PROBLEM DRINKING: THE BIGGER PICTURE

The government's education-based 'sensible drinking' strategy for countering alcohol misuse is not evidence-based and is built on the false presuppositions that an intemperate minority contribute the bulk of alcohol related problems in the community and that people make rational and objective decisions about their drinking.

The research shows that alcohol related morbidity and mortality are directly related to the quantity of alcohol consumed by a population, which in turn is directly related to the availability and acceptability of alcohol in that population. This means that price is the major determinant of consumption, and taxation is a very effective preventive tool. At a deeper level alcohol dependence is a bio-psycho-social example of what can happen when something other than God becomes a top human priority.

Millions of us enjoy drinking alcohol with few, if any, ill effects. - Tony Blair, 2004

So begins the Prime Minister's introduction to the Alcohol Harm Reduction Strategy for England (AHRSE). (1) After reminding us that moderate drinking can produce some health benefits, Mr Blair laments the fact that 'alcohol misuse by a small minority' is responsible for two major problems: anti-social behaviour including crime, and harm to health. He advises that alcohol-related harm costs the country an estimated £20 billion per year.

The implication seems to be that our costly problems with alcohol are all due to a small minority of people who misuse alcohol. Ultimately, Mr Blair concludes, it is down to individuals to 'make informed and responsible decisions about their own levels of alcohol consumption'. This emphasis carries through into the Government's more recent white paper where provision of information and controls on advertising are emphasised as preventive strategies. (2)

This seems a very reasonable - indeed, a very Christian - position to take. Surely people are responsible for their behaviour in respect of drinking alcohol, as in every other area of life? And didn't the apostle Paul offer similar advice when he exhorted Christians to avoid drunkenness? (3) AHRSE would therefore appear to be right to emphasise education about sensible drinking. However, there are a number of problems with this approach.

Problems with sensible drinking

There is virtually no supporting research evidence regarding education on sensible drinking as a strategy for preventing alcohol problems. (4) In addition, there is also the prevention paradox. (5) This is based upon the observation that, whilst very heavy drinkers do incur more alcohol related problems, they are (as the Prime Minister observes) a small minority. Alcohol related problems occur much less frequently amongst the moderate majority, but this population is very large indeed. So, the mathematics of a lower problem rate amongst a very large number of people can still result in a larger overall number of problems than does a high rate amongst a very small number. In other words, the people who do not misuse alcohol at all often contribute the bulk of alcohol related problems in a community. The paradox is that prevention of alcohol problems in a population can therefore require us to give more attention to the moderate majority than the intemperate minority.

Sensible drinking
An upper limit of 14 UK units per week for women and 21 UK units per week for men. (6) It is wise to ensure at least one or two alcohol free days each week. (7)

Another problem with the sensible drinking approach is that it presumes that people make rational and objective decisions about their drinking without undue influence or constraint. In fact, we live in a society that puts all kinds of pressures on people in respect of their drinking. That people are not well informed is only part of the problem. Alcohol is promoted by the alcohol beverage industry and social expectations. Alcohol also itself impairs people's ability to make sensible decisions. A very complex and difficult balance between the benefits and risks of alcohol consumption needs to be achieved. Advice that is right for one person will be harmful for another.

Sensible policy and practice

Happily, evidence-based strategies relying on a population-based approach could bring about great benefit. Extensive research has shown that, over time and between populations, alcohol related morbidity and mortality are directly related to the quantity of alcohol consumed by a population, which in turn is directly related to the availability and acceptability of alcohol in that population. The real price (in relation to disposable income) is thus the major determinant, and taxation is a very effective preventive tool. (8) Other strategies include licensing laws, server liability laws (where vendors become responsible for ensuring underage or intoxicated drinkers are not served), and targeted contextual policies (for example, against drinking and driving). Treatment services are also important, and early interventions are effective amongst those at high risk. (9)

At the individual level, much the same principle applies. There will always be the exceptional person who drinks enormous quantities of alcohol without harm, or the truly modest drinker who does sustain harm; but, in general, the more an individual drinks the greater their risk of the whole range of alcohol related pathologies. Therefore, when consulting with individual patients, there is a role for the sensible drinking message as a valuable guide to practice.

