Examination of Witnesses (Question Numbers
600-618)
MS SONYA
BRANCH, PROFESSOR
DAVID FOXCROFT
AND MR
ALAN DOWNEY
2 JULY 2009
Q600 Dr Naysmith: We have also been
told that people in so-called vertical drinking establishments
tended to drink a lot more than the recommended guidelines in
one session. If people are being served when they are drunk surely
it makes a mockery of the laws about serving people when they
are inebriated if this is happening regularly in these kinds of
establishments.
Mr Downey: It is true that we
observed apparent breaches of the law relating to the serving
of people who were or appeared to be intoxicated. Clearly, there
was an element of judgment involved on the part of our research
team because they were observing without revealing that fact.
That means judgment would come into play particularly in the case
of somebody who perhaps was only marginally intoxicated, if there
be such a thing. Clearly, the judgment would be much easier to
make if somebody had clearly been drinking to excess over a long
period of time.
Q601 Jim Dowd: Mr Downey, does the
KPMG report tell us anything about the effectiveness or otherwise
of self-regulation?
Mr Downey: I am not sure it tells
us anything about whether self-regulation as a principle works
or does not work across the board. I should like to confine my
comments to the specific question of the standards. For a number
of reasons we found that the approach adopted in this case did
not appear to have significant effect. It is not that the standards
themselves are a bad set of standards. We reached the conclusion
that they could do with some updating and clarification in a number
of respects. The issue was more to do with the fact that the awareness
of the existence and detail of the standards was limited, that
there were breaches in a significant number of cases and that
enforcement did not appear to be consistent across the country.
Therefore, I think it is clear in those respects that this particular
approach has not worked. I am not sure I can speculate on whether
that means self-regulation can never work in all circumstances.
Q602 Jim Dowd: If the standards were
more widely known and an effort was made to convey them to all
those in the industry do you believe it would have a beneficial
effect?
Mr Downey: I believe it would.
Q603 Jim Dowd: I do not wish you
to say anything that would compromise you, but do you believe
the industry takes the social responsibility standards seriously?
You can plead the fifth if you wish.
Mr Downey: One matter we observe
in the report is that this is a very diverse industry. We are
talking about a very large numbers of premises and establishments
of very different kinds ranging from small family-owned businesses
to establishments that are part of big chains. I would not go
as far as to say that the industry is not taking it seriously.
I think it is quite difficult in this case even to talk in terms
of the industry as if it were a monolith. We came across plenty
of examples of good practice in terms of advertising, checking
age, serving free water on request and so on. That suggests there
are certainly many individuals and companies in the industry that
take these issues very seriously, but it is a diverse and widespread
industry and I am not sure I can really comment on it as a whole.
Q604 Jim Dowd: I suppose that in
many senses it mirrors the retail industry. There are very big
players at one end and very small ones at the other. Did you find
it was easier for the larger organisations for structural reasons
to comply with the code than smaller ones?
Mr Downey: I cannot answer that
question because in conducting our research we did not ask researchers
to make a record of the ownership nature of the establishments
they entered, so we have names but no addresses. We do not know
whether they belonged to a chain or were independent establishments.
Q605 Jim Dowd: Insofar as you are
aware how did the Home Office respond to your report? Have you
seen any changes, initiatives or action flow from it?
Mr Downey: I cannot really answer
that question. We were engaged to conduct a piece of independent
research which we did. We handed it over and we have not subsequently
been engaged by the Home Office to do any further research or
been asked to follow what policy may or may not have developed
in the mean time.
Q606 Jim Dowd: You have no proprietorial
sense of your work; you just let it go out into the world to find
its own way and do not care what happens to it?
Mr Downey: To take another example,
we do a great deal of work as a firm in the area of public sector
performance and productivity and take a huge interest in that
subject and publish views and articles and talk to the media about
it. It is not only appropriate but important we should do so because
we have a point of view that we believe is valid. This was more
of a one-off study. We have not been commissioned before or since
to do any work in the area of alcohol use and abuse, so it is
less appropriate that we have a point of view and perhaps less
surprising that we do not have a strong proprietorial view on
the issue.
Q607 Dr Naysmith: Professor Foxcroft,
we understand that you have reviewed the evidence on alcohol advertising
and young people. Can you tell us a little bit about your findings
and perhaps the context in which you did this work and why you
undertook it?
