UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE
To be published as HC 1536-ii

House of COMMONS

Oral EVIDENCE

TAKEN BEFORE the

Science and Technology Committee

The evidence base for alcohol guidelines

Wednesday 26 October 2011

Anne Milton MP, Dr Mark Prunty and Chris Heffer

Evidence heard in Public Questions 64 - 102

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Oral Evidence

Taken before the Science and Technology Committee

on Wednesday 26 October 2011

Members present:

Andrew Miller (Chair)

Stephen Metcalfe

Stephen Mosley

Pamela Nash

Graham Stringer

Roger Williams

________________

Examination of Witnesses

Witnesses: Anne Milton MP, Parliamentary Under Secretary of State for Public Health, Dr Mark Prunty, Clinical Adviser, Alcohol and Drugs, Department of Health, and Chris Heffer, Deputy Director, Alcohol and Drugs, Department of Health, gave evidence.

Q64 Chair: Good morning, Minister. Thank you for coming to see us this morning. For the record, perhaps your two colleagues could introduce themselves.

Chris Heffer: My name is Chris Heffer. I am Deputy Director for Drugs and Alcohol within the Department of Health.

Dr Prunty: I am Mark Prunty. I am an addiction psychiatrist, practising in Surrey, and I am Senior Medical Officer for drug and alcohol policy at the Department of Health.

Q65 Chair: As you know, the purpose of this inquiry is to explore the Government’s view on the evidence base related to alcohol consumption guidelines and how well they are communicated to the public. How rapidly is the evidence base on alcohol evolving, and how does the Department of Health monitor new scientific research?

Anne Milton : In a variety of ways. We are mindful always of new research that is emerging. If only somebody w ould publish something definitive, my job would be a lot easier. It is a constant process. There is no beginning and no end to it. We constantly look at research. We have people like Dr Prunty in the D epartment , who gives us some expertise, but we also commission quite a lot. NICE, for instance, has issued guidelines on alcohol in pregnancy for health practitioners in 2007. There are a variety of bodies that we can call on and from who m we commission advice and support. It is the job of officials and, indeed, the job of M inisters to keep an eye on what is emerging.

From my point of view, the most important thing is to keep an open mind. The most dangerous thing we could ever do is to think for one minute that we have, at any one time, all the evidence we need or that the advice is accurate. We need to remain open-minded and be receptive to new research that is emerging.

Q66 Chair: Do you, in any way, directly fund or co-ordinate health research on alcohol?

Anne Milton: I am sure we have from time to time. I am going to ask Chris Heffer, if I may, Chairman, to give you details because he will know when it was last done.

Chris Heffer: The Department has funded a variety of bespoke research into particular topics. In recent years it has funded the NICE review, as the Minister said. NICE came out with a range of alcohol health policies in 2009. The Department has funded research on issues such as pricing and licensing as well. The Department has a wider range of research and development budgets to look into policies regarding alcohol. We have not, to my knowledge, done specific research on the guidelines of particular health risks. That said, we have done particular works, for example, two years ago when we did the campaign Drinking Causes Damage You Can’t See. We have also done particular aspects of risks around cancer, and for that one we updated the risks we knew. We worked with Cancer Research UK, who have a lot of expertise and credibility. Their name and branding was on the adverts as well. We were checked by the ASA pre-clearance process as well and, in particular, about the wording. We even had to discuss whether it was "Drinking more than two pints" or "Two pints and more". We even got a challenge from the ASA as well. Somebody wrote in to say that they did not agree with our evidence. That was scrutinised and justified. As and when there are specific uses or things we are trying to do, we follow proper process. We update the evidence base when we require it and we go through the external scrutiny process that that requires.

Anne Milton: Some of the changes that we are proposing to the creation of Public Health England is making sure what we have in place. It is good that the Campaign for Science and Engineering recently praised the Department. I have a quote here, which says: "We urge the rest of Whitehall to follow Defra and DH’s lead in thoroughly embedding scientific advice in departmental structures", which I believe we have. Of course, it does not end with evidence and guidelines on alcohol. We also need to collect a body of evidence about creating behaviour changes.

Q67 Chair: That is interesting, because last week Sir Ian Gilmore was before us. He suggested that the Government do not use a sufficient evidence base and mentioned, in particular, social science data.

Anne Milton: No. That is what we have just started to do.