Abstinence

Some Christians, and others, believe that complete abstinence is the best policy to prevent problems with alcohol. Notwithstanding the possible health advantages of alcohol consumption in relation to cardiovascular disease (in post-menopausal women and men over 40 years of age), there is no reason to dissuade those who adopt such a practice. But this does not mean that abstinence will appeal to everyone. Not only does scripture appear to indicate that Jesus drank wine, but in the fourth gospel an account is given of Jesus miraculously turning approximately 120 gallons of water into wine, for guests who had apparently already had a fair amount to drink. (10) Suggestions that this was in fact non-alcoholic wine are not generally convincing, and sometimes betray prior hermeneutical assumptions. Christians are warned against judging one another for making decisions to drink or not to drink. Indeed, to focus on either drinking or not drinking is inevitably to take the focus away from where it really belongs: 'For the kingdom of God is not food and drink but righteousness and peace and joy in the Holy Spirit'. (11)

Dependence

So far we have not touched on the important phenomenon of alcohol dependence. This is not because dependence is not important; certainly, it has great clinical significance. However, dependence can only be properly understood in its overall context as one of a series of alcohol related problems arising in populations where alcohol is consumed socially. Prevention of dependence is a part of the broader question of the prevention of alcohol related problems. But dependence does provide an interesting study of what can happen when things get out of hand. Whether primarily due to excessive consumption, social and psychological pressures, or biological vulnerability, individuals who become alcohol dependent show a significant preoccupation with alcohol. To a greater or lesser extent, their lives come to revolve around alcohol. As a result, they and others suffer.

Christians believe that life is lived most fully, creatively and joyfully when it revolves around God. Alcohol can be a part of such a life, as long as it remains subsidiary - a gift for which thanks are offered to God. Alcohol dependence is a biopsycho-social example of what can happen when something other than God becomes a top human priority. Of course, no one chooses to become dependent. It is the final outcome of a pathway, the beginning of which is often indiscernible and is embarked upon in company with others who do not look like they are misusing alcohol at all. Therefore, the only sure way to avoid dependence is not to drink at all. But alcohol is not the only thing that can usurp the place of God in human lives and worshipping God is not simply a question of avoiding all risks in life.

Conclusions

Christians may rightly emphasise proper responsibility in the use of all created things, not least alcohol. Therefore, we can conclude sensible drinking guidelines do have a part to play in guiding clinical practice. But it is also proper to look for public policies that are evidence based; research suggests that, for alcohol, more than education is required. Governments must not imagine that education of the individual absolves them of their responsibility to take effective action for the public good.

References

• Prime Minister's Strategy Unit. Alcohol Harm Reduction Strategy for England. London: Strategy Unit, 2004:2
• Department of Health. Choosing Health: Making Healthy Choices Easier. London: The Stationery Office, 2004:27
• Romans 13:13; Galatians 5:21
• Babor T et al. Alcohol: No Ordinary Commodity. Oxford: Oxford University Press, 2003:189-207
• Kreitman N. Alcohol consumption and the prevention paradox. British Journal of Addiction 1986; 81:353-363
• Royal College of Physicians, Royal College of Psychiatrists, Royal College of General Practitioners. Alcohol and the Heart in Perspective: Sensible Limits Reaffirmed. London: RCP, RCPsych & RCGP, 1995
• Department of Health. Sensible Drinking: The Report of an Inter- Departmental Working Group. London: Department of Health, 1995
• Edwards G et al. Alcohol Policy and the Public Good. Oxford: Oxford University Press, 1994
• Babor T et al: Op cit
• John 2:1-11
• Romans 14:13-17