introduce minimum unit pricing were likely to be withdrawn.  As I have said above I am less convinced of the need for minimum pricing but what I am now convinced of is the importance of minimising the impact of Big Alcohol on public health policy.  No doubt there is some smug triumphalism taking place in bodies such as the Wine and Spirits Trade Association, to which I say be careful what you wish for-public image is paramount.  This is not the result of a strategic withdrawal but craven capitulation driven by party political manoeuvring and hypocrisy.   Furthermore those sincere protestations from parts of the alcohol industry that do put a high emphasis on behaving responsibly will now have a hollow ring as “Big Alcohol” has been flushed out and shown to be morally bankrupt if it was ever in doubt.   Just one final thought- is “Big Alcohol” really interested in continuing the British pub model if it can sell the product elsewhere?

Dr John Foster is Principal Research Fellow at the University of Greenwich-School of Health and Social Care.  

Alcohol No Ordinary Commodity: Some Ramblings

Those of you with even a modicum of knowledge of alcohol policy will know that this title is not original but taken from a very famous book by Babor et al.  However it is a good way to introduce a few of my rambling thoughts on how normalised alcohol has become in our culture.  The stimulus for this was an encounter on twitter.  Many tweets (I am just of guilty of this) are bit jokey and often somewhat facile.  I received a tweet inviting all people following the strand to a school fete where high end vodka would be sold.  The school was in the independent sector and catered from children of all ages.  There was an interaction to establish what was taking place.  Apparently there was a licence for this event and it was not to promote the product.  Now I am sure academic careers have been made on discussing the distinction between promotion and selling but as the reasonable man it strikes me that the ultimate aim is the same-to sell more of the product.  In the past I have been a treasurer for a PTA and I know the financial pressures schools are under and I have no doubt this is perfectly legal but have we really reached a point where everything is a marketing opportunity?

It has been a couple of months since my last blog and in that time I have been involved in a rather bruising encounter with someone who represents the licence trade and it has become clear to me that if my experiences are typical there is now a chasm between the public health community and the alcohol industry in its many forms.  The gloves are off and it is imperative that we must stop scoring own goals.  I do not consider the recent decision on the part of the Office of National Statistics not to rely on alcohol attributable fractions when calculating alcohol related morbidity to be an own goal and accept that a case has been made that the way they are currently being used is not sufficiently robust to base policy decisions upon.  Furthermore they way they have been calculated has been transparent from day one.  However I have a plea.  Even if it prestigious to work with the BBC and I understand the need for sound bites, can we be transparent please.  Recently the University of Sheffield announced what turned out to be a fourfold overestimate of alcohol related morbidity/mortality in the elderly.  I looked in vain for details as to how the calculations were made as I doubted them but could not find any.  We all have deadlines to meet but if you are not sure, and the figures have not been adequately checked, don’t release them.   It is not merely the reputation of a prestigious department that is called into question but those of us who want to see some checks and balances in an atmosphere that increasing lauds unfettered capitalism.

Now back to the normalisation.  Over the past 10-15 years it has become increasingly commonplace to see two or three sections of a supermarket entirely devoted to selling alcohol, often at cut price.  Not to mention strategically placed bottles of wine at the end of aisles where no alcohol is sold to remind us to treat ourselves (if we had forgotten).   We will shortly be in the Christmas season and no doubt there will be more of this.  I note that in Northampton the large supermarkets are going to work with the police to prevent alcohol related crime over the Xmas season.  How is this going to tally with selling alcohol at discount prices?  Silly me, of course they will only sell to “responsible consumers.”  However we cannot entirely blame the supermarkets.  They are merely reflecting what we as customers expect and demand.  We seem quite happy to acquiesce in the supermarkets desire to treat buying alcohol as routinely as milk and bread.   How have we reached this state of affairs?   

In a post script a tweet was sent out on Saturday night thanking people for attending the fete with a photograph of the vodka attached saying that the majority was sold.  There were also a number of congratulatory tweets that followed.  It appears that as the country slides further to the right in a bid to become leaner and fitter (and for the vast majority significantly poorer) that we must all worship on the altar of unfettered capitalism regardless.  So it seems it is ok to sell alcohol at a Xmas school fete and nobody bats an eyelid.  I suggest at some point we appear to be losing the plot. 

Alcohol Addiction and Education: Some random thoughts

Over the past weekend I was involved in a twitter conversation and I happen to make the observation that alcohol consumption was linked to price.  The reply which came from people I know to be health professionals left me a little surprised.  The link between alcohol and price was doubted and then a comment was made how will this help the addict?  Further conversation stressed the need for more education.   Clearly there are evidential blind spots in operation here.  Lets deal with price first.  As the alcohol industry will not tire of tell you there is no proof of a causal relationship between alcohol consumption and price.  In this they are correct, but what they won’t say is when looking at wider population effects this is almost impossible to show.  What we have is the very next best thing, a plethora of cross-cultural/international evidence that shows there is a strong relationship with greater levels of alcohol-related harms and low priced alcohol.  Paying a realistic price helps the addict because it means that alcohol is not so ingrained into our culture. 