Q68 Chair: So this is the beginning of a process.

Anne Milton: There is an emerging and growing body of evidence out there about how to change people’s behaviour. One of the problems for a non-scientist like myself-I would not consider myself to be one-is that you expect somebody to come up with an absolute answer and, of course, it is not nearly as simple as that. This is terribly important because at the end of the day we want to change people’s behaviour and help them lead a healthier life. It is terribly important that we continually keep an eye on what is most likely to achieve that. Chris mentioned the precision with which words are looked at that might be used in campaigns.

Dr Prunty: It is probably worth mentioning in relation to the research that has been commissioned that a major piece of research into identification and brief advice draws upon the guidelines to help people who wish to change their drinking to lower risk levels. That is a randomised control trial that has been funded by the Department in recent years and will be reporting shortly. We also work with the MRC, which have made alcohol and drugs a priority for their funding of research across the UK.

Q69 Chair: The Department receives advice from a wide range of areas. There are some that are more formal than others, and NICE is a good example. Would there be some benefit in having a standing expert committee on alcohol to advise Government?

Anne Milton: I am a relatively new girl to this; I know that there have been, but I would never prescribe a certain structure in order to ensure that the Department gets advice. Different areas require different approaches. We are in the process of producing an alcohol strategy, which is in its early days. The important thing is a receptive and open mind. I am a firm believer that Government at any level should have the humility to understand that they might not always have got it right and, indeed, they might need to change its mind. In terms of giving the public advice and wanting to change their behaviour, what matters is not only that we have confidence in the advice that we are giving but that the public has confidence in the advice they get. That is a terribly important part of this.

Q70 Graham Stringer: It is a very radical view of Government that it should be able to change its mind.

Anne Milton: I know. I will probably end up on the front page of somebody’s headlines tomorrow, but it is what I think.

Q71 Graham Stringer: It is very welcome, Minister. As to the Government alcohol guidelines, are they just for public information, to help people run their lives, or is their intention to try and change behaviour?

Anne Milton: If you look at the figures, 58% of the public drink only twice a week or less and 15% of the public abstain entirely from alcohol. If you look at alcohol, there is a proportion of the public whose behaviour we would like to change because the alcohol they are consuming is causing harm to their health. There are some members of the public who are causing themselves no harm. It is both. It is to give people information. The next step, which is probably more tricky, is to make sure that information is given to them in a way that they can understand and accept. That comes back to the credibility point.

The next step is helping them to change their behaviour, which is why in the Public Health White Paper we talk about public health being everybody’s responsibility, but, at the end of the day, a person has to make a choice. At the end of the day, an individual makes a choice about how much or how little they drink.

Q72 Graham Stringer: Is there any evidence that the guidelines have changed behaviour at all?

Anne Milton: Behaviour has changed. The difficulty in a lot of these areas-it is also true of smoking and obesity-is that it is quite difficult to demonstrate causality. That is always a difficulty. Smoking is a good example. If you look at the ban on smoking in public places, it might have altered behaviour but, at the same time, there was a great deal of reporting in the media and a lot of chat shows talking about it. Many other things were going on at the same time that we banned smoking in public places. There was a change in behaviour down to all the discussion in the media about the downs that smoking can give you, or was it simply the banning of smoking in public places? It is quite difficult to demonstrate causality. All you know is that behaviour did change. There are very clever people, and Dr Prunty is one of them, who try and tell me what exactly it was. There are statistical experiments you can do, research tools at your disposal, to try and iron out some of those factors.

Q73 Graham Stringer: It would be helpful to the Committee if you describe what changes have taken place in recent years and if any of those changes at all could be put down to the guidelines.

Anne Milton: Yes. If you look at awareness, 90% of people understand about units of alcohol now. The age at which young people start drinking is going up, which is positive. The amount of alcohol that young people are drinking is going down slightly. Total alcohol consumption has gone up. I could go on and on. I would be happy to send you more figures, because the picture is quite confusing. The amount of alcohol that is consumed has gone up, but it is being drunk by a smaller number of people. For instance, 10% of the population who drink to excess are drinking 40% of the alcohol. One third of those who drink to excess are drinking 80% of the alcohol. As a result, we have a smaller number of people drinking more. Have the guidelines had an impact? They have inasmuch as we know that the first step in changing behaviour is for people to be aware of the harm that it can cause. I still think that your point is well made. Whereas people accept the harm that smoking and being overweight cause, there is still an issue in people accepting the harm that alcohol causes. That is a message that we still have not got through with the guidelines.

