Alcohol Guidelines - Science and Technology Committee Contents


4  Public understanding and communication

38. An inherent difficulty of developing generic guidelines for the public on sensible drinking is the loss of recognition of individual risk factors. Individuals vary not just by age and gender but also by factors, such as body weight or socio-economic background, that will influence the health risks they face when drinking alcohol. Yet the Government also has to tread a fine line between informing and over-informing the public because the more complex guidelines become, the more difficult they may be to communicate. We delved into this issue with witnesses. Sir Ian Gilmore, Royal College of Physicians, warned about reaching a level of complexity that would not be understood by the public[97] and Professor Heather, Alcohol Research UK, told us:

    There are lots of risk factors—individual personality, and genetic and social factors. For example, socio-economic status is a big risk factor for alcohol-related harm. Recent research shows that middle-aged men in the lowest quintile had a four times higher rate of alcoholic liver cirrhosis than those in the highest socio-economic status quintile. That cannot be explained by differences in consumption. There are lots of risk factors, but they cannot all be incorporated into guidelines, as it would make them immensely complex.[98]

With this warning in mind, we will explore the public understanding and communication of the Government's alcohol guidelines.

Effectiveness of guidelines

39. Alcohol consumption guidelines could have two purposes: to inform people and their drinking choices or to seek to influence and change behaviour. In both cases, decisions on how much to drink would remain at the discretion of the individual because the guidelines impose no legal obligation. We wanted to know whether the Government saw the guidelines as a tool for information or for influencing behaviour and Anne Milton MP, Parliamentary Under-Secretary of State for Public Health, told us that they were seen as useful for both.[99] As the Government considers the guidelines to have a dual purpose of raising awareness and influencing public behaviour we have therefore also considered the evidence relating to the impact of guidelines on public awareness and behaviour.

INFORMING THE PUBLIC

40. In our view, there are four levels of public understanding of the alcohol guidelines:

a)  knowing that drinking guidelines and alcohol units exist;

b)  knowing what the drinking guidelines are;

c)  being able to identify the unit content of alcoholic beverages; and

d)  understanding the health risks of drinking.

41. A 2009 survey by the Office for National Statistics (ONS) showed that overall, 90 per cent of respondents "said they had heard of measuring alcohol consumption in units", up from 79 per cent in 1997.[100] This statistic was echoed by the Minister.[101] The ONS noted that "on the whole, the more people drank, the more likely they were to have heard of units".[102] Awareness of alcohol units was consistently over 80 per cent across gender, age and socio-economic groups (with the exception of women over 65, amongst whom awareness was at 78 per cent).[103] These figures were broadly in line with those supplied by the charity Drinkaware.[104] Moreover, public awareness of what the guidelines were had increased since 1997. However, the ONS acknowledged that having heard of daily recommended levels did not necessarily mean that people knew what they were:

    Forty four percent of people thought correctly that, for men, drinking three or four units a day was within the guidelines, and 52 per cent said correctly that for women, drinking two or three units a day was a recommended maximum. These percentages have increased significantly from 35 per cent and 39 per cent respectively in 1997. [...] The percentage of people who said they had heard of but did not know the limits decreased from around 44 per cent in 1997 to around 30 per cent in 2009.[105]

42. Awareness of the existence of alcohol units did not necessarily translate into an understanding of the unit content of alcoholic drinks. While 69 per cent of respondents correctly identified one unit as being equivalent to a 25 ml measure of spirits, and 63 per cent correctly equated a unit with half a pint of beer, only 27 per cent accurately identified how much one unit of wine was ("less than a small glass").[106] Around half of respondents incorrectly thought that one unit of wine was equivalent to one glass of wine. The ONS offered a partial explanation, which was that public information on the alcohol content of wine had changed over time.[107] Drinkaware's findings were less positive: the charity reported that only 38 per cent of adults were able to select a drink from a list which correctly contained one unit of alcohol, and that this figure did not improve much if the person was aware of the term "units".[108] Drinkaware stated that "for consumers who are unable to make a direct correlation between "units" and "drinks" the practical impact of guidelines will be limited".[109] The Department of Health (DH) has acknowledged that "public understanding of both unit measures (especially for wine) [...] needs to improve".[110]