Secondly the panacea of education that is often beloved of health professionals and certainly the alcohol industry largely because it makes barely a dent in their profits.  I support alcohol education so long as it is delivered in an evidence based way-which unfortunately is rare.  But even when delivered according to the evidence, behavioural change is minimal.  The alcohol industry loves it because it gives the impression of doing something but in reality has a minimal effect.  The result of education is to increase knowledge but the evidence for behaviour change is very weak, indeed sometimes it has shown that it encourages rather discourages experimentation.  So please let us have evidence driven education programmes but accompanied by measures that really will have an impact;-increase in price and reduction of availability.

Especially whenever representatives of the alcohol industry are asked to comment on consumption the spectre of the predominance of the responsible drinker or consumer is raised-ergo people who are not responsible are "spoiling the fun of the majority.”  Alcohol is fun I am a drinker and most of time I consume responsibly but there will be occasions when I don’t but I think elements of “fun for the majority” need to be unpacked.  It may be a bit po-faced but I despair of some of the attitudes that surround drinking.  I have lost count of the number of times I have heard comments along the lines of when I get home “there will be a nice glass of something cold waiting for me.”  Notwithstanding the inherent dangers of using alcohol as a reward (see my last blog-Home drinking: because I am worth it) if the words “glass of something cold” was replaced with “a joint” “ a valium”, “line of coke” “syringe of heroin” it does not quite have the same ring.

This week I read something that threw into sharp relief the dysfunctional culture that surrounds drink.  Devon and Cornwall police returned 27 sixteen year old youths staying as a group without their parents in Newquay who were “running riot” having  smashed up their rented accommodation whilst on drunken sprees with alcohol brought down from Bristol, Birmingham and Guildford respectively.   For some on twitter apparently this was caused by a “lack of alcohol education.”  If ever there is a case of the horse having bolted this is it.  I am less critical of the young people than their parents.  Nice to give someone a rite of passage provided other people pick up the tab.  No doubt most of the parents would regard themselves as responsible I beg to differ, I shudder to think what messages they have been given albeit not consciously concerning how alcohol is fun.  Education has no chance when it is undermined in such a manner by our wider culture.  

Now for some final thoughts about addiction, I welcome more treatment services but I also feel that wider society can help the addict by realising that an addiction is just the extension of an unhealthy habit and “there but for the grace of God go I.”  I have worked with individuals who were addicted to alcohol for many years and understand from talking to many of them that the main challenge they face is relapsing on leaving treatment services.  They will describe putting themselves in situations where eventually they are overwhelmed by cues. (although they are unlikely to use such a word) usually in response to a stressful situation or wishing to test themselves.  A cue is something that they associate with drinking, such as a pub, going back to areas where they drank, the smell of alcohol.  I spoke to someone recently who had been drinking for many years and could provide a thirty year perspective.  The main challenge he now faces is that alcohol is far easier to obtain and cheaper- he stressed the role of supermarkets in making alcohol easily available. 

The addict plays a vital role in helping to persuade ourselves that we are not like him or her for we use alcohol “responsibly”.  I may be making a utopian suggestion here, but if we paid a realistic price for alcohol, accepted some restrictions on its’ availability and examined some of our own beliefs and attitudes to alcohol we might be creating a creating a healthy culture for us all and at the same time making recovery for those who have become addicted to alcohol just a little bit easier.

Dr John Foster is Principal Research Fellow at the University of Greenwich-School of Health and Social Care.   This blog represents my personal opinions and do not represent those of the University of Greenwich.

Home Drinking: "Because I'm worth it"

In my last blog I made a plea for greater use of the public house because it is a social environment in which to consume alcohol.  Arguably one of the biggest shifts in the UK alcohol culture over recent years has been the move towards drinking away from licensed premises.  There are a number of positive elements in the UK alcohol culture but it is questionable whether consuming more alcohol in our homes is one of them.  If there is a change I would like to see over time it is that alcohol plays a greater role in social culture rather than drinking filling a void because alcohol happens to be present.  The purpose of this article is to suggest that the rise of home drinking is a reflection of wider societal trends.  For the record I drink both at home and in a pub.