Q74 Graham Stringer: There are two kinds of harm, are there not? There is the harm to health, to the liver or from initiating cancer, and then the social harms of violence and accidents. How do you work with the Home Office to co-ordinate alcohol policy?

Anne Milton: Very closely. As a relative new girl, I do not know what has happened over the previous 20 or 30 years. I am working extremely closely with the Home Office. As you rightly say, alcohol causes physical harm and it also causes a lot of harm to people’s mental health. There is an economic harm to employers from lost time due to sickness absence. There are associations, although probably not causality. There is some interesting new research on whether it triggers or is a component of violence, domestic abuse and so on. There is a huge range of harms. I am working closely with the Home Office because it is a crime, anti-social behaviour and health harm issue. It is also an issue not dissociated with poverty. Working with other Departments, like the DWP and Justice, is important because the incidence of alcohol abuse with offenders and ex-offenders is also relevant. The Home Office is the first port of call. What is extremely important is that the alcohol strategy is going to be a cross-Government strategy and not a Department of Health strategy. It is important because it will collect together all the other Departments.

Q75 Pamela Nash: It would not be much of a surprise to most of the people in this room that the information we have received states that most of the population do not have a full understanding of the guidelines but particularly what constitutes one unit of alcohol. What does the Government intend to do to improve the understanding of the population about the guidelines and risks, particularly through publicly funded initiatives?

Anne Milton: I will circulate to you some of the possibilities for increasing awareness. In the Public Health White Paper we talk about the Nuffield ladder of interventions, the bottom of which is doing nothing and the top of which is banning something. We keep every rung of that ladder of interventions open and available. We are working with industry to see if we can get some voluntary agreements. Currently, we have got some of the industry to sign up to some voluntary pledges on exactly this issue. One of those is labelling, which refers to units and points out harms in pregnancy. That is one thing we can do, and it is only the start. The Drinkaware campaign-I have brought a sample which I am happy to leave with the Committee or you can pass it round-explains some of them. It is always interesting when, as a Member of Parliament, you find yourself as a member of the public getting through your door something that you heard about in the Department in which you work. I have another one here, which is the one which came through my door, and its aim is to raise awareness about alcohol and the harm it causes.

We know that there is no one magic bullet or one single factor. The Public Health White Paper talks about taking a "life course event". If, for instance, you want to raise awareness, one of the ways you can do it is with schoolchildren. Probably, they are responsible for most of the increase in recycling by their parents, because they nag their parents. They learn about climate change in school and they go home and nag them. Informing children can be quite useful not just for their own health but they also nag their parents about it. In relation to teenagers and young adults and some of the harder to reach groups, informing could be done through sports clubs and that sort of thing. We target particular groups, and pregnant women would be one of them. There is a variety of things we can do. There is often a slight tension in whether you target certain groups or you try and hit everybody. Again, the research basis is mixed somehow, which is more effective. With some campaigns it is better to target. I will ask Mark, as the addiction expert, whether he would like to add anything.

Dr Prunty: In terms of targeting, we particularly looked at adults in the 33 to 55 age range, and particularly those in the lower social classes with social marketing campaigns in recent years. Work has been done to assess what the best messages are for that group. That is a particularly important group because that group is more willing to listen to messages. That is also the group that is going to be experiencing the long-term harms from alcohol. We have also produced, as the Minister said, information focusing on those people who wish to reduce their consumption to low-risk levels to make sure that they have accurate and scientifically sound evidence, which is what we provided through the benchmarks and distributed through Drinkaware, NHS Choices, Change4Life and other materials to the NHS, so that practitioners and professionals have the currency in a credible and meaningful form to be able to discuss the situation with patients and others. It is hitting those populations through a range of different routes.

Q76 Pamela Nash: Many of the initiatives you mentioned are done in partnership with industry. How much of it is publicly funded? How much public funding is going to be available over the period of the spending review for these projects?