43. The Association of Small Direct Wine Merchants pointed out that "a UK unit just happens to be the same as [one centilitre] of alcohol", (which is equivalent to 10 ml) and suggested that units should be replaced by centilitres (cl).[111] In contrast, Professor Averil Mansfield, British Medical Association, said:

    It is pretty clear that the units that we have at present are as good a way as any of describing the amount of alcohol that we consume. A lot of effort has been put into making them understood by the general public. For better or worse, the message should be retained because it is now fairly widely understood. [...] The other ways, in milligrams or millilitres, are rather complicated, and we need something simple and straightforward.[112]

Jeremy Beadles, Chief Executive of the Wine and Spirit Trade Association added that "the important thing is that we stick with what we have. Changing now would set us back a long way".[113] Drinkaware was optimistic, and stated:

    Between 2007 and 2010, the UK Government carried out a series of unit guideline campaigns, spending about £4 million in 2008-2009. The impact of these campaigns alongside those run by Drinkaware has led directly to an increased awareness and understanding of unit guidelines and how they translate to individual drinks. It is our belief that although there are still significant numbers of consumers to inform, we are certainly approaching a 'tipping point' with consumers and that many more are beginning to understand units on a practical level.[114]

44. Public awareness of alcohol units appears to be high, but there are problems with public understanding of how many units are in alcoholic beverages. We see no reason why the established concept of alcohol units should be changed. We consider that efforts should be focused on helping people to translate the concept of alcohol units and sensible drinking guidelines into practice.

CHANGING BEHAVIOUR

45. Despite high levels of awareness of units, the ONS survey showed that of the 90 per cent of drinkers in the survey group who had heard of units, only 13 per cent kept a check on the units they drank on a daily, weekly and/or other basis.[115] This had not improved noticeably since 1997: the average between 1997 and 2009 was around 13 per cent, with women slightly more likely to keep a check than men (despite the fact that men were more likely to drink heavily). Furthermore, women who did keep a check on units were slightly more likely to do so on a weekly basis (6 per cent) than on the daily basis (2 per cent) suggested by the government's current advice on sensible drinking, but there was no difference among men. [116] The ONS added that "it should be noted, however, that since by no means everyone who drank each type of drink knew what a unit of that drink was, it is likely that in some cases the check they were keeping was inaccurate".[117]

46. The Institute of Alcohol Studies (IAS) stated that "there is much debate both in the UK and internationally about the efficacy of drinking guidelines as a policy to reduce alcohol harm".[118] The IAS considered that:

    whilst guidelines have a role to play in educating the public and increasing knowledge about the risks of alcohol, they have not been proven to be effective at changing behaviour. The pharmacological properties of alcohol, which include loss of inhibitions in the short term and dependence in the long term, make it impractical to rely on a 'nudge' framework[119] of 'rational man making informed decisions' about drinking alcohol to effect behaviour change.[120]

Dr Marsha Morgan, IAS, stated:

    The Government have an obligation to provide, on the basis of the best evidence, information about the risks of alcohol intake so that the general public can make informed decisions. [...] the purpose of the guidelines [...] is to inform.[121]

We queried whether it would be possible to conduct research that would identify whether the guidelines had an effect on changing drinking behaviour. Dr Morgan replied:

    One of the difficulties is that it would have to be a two-tiered approach. If our basic premise is to provide guidelines in order to inform the public, we would first have to see whether they are actually informed. In other words, you would have to look at a scenario whereby you questioned a group of people, provided information on the guidelines and then revisited the matter. Running in parallel, or even sequentially, you would then look at individuals' drinking behaviour and see whether the acquisition of knowledge had changed it. It would be a two-step procedure; whether it was done in parallel or sequentially would be up to the individuals designing the studies. It could be done, but it would be a difficult piece of research.[122]