My research has shown that the reasons why individuals are increasingly choosing to drink at home can be collapsed around the themes of convenience, cost and relaxation (Foster and Ferguson 2012).  There are some positive reasons for drinking at home.  These include; firstly, parents who have young children and cannot afford childcare, secondly, not having to drink and drive, thirdly, parties and other social occasions with friends and family and finally, the smoking ban in licensed premises.   

In 1987 Margaret Thatcher was interviewed by Woman’s Own and made the following quote “There is no such thing as society.  There are individual men and women, and there are families.”  Some readers may feel that the best way to achieve optimal individual achievement is by reducing state involvement.  This is not a philosophy I share and the rise of home drinking could be a reflection of the way the England has moved further to right.   I am old enough to have seen the demise of socialism and the results of this.  In my opinion these are overall greater self interest and selfishness and a tendency to pull-up the draw bridge “so long as I an OK”.   Could home drinking be a metaphor of the rise of an increasingly self-centred society?

Some of the research concerning home drinking has shown that individuals like the freedom and “lack of surveillance “(Foster et al 2010) provided by home drinking compared to rules and regulations imposed in licensed premises.   This has been interpreted by Holloway et al (2008) as drinkers exercising autonomy.  Such phrases and the lazy cliché of the “Nanny State” concern me for recent history suggests that untrammelled individualism is not a good thing.  I am not sure there is empirical evidence but it strikes me that the more freedom an individual or an organisation is given the more self-centred and atomised they become and in time lack of regulation or boundaries can lead to increasingly destructive behaviours.  The reason why western capitalism is in chronic crisis is not due excessive state intervention or restrictive safeguards!   

Often when I listen to libertarians I am struck that they have a blind spot towards the fact that when exercising individual freedoms, the cost is often borne by others.   Higher levels of drinking much of which now takes place at home increases the risk of contracting some cancers, liver disease, hypertension and depression.  These result in health costs that are incurred by the general population either in reduced services or increased taxation.

The recently published Alcohol Strategy made the connection that many people were now using alcohol as way of coping with stress.  Using alcohol in such a way can take place in both licensed premises or at home, however if drinking at home is commonplace the likelihood of it becoming a “creeping reflex” is heightened.  I do not intend as a general rule to use this blog as a way of giving advice but on this occasion, I will make an exception.  Drug effects are the result of a combination of three interactions.  These are a) the pharmacological effect of the drug, b) the psychological make-up of the user including what they believe about the drug and c) the social context in which the drug is taken.  At lower doses b and c are likely to be the most important.     

The pharmacological effects of alcohol are dose related, this means that as more alcohol is consumed the pharmacological actions become predominant.  Alcohol is a sedative and depressant, the chemical action is not to relieve stress.  If an individual believes that alcohol helps them to relieve stress or is a reward after a hard day then this is known as an expectancy effect, it is not a chemical property of the drug.  When alcohol is used as an occasional relaxant then it is unlikely that consumption will increase, but the stronger the belief that alcohol helps to relieve stress the more likely such behaviour becomes habitual.  Tolerance occurs as the body and brain become more used to the drug and higher doses of the drug have to be taken to achieve the same effect.   Thus the probability is that consumption levels will creep upwards.  If this happens then the pharmacological effects of alcohol will become predominant, and the individual is likely to become more depressed and anxious.  Thus drinking to relieve stress can result in greater levels of depression and anxiety-presumably the opposite of the originally desired effect.

I will conclude with a thought about stress levels.  For previous generations many of whom are still alive, stress may well have meant whether they survived armed combat or a bombing raid.  Isn’t the belief that it is necessary for us to reward ourselves for having got through the day just a little self-indulgent?

References:

Foster JH and Ferguson C.  (2012).  Home Drinking in the UK: trends and causes

 Alcohol and Alcoholism, DOI 10.1093/alcalc/ags020

Holloway S, Jayne M and Valentine G. (2008) Sainsbury’s is my local’: English alcohol policy, domestic drinking practices and the meaning of home. Transactions of the Institute of British  Geography, 33,  532–547.

Dr John Foster is Principal Research Fellow at the University of Greenwich-School of Health and Social Care.   This blog represents my personal opinions and do not represent those of the University of Greenwich.

We are all poorer if we lose our local

 

There will no doubt be a plethora of comment concerning the proposal to introduce minimum pricing and I don’t propose to add much to it.  Except to say I am in favour and believe it will result in overall social benefit.  It is important for the proponents of minimum pricing to rebut the arguments put forward by such bodies as the British Retail Consortium that this will penalise the “responsible drinker.”  Highest estimates indicate that it will cost such a person approx £20, this is the price of a cheap concert ticket or modest three-course meal.  That’s all I wish to say about minimum pricing instead I wish to make a plea for us to support the British pub.