Anne Milton: Of course, this is in the light of the changes that are currently going through Parliament. If approved, the responsibility for public health will move to local authorities. Interestingly, local authorities already do quite a lot of work on the social harm from alcohol. Crime and anti-social behaviour is a particular issue in some areas. Many local authorities do quite a lot, not specifically on health harm but with that welcome side effect. We have community alcohol partnerships. Work is going on to line up people who come drunk into A and E and informing the police to target hotspots so there are opportunities for brief interventions. We will be announcing the allocations that local authorities will be getting soon. We are doing quite a lot of work to separate out what is currently spent by PCTs. It is a matter of what is spent locally and nationally. Experience would suggest that local campaigns, generally, work better because the different type of alcohol consumption patterns vary.

I was at an all-party group yesterday and the Member of Parliament for Newquay attended. They have a specific problem that is probably not shared by many other places. You might do a campaign there in a very different way-because they have a population that is staying for a week, getting very drunk and then passing out again-from the way you would target the harms caused by alcohol in rural areas, where you have, maybe, a high degree of poor mental health, where suicide rates are high and where unemployment is an issue. The figures we have-I am looking at Chris Heffer-we can certainly forward to the Committee, but we are in a changing environment. It has been quite difficult for us to extract from the primary care trusts what they are spending on public health as a whole, let alone what they specifically spent on alcohol.

Q77 Pamela Nash: Those figures will be helpful.

Anne Milton: Yes. We will give you what we can, certainly.

Q78 Pamela Nash: You mentioned a few groups that you were targeting at the moment. Is there any group of people that is of particular concern to the Department at the moment in terms of their understanding of alcohol guidelines for those who are at risk?

Anne Milton: The Change4Life campaign is a national campaign, which will be including alcohol. Many of you might be aware of it. To its credit, you might not know that it is a Government campaign. If you did not spot it as a Government campaign, it has been enormously successful, because Government campaigns tend not to have the resonance with the public. 90% of adults say that they have heard of messaging about alcohol in units and 75% have heard of drinking units. I do not think there is any specific group, if I am absolutely honest. I would not say it and officials should not say it either. You always target those who are at most risk, so the higher drinkers are most at risk. At the extreme end of that you have the alcoholics. It is a matter of making sure that adequate support and rehabilitation services are available for people who are alcoholics or addicted to alcohol. That is why in the Public Health White Paper we talk about a "life course event". What you have to do is to punch into this, as you do with all health programmes, at every single level.

Q79 Pamela Nash: In your experience, do you think there are other interventions, such as minimum pricing or restricting advertising alcohol products or even their availability, and that targeting them and changing these might be more successful than promoting the guidelines?

Anne Milton: They can be. The big mistake is that each of the interest groups-in the wider sense, the NGOs, the industry, the Royal Colleges and all the rest of it-have a pet idea, and we do as individuals. We tend to believe that what worked for us works for other people. The danger is that Members of Parliament, possibly, believe that they have expert knowledge when we only have anecdotal knowledge. Am I the target group? No, I am probably not. What would work for me would not necessarily work for a 16-year-old who is already drinking to harmful levels.

As to pricing, taxation has altered. We have put additional duty on beer that is over 7.5% alcohol and reduced the duty on beer that is at 2.8% or below. Already, there has been a response from the industry. Already, they are dropping the alcohol strength to get below that duty level. There is no doubt that price can manipulate the market. Increasing duty on high- strength alcohol is not a bad idea because for every litre sold there is less alcohol in it, which is a move in the right direction. There is a lot of debate as to how much elasticity there is on price. In reality, alcohol has become more expensive, certainly as regards the on-trade. It has gone up above RPI year on year. The off-trade, which now sells 65% of alcohol, has become increasingly cheaper, certainly since 2001. There is a very big difference between on-trade and off-trade on prices. We have seen some behaviour change. That causes its own problems that I will not go into now. You have all the things that you can do on pricing. However, the reason why alcohol is more affordable is more to do with rising incomes than price itself. The picture is complicated on price.

Other issues are advertising. There are already rules about advertising, particularly to children. One of the pledges that has been made collectively by the industry is about advertising close to schools, which is an issue. Again, it is important for us as Government Ministers, and for our officials, to remain open-minded. Sadly, for me, what seems like a good idea, when I ask officials to drill into it, is not quite as simple as that. Members of Parliament and members of the public write to me with what seem to be wonderful ideas, but once you look into them they sort of work but not completely. So open-minded and multi-faceted approaches are what we have to do. This Committee’s report will be useful for us to put into the mix of our evidence, until something emerges that says, "This is what you have to do."