Professor Foxcroft: Perhaps I
may speak of the work of the science group of the European Alcohol
and Health Forum that commissioned some work on the relationship
between alcohol marketing and the uptake of drinking behaviour
in young people. This particular report drew together two systematic
reviews that have been produced very recently in this area. One
of these reviews was led by one of my colleagues, Dr Lesley Smith
of Oxford Brookes University; the other one was led by Dr Peter
Anderson of the University of Maastricht. Each of these systematic
reviews conducted independently focused on the best quality evidence
for looking at the relationship between exposure to alcohol marketing
and the uptake of drinking behaviour and the scale of it in young
people as well as other evidence on this particular issue. I do
not think I can do any better than quote some points from the
science group's report. First, there is a section which relates
the conclusions reported by Dr Smith in her review. She concluded
that the data from these studies included in the systematic reviews
"suggest that exposure to alcohol advertising in young people
influences their subsequent drinking behaviour. The effect was
consistent across studies. A temporal relationship between exposure
and drinking initiation was shown, and a dose response between
amount of exposure and frequency of drinking was clearly demonstrated
in three studies. It is certainly plausible that advertising would
have an effect on youth consumer behaviour as has been shown for
tobacco and food marketing." The important thing about this
systemic review and that of Dr Anderson is that they looked only
at those primary research studies that reported on exposure at
time A and looked at drinking behaviour subsequently at time B,
so you can draw an inference about the causal impact of exposure
on subsequent drinking behaviour. Dr Anderson's systematic review
concluded that, "Longitudinal studies consistently suggest
that exposure to media and commercial communications on alcohol
is associated with the likelihood that adolescents will start
to drink alcohol and with increased drinking amongst baseline
drinkers. Based on the strength of this association, we conclude
that alcohol advertising and promotion increases the likelihood
that adolescents will start to use alcohol and to drink more if
they are already using alcohol." The science group's report
reinforced the conclusions made in those independent systematic
reviews and also added the point that, "These findings are
all the more striking given that only a small part of the total
marketing strategy has been studied and is corroborated by the
results of other methodologies including qualitative, econometric,
cross-sectional and experimental studies. It should be stressed
that the studies come from countries with a long history of advertising
and with relatively high levels of alcohol consumption and it
is difficult to speculate on the size of the impact of marketing
and cultures with either a short history of advertising or low
alcohol consumption." The key point there is that the studies
included in the systematic reviews focused only on exposure to
particular types of alcohol marketing and were able to pick up
only a small part of the marketing mix but were still able to
show an association between exposure to alcohol marketing and
the uptake of drinking behaviour in those young people, children
and adolescents who had not already started drinking and increased
levels of drinking in those young people who were already drinkers.
Q608 Dr Naysmith: How consistent
were these results with other similar studies?
Professor Foxcroft: There have
been a number of other reviews in this area which have taken a
much broader perspective and incorporated different methodologies.
I believe these results are pretty consistent. A fairly consistent
message comes across from not only the very high quality systematic
reviews drawn upon by the European report but also methodologies
used in other reviews.
Q609 Dr Naysmith: Sometimes we hear
that results are inconsistent in this area, but is it right you
suggest that these are reviews on which we can rely as being the
best evidence we can get?
Professor Foxcroft: That is my
view.
Q610 Dr Naysmith: Why do you believe
some of other studies are brought in to muddy the waters?
Professor Foxcroft: Whenever you
look across at a number of different research studies you will
find some that do not clearly demonstrate an effect in a particular
direction. There are some studies that show that, but the important
point here is that they are very much in the minority. When you
look across the majority of studies with a range of different
methodologies you see a clear and consistent picture of an effect
and association between exposure to marketing and the uptake of
drinking behaviour in young people.
Q611 Dr Naysmith: Is there such a
thing as the precautionary principle in public health? If so,
how does it work in public health?
Professor Foxcroft: The precautionary
principle has a potential for helping public health in its decision-making.
Decision-making for public health can be challenging if there
is little or no evidence on a specific issue, or if there is conflicting
evidence. The precautionary principle provides a basis for decision-making
when faced with scientific uncertainty. For the sake of argument,
if there is still some uncertainty about the health risks to children
and young adolescents from exposure to alcohol marketing the precautionary
principle suggests that those health risks should be assumed to
be true and proportionate action should follow. That is the precautionary
approach. The principle can also be extended to deal with scientific
uncertainty on the effectiveness of particular public health interventions
or actions. For example, it is a worry that so many different
types of alcohol education and prevention programmes proliferate
in schools and among young people when there is considerable scientific
uncertainty about the effectiveness of many of these approaches.
With an extended precautionary principle only those interventions
for which there is some pretty good provisional or preliminary
evidence of effectiveness would be supported by the principle
and only if there is an ongoing programme of good quality research
and evaluation to look at the effectiveness of those particular
prevention programmes, for example in a UK context. Ultimately,
if after a period of time we find out that these prevention efforts
and programmes in schools are ineffective we can divert resources
to somewhere else that is a little more useful. I suspect that
aspects of the precautionary principle are used implicitly by
many public health workers in public health settings; otherwise,
why are so many public health interventions implemented that are
based on insufficient scientific evidence? That is a worry. I
suggest that to bring the principle out into the open so it is
used in a transparent, explicit way is a positive step.
Q612 Chairman: When you talked about
marketing in these reviews did that include sponsorship?
Professor Foxcroft: The studies
that we included in the reviews covered a range of different marketing
exposure from exposure to alcohol ads on television to exposure
to alcohol trails in various media, including television, music
videos and films to exposure to alcohol messaging through sponsorship.
Some studies looked at the recollection of alcohol messages and
information and a couple of them looked at ownership of alcohol
branded merchandise, so there was a mix of different types of
alcohol messaging included in the systematic reviews.