47. The joint written submission from the British Beer & Pub Association, The National Association of Cider Makers, The Scotch Whisky Association and The Wine and Spirit Trade Association stated that "there does not appear to be a correlation between recommended drinking guidelines and consumption patterns".[123] They stated that "countries such as Germany and Ireland have higher overall alcohol consumption but similar recommended daily guidelines to the UK" and Italy and Netherlands have lower overall alcohol consumption but higher recommended guidelines".[124]

48. There is little evidence that the Government's alcohol guidelines are effective in changing behaviour. We recognise that it would be difficult to establish whether guidelines had had a direct effect on behaviour and also that it is a challenging area of research, particularly given the problems caused by inaccurate reporting. Behaviour could be changed by other interventions such as alcohol pricing and availability and it would be difficult to disentangle the effects of these from those of the guidelines to establish a causative effect. We are concerned that the Government views the guidelines as a tool to influence drinking behaviour when there is very little evidence that the guidelines have been effective at this. The Government should treat the guidelines as a source of information for the public.

Drinking patterns

49. In paragraph 18 we noted concerns that the move from weekly to daily guidelines had appeared to endorse daily drinking. The current guidelines advise that men and women should "not regularly drink" more than a certain number of units a day.[125] According to the DH, "regularly" means drinking every day or most days of the week".[126] The IAS stated that:

    the recommendation that 'regular drinking', defined as 'drinking every day or most days of the week' does not pose a significant health risk is a direct contradiction to the evidence base on the health harms associated with alcohol. Daily and frequent drinking is associated with a greater risk of developing dependency problems with alcohol and alcoholic liver disease and cannot therefore be considered a 'safe' or 'low risk' practice. Furthermore, the guideline for men to drink up to 4 alcoholic drinks per day on a regular basis would be classified as "hazardous" drinking under the [World Health Organisation] standards for assessing risky alcohol consumption.[127]

The Sensible Drinking guidelines were supplemented with advice that "after an episode of heavy drinking, it is advisable to refrain from drinking for 48 hours to allow tissues to recover".[128] However, the report stated that "this is a short term measure and people whose pattern of drinking places them at significant risk should seek professional advice. Such breaks are not required on health grounds for people drinking within the recommended benchmarks".[129] In other words, a 48 hour break from drinking was not deemed necessary for those drinking within guidelines. The DH website clarified that "'regularly' means drinking every day or most days of the week".[130] We were interested in whether the DH definition of "regular" was well communicated and understood by the public given that "most days of the week" was not quantified. However, it appears that many people may not be aware that advice is framed in terms of regular drinking, let alone what the definition of "regular" is. Professor Nick Heather, Alcohol Research UK, said that: "unfortunately [...] the word "regularly" in information given out by health authorities is sometimes dropped, so that it appears as an absolute maximum upper limit, which it was not intended to be".[131] He explained that "it is intended as guidance on the average amount of consumption".[132] Professor Averil Mansfield, British Medical Association, told us that she would be in favour of daily rather than weekly limits but added:

    what matters most is that the message should not be that you should drink two to three units a day. Somehow, we have to get the message over that you do not have to drink at all, and that you certainly should not drink at all on a couple of days a week. It almost gives the green light to go ahead and drink two, three or four units a day; the Government guidelines seem to indicate that that is okay. We need to tone that down so that people know it is the maximum and not something that is desirable every day, and it will not give you added health, but if they do consume that amount there will inevitably be a health risk.[133]

50. The differing risks of regular drinking and binge drinking were raised during our inquiry. Binge drinkers were defined by 2020Health as men who drink 8 or more units in a single session and women who drink 6 or more units in a single session.[134] Grampian Drugs and Alcohol Partnerships considered that "the implication that daily drinking is less risky contradicts the evidence which shows that the frequency of consumption is a key risk factor".[135] Similarly, 2020Health stated that those who drank regularly but did not binge drink or get drunk:

    may be drinking several drinks every day, and are increasing the risk of developing long-term health conditions. Given the time lag between alcohol consumption and the development of conditions such as liver disease or cancer, the harm caused by drinking is often not seen for up to 10 or 20 years.[136]