Q80 Chair: Can I just take you back to your observations about your Newquay example? I am not trying to condemn Newquay.

Anne Milton: No, we would get into a lot of trouble if we did that.

Chair: You are absolutely right that different patterns occur because of the natures of different communities throughout the country. You went on to say-I paraphrase-that it is difficult to get the hard data from the PCTs about what they are doing. Would it not be rather a good idea to gather that data in and try to identify against the background of the different community mixes what best practice is and see how effective different PCTs have been?

Anne Milton: Absolutely. Your point is very well made. It is easy to find out what they are doing. It is difficult to find out how much they spend. It is different.

Chair: I understand.

Anne Milton: Somebody who works for one of the very big charities asked me recently, "Why do we continue to do in healthcare what we know doesn’t work and fail to do what we know does work?" When you see an example of really good practice, you think, "Why don’t we transport that into other areas?" It is quite important to recognise what the barriers are to spreading best practice, because if it is a good idea, why don’t we just do it? Some of that is due to local factors; some of that is due to the fact that we are quite resistant. Health professionals and local authorities are slightly resistant to believing what other people tell us. It is not only the public with whom we have a problem. Other organisations say, "Just because it worked in Leeds, Newcastle, Manchester or Cornwall, it won’t necessarily work here because we are different."

One of the planks behind Public Health England is to better inform local areas about how they might address some of these big public health challenges that we face, gather that formal body of evidence and make sure that we disseminate right on to the ground what has been demonstrated to work in practice, what the research is currently showing and make sure that we see some of those things at work.

Q81 Roger Williams: There is a group of people who are interested in this subject who believe that the Government should be more sceptical about the commitment of the industry to responsible drinking. Included in that group was the Health Select Committee’s 2009 report on Alcohol, which said that the Government should be more sceptical about the industry’s claim that it is in favour of responsible drinking. Was this taken into account when developing the "Public Health Responsibility Deal", which was published in March 2011?

Anne Milton: I am sceptical about everybody. Everyone, including the industry, comes to a discussion with their own agenda. It is important always to have a degree of cynicism without it getting in the way and to judge things on what you see. You are right about the Health Select Committee’s 2009 report. The previous Government responded to that in March 2010. The Responsibility Deal is one positive move that we have been able to make. We have to judge it on the results that we see. In 2013-Chris Heffer will correct me if I am wrong-we will be having an independent analysis as to how much progress has been made. On the ladder of interventions, one rung is voluntary arrangements-there are all sorts of things-and I am happy to send the Committee a paper just to explain that piece of the White Paper, if it would be helpful. That ladder of interventions is out there. Indeed, on price we have already regulated and legislated inasmuch as we put up the price on stronger beers and lagers.

I have an appropriate degree of cynicism, but the world has changed slightly. Two or three years ago, probably around the time that the Health Select Committee did their report, the stories of drunken behaviour in our town centres at night were truly dreadful. The images and pictures, many of which were from Guildford, which is my constituency and has a large night-time economy-which was useful for the press because it is close to London-kept being repeated. There is a bit of a line inasmuch as 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. One of them, going back to the Home Office, is licensing, so health bodies acting as a responsible authority when it comes to licensing applications would be one approach.

Q82 Roger Williams: Of course, the Government themselves are in a difficult position-not you, Minister, I am sure-because they receive so much tax from the sale of alcohol. What involvement do you have with the Treasury on those issues?

Anne Milton: Smoking is the big one. I do not have the figures in front of me. The tax revenue from smoking is significant and probably far greater than the cost to the health service in dealing with smoking-related harm. To be completely pure, it would be entirely improper if the Department at any time was persuaded by an argument on revenue and avoided doing what it should do on public health. We are pure as the driven snow on that, Mr Williams. There is no interference. The public health messaging is quite clear.

This may be a good opportunity to mention the fact that the Prime Minister has set up a Public Health Cabinet Sub-Committee in which all the Departments, including the Treasury, have a seat. I have not yet heard them say that they want more revenue from alcohol, so could we persuade people to drink more. The point you make is important. That committee is an opportunity to bring everybody together to make sure that we are addressing this on all fronts and that our messages are clear, pure and without interference from vested interests.