Following the budget the price of alcohol will rise above the level of inflation.  Due to their economies of scale the large supermarkets will absorb these.  However the pub will be forced to pass on these rises to the consumer or work on increasingly narrow profit margins.  I have recently published a review paper (Foster and Ferguson 2012) that pointed out the trend towards more drinking in our homes was long standing but now accelerating.  Home drinking is driven by cost, convenience and a perception alcohol is associated with rewarding a days work or childcare and intrinsic to relaxation and winding-down.  However arguably the most telling section of the paper was a Mintel internet survey (Mintel 2010) of adults showing 92 (11%) of those surveyed agreed that higher prices in supermarkets would not make them use pubs and bars more often.

Home drinking has clearly become a lifestyle choice for many people-does this matter?  A pub is much more than a place that sells alcohol or provides work.  In many places it is a social glue.  I come from the south west of England and have seen many villages that previously had a vibrant pub that has closed and have become virtual dormitories as a result.  Most thriving rural communities have a public house, post office and small supermarket (often the same place), once one of these goes the others swiftly follow and quality of life is diminished.  Some readers may feel this is the price of progress and are quite happy to buy virtually all their shopping under one roof but there are those left behind not able to exercise this option.  Many rural areas are low wage economies with at best unreliable public transport.  Using a pub cannot of itself ensure that an area retains its social coherence but losing may result in an isolated increasingly atomised area.

So how about if rather than bulk buying wine or beer on discount next time we embark on our weekly shop to accompany a la liga match or DVD box set, we made a conscious decision to spend that money and socialise in a public house.  Most pubs are well-run pleasant environments selling a selection of wines, beers and spirits and a licensee who has to achieve a balance between letting their customers enjoy themselves whilst ensuring safety for all.  It is not in their interests to let standards slip.  A pub that provides only alcohol is now unlikely to survive.  In the pubs that I use there are regular activities such as music events, movies, quiz nights and games such as dominos and cards to name but a few.  If you wish to you can watch Lionel Messi slalom through another hapless defence.   There is a return back to providing some of the social activities that used to characterise them in the 1970/80s but the environments are far more welcoming to men, women and at times children and the products being sold of a far higher quality. 

If we cease to become social beings, we care less about others or the environment in which we operate and we are all the poorer for it.  So let’s chose to spend some of our disposable income in a pub rather than at home.  It takes a little effort but it is worth it.          

Foster JH and Ferguson C. (2012) Home Drinking: A key challenge for Public Health. Alcohol and Alcoholism, DOI 10.1093/alcalc/ags020

Mintel. (2010) Alcohol purchasing in supermarkets-UK. URL:http://oxygen.mintel.com/sinatra/oxygen/display/id=481064.

This is my first attempt at a blog so bear with me.  I am an alcohol researcher and in time most of my comments will be around alcohol use in the UK but this morning an article on the BBC news had me spitting feathers.  In the forthcoming budget the Coalition Government intends to stop national public sector pay deals in a bid to allow private sector pay in the regions of the UK to catch up.

When is this demonisation of the public sector going to stop?  Shortly there will be an increase in public sector pension contributions and this is likely to reduce most public sectors disposable income by £40-60 per year that is over £500 possible spending money lost to the wider economy annually per head.  Something that is barely mentioned when bland and complacent comments are made about economic growth.

The result of regional pay deals is likely to mean diminished standards of living to all but the very rich-why?  One of the failures of all politicians is to be honest about current employment in the UK.  Often a picture of work practices 30 years ago is assumed.  Jobs if they can be found now are often poorly paid, part-time, short-term contracts and with minimal employment protection.  This is the Britain of the much vaunted private sector led economy.

Now you can argue about whether it was a good policy to spread many public sector jobs outside of London and the South East.  I live in London and originally come from the south west and can attest that generally the standards of living are far lower outside what I have heard called the "gated community inside the M25" than within it.  The impact of regional pay deals is the disparity between the south east and the rest of Britian is likely to get wider.  A public sector salary in an area outside of the south east (e.g Newcastle) is likely to provide a good standard of living but this also supports businesses and services in the local area.  There does seem to be a belief held by some that public sector workers dont pay taxes or contribute to the wider economy.  I very much doubt business in areas such as the North West, North East, South Wales and Central Scotland (already struggling) to name but a few are jumping for joy.

We are all going to be poorer.  The aim is to allow private sector salaries to catch up in the regions.  It is not going to happen because there are no jobs now and thus for the few that exist low salaries can be paid in the regions.  This is the law of the market and we all know where that has led us.  In short the private sector is not going to catch up because of the structural changes in employment which politicians of all hues fail to acknowledge.  As a result of these vindictive proposals the country becomes more divided, the middle is squeezed even harder. the rich get richer as we slide inexorably further to the right.