The Royal College of Physicians suggested that a simple remedy to the problem would be to recommend that people should have three alcohol-free days a week to stay within safe drinking limits.[137] In Scotland, the advice is to "aim to have at least two alcohol-free days a week".[138]

51. Professor Heather explained the different types of harm that could be expected from different drinking patterns:

    Long-term average drinking is related to chronic illnesses. Binge drinking [...] leads to intoxication-related harms such as accidents and violence. [...] There are two types of harm. In my view, therefore, there should be two types of guideline.[139]

    [...] my advice is that the guidelines should take this form. For example, men should not drink more than X units a week, probably 21, and never more than Y units in a day, whatever that might be—perhaps eight units, as at present, or a bit lower.[140] As well as that, there should be at least two days' abstinence. We should revert to the old weekly limits of 21 and 14 for the average guideline, and have another daily limit that should never be exceeded on any day. That would help communication.[141]

The Sheffield Addiction Research group and 2020Health both broadly agreed with this suggestion.[142] The International Scientific Forum on Alcohol Research and Alcohol in Moderation drew attention to guidelines in the USA and Australia that had upper limits for individual drinking episodes.[143] The DH stated:

    We are aware that some governments do offer advice on levels of consumption for individual drinking episodes, in addition to advice for regular drinking. For example, the 2009 Australian Government's guidelines, do include such advice. [...] The recommendations are based on statistical evidence of the lifetime risk of death from injury related to individual drinking episodes. While we do see some possible value in such a guideline, we have no plans at present to introduce this within the UK. We believe that this would require particular consideration of its likely impact and its real value in influencing the behaviour of individuals who currently choose to engage in 'binge' drinking.[144]

52. It is unclear to us how the term "regular", as applied to all adults who drink, relates to the advice to take a 48 hour break after heavy drinking episodes. We suggest that, if daily guidelines are retained, the Government consider simplifying the guidelines so that, as is the case in Scotland, all individuals are advised to take at least two alcohol-free days a week. This would enforce the message that drinking every day should be avoided, and would helpfully quantify what "regular" drinking means to the public.

53. On balance, we consider that introducing guidance for individual drinking episodes could be helpful to inform the public and we invite the Department of Health to consider the suggestion as part of a review of the evidence base, taking into account social science evidence, including evidence from other countries on the impact that similar guidelines have had on drinking patterns. Guidance for individual drinking episodes should only be introduced if guidance is provided in a weekly context again, as having two daily drinking limits would be confusing to the public.

The role of the drinks industry

54. In March 2011, the Government published The Public Health Responsibility Deal. It said:

    Businesses have both the technical expertise to make healthier products and the marketing expertise to influence purchasing habits. If the full strength of these skills can be directed towards activities to encourage and enable people to make healthier choices—as many responsible businesses do already—the benefits could be great.

    The Public Health Responsibility Deal has been established to maximise these benefits. By working in partnership, public health, commercial, and voluntary organisations can agree practical actions to secure more progress, more quickly, with less cost than legislation.[145]

The Government's core commitment on alcohol is to "foster a culture of responsible drinking, which will help people to drink within guidelines".[146] Specific pledges include ensuring that over 80% of products on shelf (by December 2013) will have labels with clear unit content, NHS guidelines and a warning about drinking when pregnant.[147]

55. There have been strong criticisms about the increased involvement of industry in communicating messages about sensible drinking. For example, the Royal College of Obstetricians and Gynaecologists (RCOG) argued "there is a conflict of interest in engaging with business to promote products" although it acknowledged that "there are examples of responsible drinking programmes developed by the drinks industry, such as [Drinkaware]".[148] The British Medical Association (BMA) stated that "industry self-regulation has at its heart a conflict of interest that does not adequately address individual or public health".[149] Sir Ian Gilmore considered that "it is a great disappointment to me that the present Government's policy seems to be against funding public health information; they are devolving it to other organisations, including those funded by the drinks industry".[150] A 2009 report by the House of Commons Health Committee on Alcohol stated:

    It is time the Government listened more to the [Chief Medical Officer] and the President of the [Royal College of Physicians] and less to the drinks and retail industry. If everyone drank responsibly the alcohol industry might lose about 40% of its sales and some estimates are higher. In formulating its alcohol strategy, the Government must be more sceptical about the industry's claims that it is in favour of responsible drinking.[151]