Q83 Roger Williams: I am glad you were able to put that point on the record. I understand the point you make about the drinks industry wanting to have a good and positive brand. Yet it was the 2009 report which said that, if everybody who drank drank responsibly, that would lead to a reduction of 40% of all alcohol that was sold. I still find it difficult to understand what the impetus is for the industry to be so anxious to promote responsible drinking.

Anne Milton: Brand is one of them. One of them is the pressure that the Government are putting on them, and they do not want to have to pay the duty on alcohol. What is quite interesting is if you put into that mix the trends that we are seeing. Young people are drinking less and they are older when they start drinking. There are things that the industry can do that means they continue to sell their product without it causing harm to people. If I may remind you of the figures, one third of the people who drink to excess are drinking 80% of the alcohol. As to the strength of alcohol, the average bottle of wine in the 1970s was 9%. It is now 12.5%. We have seen a market emerge where the amount of alcohol in any one bottle is much greater. Reducing the level of alcohol probably does no harm to their sales but reduces the harm to people’s health.

Q84 Roger Williams: Do the Government have any plans to introduce regulations to make businesses provide information through labelling at the point of sale?

Anne Milton: I do not know if these have been forwarded to the Committee, Chairman, but it might be quite useful for you to have. I am happy to make sure that that happens. One of the pledges in the Responsibility Deal is on labelling.. The companies that have signed up have said that 80% of alcohol products will have clear labelling, including warnings about pregnancy, units and the guidelines by, I think, 2013. It is a start.

Q85 Chair: Are there any companies that are not prepared to sign up to that deal?

Anne Milton: I am sure that there are but not many.

Chris Heffer: There are not many major companies. About 100 companies cover about 80% of the industry. Most of the major companies are doing so. If I may speak for them briefly-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%. There will be an independent verifier by December 2013. When you walk into a supermarket and examine the bottles, 80% of their bottles should have those three elements that the Minister mentioned.

Anne Milton: Just as an aside, individual companies sign up to different pledges. ASDA have said that they will take out displays in the foyers of their shops. Nothing is an end in itself. Until we reduce the deaths of 15,000 a year from alcohol, we will not be satisfied.

Q86 Roger Williams: Have you any idea of how close to achieving that target of 80% you are at the moment?

Anne Milton: We have just started this process. You are probably as impatient as me. Since we have only been in Government for 15 months, I do see why that should be an excuse not to have done everything we want to do. I am terribly impatient. It would be unfair to measure progress now because different people are in different places on some other public health issues. We have moved a tremendous way. Some of it is about how difficult it is for the industry to get it in place. As you will know, and there is no point in shying away from it, there has been a lot of concern about the Public Health Responsibility Deal, unfairly, in some ways. The proof of the pudding will be in that independent assessment in 2013.

Q87 Stephen Metcalfe: The current alcohol guidelines broadly distinguish between gender, age groups, pregnant and non-pregnant women, but there are other categories that could be considered as well. How do you determine the appropriate level of complexity? How many different sub-groups should there be?

Anne Milton: Absolutely, quite. Not only is the pattern of alcohol drinking complicated but the harms that it causes are complex. Different groups suffer different degrees of harm. It is an outstandingly complex picture. If you contrast that with smoking, the message is quite clear: don’t smoke. 80% of people die every year from smoking. It is not quite as simple with alcohol. You need the message to give information to different groups of people who have varying abilities to absorb that information and you need to align it so that it alters their behaviour. We want to give them the information in a format that they can understand, in a place where they will read it and in a way that is meaningful to them, that does not give them the opportunity to deny that it is relevant to them but produces a change in their behaviour. It has to have their confidence as well.

These are Government messages. One of the difficulties for Government these days-it has become an increasing problem-is that, just because the Government tell you to do it, nobody necessarily believes it. There was a time when we were more inclined to do what the Government told us to do. Now I think we are less inclined to. It is really the power of campaigns like Change4Life because it does not look and feel like a Government campaign. It is a recognisable brand and it is trusted. All the market research that has been done on Change4Life demonstrates that people trust that messaging. Then you get into the different types of media.

Take television. If you wanted to reach the average 13 to 15-year-old, I would suggest that today television is not your answer because they do not watch it any more. The 10-year-old age group does watch television. There are all the social media differences. I do not know if Chris or Mark want to add anything.