Q613 Chairman: In view of the findings
I assume you believe that the current regulation of the advertising
of alcohol does not afford the protection of young people that
it should do. Do you agree with that analysis?
Professor Foxcroft: The studies
included in this work looked at the association between exposure
to marketing and drinking behaviour in young people in a number
of different countries, mostly the United States, New Zealand,
Belgium and Germany, but interestingly not the UK. Therefore,
that evidence is not of direct relevance to the UK. Personally,
I am not familiar—it is not my area—with the particular
regulations about the portrayal of alcohol in the media in this
country. If there is concern about that I think it follows that
there is also concern about young people's drinking.
Q614 Chairman: The World Health Organization
published a report entitled Alcohol: No Ordinary Commodity
which states that public education is one of the least effective
policy responses to the problems of alcohol. Do you agree with
that analysis?
Professor Foxcroft: There is now
pretty good evidence that certain types of alcohol education which
give information about risks associated with alcohol and raise
awareness of those risks are ineffective. I have talked mostly
about education of young people because that is the area about
which I know most. Evaluations have shown a consistent picture.
A number of different studies have shown that traditional types
of alcohol education in schools, just telling people about the
risks associated with alcohol and raising awareness of those risks,
are ineffective. I believe that that is the message put across
by the WHO report. Having said that, there is a growing body of
evidence that relates to different types of prevention programmes,
not necessarily education but prevention programmes that look
at the effectiveness of early intervention with young people that
take a social developmental approach and have been shown in some
studies to have an impact in reducing not only alcohol-related
harm but other sorts of harms to young people, including drug
dependence and drug harms, mental health issues, suicides, suicidal
behaviour, aggressive and disruptive behaviour in schools, later
violence and crime and also the use of health services, which
was an interesting finding in some of the studies. A good source
of information on this particular type of prevention programming
is a recent report from the US National Academies of Science which
has reviewed the effectiveness of prevention programmes for young
people and highlighted a number of early intervention-type programmes
that may be effective in this country, though more research would
be needed. One of the benefits of such an intervention is that
the impact covers a number of different behaviours. I believe
it was Keynes who said that early intervention was a massive multiplier.
Q615 Chairman: The question of intervention
in early years was a matter we looked at in our inquiry into health
inequalities a few months ago. Is there anything that you believe
can be done that is specific to alcohol misuse and the protection
of young people? Given your knowledge and research do you have
any view on that? How do we start to get there?
Professor Foxcroft: There are
a number of strands that possibly are useful in a policy approach
to reducing the harms to young people associated with alcohol.
One of those approaches is to look at availability. We know that
young people are most likely to have their first experiences of
alcohol in a family setting usually from parents, so some work
in looking at how parents introduce alcohol and whether they should
be introducing it and at what age would be appropriate. That is
a policy option that could be useful especially given we know
that young people drink earlier and heavier which is a problem.
The second aspect would be to look at the whole of the marketing
mix: product placement, price and promotions. I know that you
have already been considering options in that respect. Third,
early intervention is something that offers a potential impact
across a range of different behaviours which are relevant to health.
As to information campaigns and awareness raising that is something
that might be considered although there is a problem in terms
of scale. If you are to look at implementing information campaigns
and awareness raising there needs to be an increase in resource
by an order of magnitude. You talked earlier about the funds made
available to Drinkaware Trust compared with the funds used by
the alcohol industry to promote alcohol products. Clearly, there
is a huge discrepancy there. We know that alcohol marketing influences
in a dose-response manner and it is probably the same with counter
marketing or advertising or marketing around risks. Dose response
and volume are important. Therefore, we need to increase the level
of resource in that regard; otherwise, I have concerns about whether
it is an effective approach. I also suggest that a clear and explicit
decision-making framework to support policy and action would be
useful—maybe the precautionary principle would be an appropriate
way forward—and there should be more R&D so we do not
end up talking about lack of evidence on the same issues in five
years' time.
Q616 Chairman: How big would the
volume of advertising of alcohol be on a scale of one to 10, one
being not very important and 10 being very important in view of
what you have reflected on in these studies?
Professor Foxcroft: I do not understand
the question.
Q617 Chairman: The effect of the
volume of advertising is disputed. We have had evidence that it
is the volume of advertising that creates take-up or, to put it
simply, that advertising works. How significant would that be
on a scale of nought to 10, nought being not very important and
10 being very important? Basically, the article in The Lancet
last week said that there should be a reduction in the volume
of advertising of alcohol. What would you say to that?
Professor Foxcroft: Clearly, there
is a dose-response relationship demonstrated in the systematic
reviews picked up by the science report for the European Alcohol
and Health Forum. I suggest that that needs to be considered.
I hesitate to say where on the scale it should be placed, but
I certainly believe it is an important aspect to consider when
looking at this.
Q618 Chairman: We all understand
that there is no silver bullet here in terms of changing alcohol
habits. I am just interested in volume. In any event, you believe
that it is important as are many other things?
Professor Foxcroft: Yes.
Chairman: I thank all three witnesses
very much.
| 