56. When we put these concerns to Jeremy Beadles, Chief Executive of the Wine and Spirit Trades Association and co-chair of the Alcohol Responsibility Deal, he replied:

    [The Public Health Responsibility Deal] is not about setting or dictating Government policy; it is about the alcohol industry and other organisations finding ways of delivering things that the Government wish to have delivered, such as unit labelling and point of sale information. To be frank, it would be extremely time-consuming and costly putting it through Europe and getting the legislation out on the other side, and frankly impossible in terms of providing unit information in a pub environment. The evidence base would be extremely difficult to put together, and the cost of administering a scheme of that nature would be disproportionate. If the industry is prepared, willing and happy to do this stuff and can roll it out through its mechanisms, I am not sure that I see a problem. [...] the Responsibility Deal now has more than 220 businesses signed up to it. It is one of the largest voluntary agreements ever put together.[152]

The Minister acknowledged the importance of being aware that all interest groups had their own agenda and added "we have to judge it on the results that we see. In 2013 [...] we will be having an independent analysis as to how much progress has been made".[153] She stated:

    the drinks industry are interested in their brands, so, if a brand is associated with crime, anti-social behaviour and people being paralytically drunk, it is not necessarily a positive brand. However, they are there to sell alcohol. We have to work in those areas that we can, make sure it is properly scrutinised and analysed so that we have confidence, and be aware of the fact that there are legislative and regulatory tools which we can take into account.[154]

DRINKS LABELLING

57. The labelling of alcoholic beverages with guideline advice is an important way of communicating alcohol content and guidelines, and was a key focus of our inquiry. Figure 2 shows what information will be included on labels under the alcohol pledge.
Figure 2: Format of alcoholic beverage label[155]


58. The pledge to have over 80 per cent of products on the shelf with "labels with clear unit content, NHS guidelines and a warning about drinking when pregnant" by 2013 is voluntary, although some, such as the BMA, considered that mandation was necessary.[156]

59. We asked the Minister how close the Government was to achieving the 80 per cent target. She responded that the process had just started recently, noting "how difficult it is for the industry to get it in place" and that there had been a lot of concerns about the Public Health Responsibility Deal.[157] We were also informed that around 100 companies covered approximately 80 per cent of the industry and that most of them were signing up to the pledge.[158] Mr Heffer, Deputy Director, Alcohol and Drugs, DH, added that:

    the advantage to them is that they are doing this voluntarily—some of their brands do not have to comply. If you are bringing in a special product from America for the whole of Europe, they can exclude that brand while offering a choice of products to consumers across the rest of Europe. A mandatory approach would mean that that brand was probably not stocked. Most of the brands have signed up for most of their products. That should add up to 80 per cent. There will be an independent verifier by December 2013.[159]

60. In addition to labelling of alcoholic drinks, the drinks industry is involved with campaigns to increase consumer awareness of units in "the on and off trades", working with Drinkaware.[160]

61. We are mindful of the concerns expressed by medical experts and relevant organisations about the involvement of the drinks industry in communicating public health messages concerning alcohol. There is clearly a risk that drinks companies could face a conflict of interest as promoting a sensible drinking message could affect profits. However we have heard no evidence to suggest that the alcohol labelling pledges within the Public Health Responsibility Deal could be achieved without the cooperation of drinks companies. Nor have we heard sufficient evidence to suggest that, given the Government exercises proper scrutiny and oversight, a conflict of interest would jeopardise the progress of the alcohol pledges.

62. We are concerned that there will not be an independent assessment of the programme until the target date of December 2013. We recommend that the Government immediately set an interim labelling target for December 2012. It should then conduct a preliminary assessment of the progress of the alcohol pledges in the Public Health Responsibility Deal in December 2012. If through the voluntary involvement of the drinks industry, the intermediate target has not been met by December 2012, the Government should review the initiative, including the possible need to mandate compliance with labelling requirements.