Dr Prunty: The key issue is that the core messages follow the evidence. You can say certain things with a level of clarity and specificity which are supported by the evidence and other things that require a more narrative approach. There is a huge variation between individuals around the effect of even drinking at average levels, but there is a very strong evidence base around, for example, the benchmarks of 2 to 3 units or 3 to 4 units, that allows you to state with a great deal of confidence that, if you drink at those levels, as an adult, it is a low risk. There is an evidence base around pregnancy and the risk to the foetus, which is not as strong, but there are good systematic reviews that help us to give a very clear and concise message on levels of consumption. There is also softer information about the frequency of drinking, drink-free days, weekly and daily consumption. There are differences between gender, body size and other problems that require a different approach to reflect the complexity but are still able to inform the public who are interested in minimising their risks.

It is about disentangling those and not trying to throw them altogether so that actually no message is received. For the various groups for which the evidence would be less strong, you can give a single message. Older people may be an example of that. It is about trying to look at the core evidence for a particular group and trying to understand what is best presented in a particular format, such as a benchmark, and what is best presented as helpful narrative in a range of different media.

Anne Milton: Then there is the growing evidence base about social norms. In the US they put up posters saying how much students drank, which was a lot lower than most people thought. There is definitely something about people drinking because they think that is what most people are doing. All of that puts the message across in quite an oblique way.

Q88 Stephen Metcalfe : One of the interesting things you said at the beginning was that you do not want to make the guidelines either so complex or that people can deny they apply to them. Is the group who you said drink up to 80% of the alcohol particularly prone to denying that the guidelines apply to them, and are they a particular type of group of people?

Anne Milton: Yes. This is quite interesting. Dr Prunty is an addiction psychiatrist; so he will speak with far more knowledge and give you a far more informed opinion than I can simply as a Minister. But you are hitting on quite an important point, which is that people do things that they know harm their health. 22% of people still smoke, even though the evidence demonstrates that people are very aware of the harm it is doing to them, but still they continue to do it. On all matters concerning public health, we have to take one step away from the particular issue we are dealing with and ask why these people are doing it in the first place. In relation to the 10% who are drinking to excess, who are drinking 40% of the alcohol, we have to look at why it is that people feel a need to get very drunk and harm their health.

There is a wider issue about people’s mental health and wellbeing. There is a genuine issue-I am sure the Committee does not want to go into this today-and we must be open- minded about this, as to why it is necessary for young people to go out regularly and frequently and get very drunk. If you talk to those on street pastors projects, as I have done, street angels or whatever you want to call them, they will say that our town centres, where people drink a lot, are full of very sad young people. There is another issue to address, which is: who is doing this?

Q89 Stephen Metcalfe: Does that lead you toward almost personalised or tailored drinking advice for different groups of people? As you said, how do you get that advice to them? I am talking about middle-aged men who are heavy drinkers because they always have been or young people who are drinking to excess. How do you get them to think, "It doesn’t affect me at the moment because I’m so young. I’ll deal with that later." It is getting that detail across about what the real harm is.

Anne Milton: That is right. That is why localising public health, embedding it within local authorities, is so incredibly powerful. It is important because it is about what the public believe the Government are doing for them. There is no doubt that most people drink at low risk levels. It would be unwise and inappropriate for the Government to demonise people who are not doing anything wrong. Targeting becomes important.

I know that Mark Prunty mentioned the value and impact of brief interventions with some of that group who might be the people with whom the police have contact. Community Alcohol Partnerships are important for that. It might be the people who are known to the local licence trade. The opportunity for brief interventions can be very powerful as it is very targeted.

Q90 Stephen Metcalfe: From what you are saying, you are talking about those right at the extremes as opposed to those who may not even realise that they have a problem. Do the Government need to put more resource into helping people who probably do not see themselves as problem drinkers but understand that they may be doing themselves more harm than they believe, through tailored advice, not so much intervention, because some people may not be having any contact with someone who can tell them that they are drinking too much?

Anne Milton: I am going to ask Dr Prunty to answer the question on how you get people to accept that what they are doing causes harm, because that is a question for a psychiatrist.