97   Q 23 Back

98   Q 26 Back

99   Q 71 Back

100   Office for National Statistics, Opinions Survey report No. 42, Drinking: Adults' behaviour and knowledge in 2009, 2010, p 61 Back

101   Q 73 Back

102   Office for National Statistics, Opinions Survey report No. 42, Drinking: Adults' behaviour and knowledge in 2009, 2010, p 56 Back

103   Office for National Statistics, Opinions Survey report No. 42, Drinking: Adults' behaviour and knowledge in 2009, 2010, p 61 Back

104   Ev 56, paras 6.1-6.2 Back

105   Office for National Statistics, Opinions Survey report No. 42, Drinking: Adults' behaviour and knowledge in 2009, 2010, p 14 Back

106   Office for National Statistics, Opinions Survey report No. 42, Drinking: Adults' behaviour and knowledge in 2009, 2010, p 64 Back

107   Office for National Statistics, Opinions Survey report No. 42, Drinking: Adults' behaviour and knowledge in 2009, 2010, p 56 Back

108   Ev 56, para 6.2 Back

109   Ev 56, para 6.2 Back

110   Ev 30, para 26 Back

111   Ev w4, para 3.3 Back

112   Q 35 Back

113   Q 35 Back

114   Ev 56, paras 6.1-6.2 Back

115   Office for National Statistics, Opinions Survey report No. 42, Drinking: Adults' behaviour and knowledge in 2009, 2010 Back

116   Office for National Statistics, Opinions Survey report No. 42, Drinking: Adults' behaviour and knowledge in 2009, 2010, p 58 Back

117   Office for National Statistics, Opinions Survey report No. 42, Drinking: Adults' behaviour and knowledge in 2009, 2010, p 58 Back

118   Ev 75, para 2 Back

119   The nudge framework refers to the use of non-regulatory interventions that seek to influence behaviour by altering the context or environment in which people make choices. Back

120   Ev 75, para 2 Back

121   Q 2 Back

122   Q 6 Back

123   Ev 44, para 27 Back

124   Ev 44, para 27 Back

125   Ev 27 [Department of Health] para 3 Back

126   "Alcohol advice", Department of Health, 22 March 2011, dh.gov.uk  Back

127   Ev 74, para 2 Back

128   Ev 27 [Department of Health] para 3 Back

129   Department of Health, Sensible Drinking: Report of an inter-departmental working group, 1 December 1995 Back

130   "Alcohol advice", Department of Health, 22 March 2011, dh.gov.uk Back

131   Q 16 Back

132   Q 16 Back

133   Q 38 Back

134   Ev w7, para 4.6 Back

135   Ev w32, para 3.1.2 Back

136   Ev w7, para 4.4 Back

137   Ev 72, para 32 Back

138   "Keeping within the limits", DrinkSmarter, December 2011, drinksmarter.org  Back

139   Q 17 Back

140   Note by witness: Within the context of the weekly limit. Back

141   Q 13 Back

142   Ev w23, para 2.2.3; Ev w6-7, para 3.3 Back

143   Ev w13, para 4.6 Back

144   Ev 29, para 20 Back

145   Department of Health, The Public Health Responsibility Deal, 22 March 2011  Back

146   Department of Health, The Public Health Responsibility Deal, 22 March 2011 Back

147   Department of Health, The Public Health Responsibility Deal, 22 March 2011 Back

148   Ev w41, para 4.4 Back

149   Ev 80, paras 3 and 5 Back

150   Q 13 Back

151   Health Committee, First Report of Session 2009-10, Alcohol, HC 151-I Back

152   Q 43 Back

153   Q 81 Back

154   Q 81 Back

155   Ev 46 [The British Beer & Pub Association, The National Association of Cider Makers, The Scotch Whisky Association and The Wine and Spirit Trade Association] Back

156   Ev 80, paras 3 and 5 Back

157   Q 86 Back

158   Q 85 Back

159   Q 85 Back

160   Ev 44 [The British Beer & Pub Association, The National Association of Cider Makers, The Scotch Whisky Association and The Wine and Spirit Trade Association] paras 23-24  Back


 
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