Dr Prunty: That’s for a Nobel Prize. I take the point you are making. There is a group of heavy drinkers who are at very high risk of harm, and there are those who are drinking either above the recommended levels or substantially above the recommended levels. Both of those groups, as compared with the general population, are much less willing to accept at face value that the claims about health are not exaggerated-44% of those drinking above the lower risk guidelines would think that the claims are exaggerated. It is only about 15% of the higher risk drinkers who are at particular risk of harm who wish to change their behaviour at this time, whereas 87% of the general public think that, probably, it is sensible for your health to stay within guidelines. There has to be a range of different mechanisms. Where you can interface with professionals who have skills and can recognise that you may be drinking at certain levels that may harm you, then there is an evidence base which we have been promoting and materials we have produced for identification, brief advice and giving the right advice in those circumstances.

Also, the Department has produced toolkits for local areas to look at how to identify the needs of your particular population in those high risk groups and use social marketing techniques to deliver to your population the range of different factors that affect their drinking, whether it is unemployment, social status or other factors. The focus has been about developing the support and skills so that those people, either through public campaigns locally or where they interface with systems that give advice, know that the knowledge and skills about how to do that is available. There is quite a substantial body of materials.

Chair: Colleagues, we have four more very important questions that we need to get through in a fairly tight time scale.

Q91 Graham Stringer: You have answered a number of questions that I was going to ask. I have two or three follow-up questions. In terms of the target groups that we were talking about, do you agree with your colleague that we should be one of the target groups as to how we deal with alcohol? Do you think that some of our bars should be closed earlier and some of the bars closed down completely, as one of your colleagues suggested?

Anne Milton: Perhaps I could answer that question as a Member of Parliament rather than as a Health Minister. I do not like the word "should". Members of Parliament or people who work in jobs similar to the one that we do, which have fairly anti-social hours, are often working at a distance from their family and are susceptible to certain sorts of risky behaviour. Drinking and poor mental health are, without doubt, two of them. Interestingly, one of the Responsibility Deal networks that we have is on health in the workplace. It is about employers looking after the health of their work force better. We do not have an employer. Our constituents are our employers, I suppose, if anybody is. We probably do not do enough. I know that the Occupational Health Department of the House has tried to do more about Members of Parliament looking after themselves. There are a few notable people who have demonstrated wonderful stories of weight loss. One was in the papers this weekend.

It would be quite interesting, Chairman, if this Committee did a research project to see how much Members of Parliament knew about the guidelines on alcohol and whether they felt they exceeded their daily and weekly limits, and in practice how much alcohol was consumed on the parliamentary estate. I am sure the Daily Mail would love it.

Q92 Graham Stringer: It might be interesting getting a vote on it. You also talked about changing behaviour by price mechanism and alcohol strength. When I have dealt with problems of alcohol as a constituency MP, all the professionals say to me is that nobody other than people with alcohol problems buys the extra strength ciders from supermarkets, White Lightning, for instance, and yet the last Government and this Government have resisted increasing the duty on that kind of alcohol. Do you not think you could improve people’s health by changing those duty limits on strong cider?

Anne Milton: We have done it and we are having an on-going discussion with the Treasury. We have seen an additional duty on stronger beer. It is quite encouraging to see the industry responding by dropping the strength of some of their beers to fall under that threshold. It would be something that we would have to keep under review if the industry was chasing our tails on it. Also, lowering the duty on the lowest alcoholic drinks is important because, as we must not forget, the majority of people drink safely. There is always this tension of penalising the majority for the behaviour of a minority.

Let me say a word on pricing. Minimum unit pricing is an expression not used by this Committee but used slightly carelessly sometimes by others. Our advice is that that in itself is probably illegal as it contravenes European free trade legislation. I know that Scotland is thinking about introducing it. They will be challenged and that will clarify the law. Our advice is that that is illegal. We have to be very careful about penalising the majority because of the minority. We have said that we will increase the duty by 2% over RPI during the lifetime of this Parliament, so duty will go up across the board. Again, I draw your attention to the difference between the on and the off-trade. We will set out our plans in the Alcohol Strategy, which will either be this year or early next year, which will say more about what we are going to do on price. As Mr Metcalfe was saying, targeting is quite an important point. You have to look at the patterns of drinking that are going on, which would suggest that it is not as simple as one would assume and there is debatable evidence about the amount of price elasticity there is.

Q93 Graham Stringer: We had medics before us last week. There was clearly a disagreement between them about whether the advice should be weekly or daily. The Royal College of Physicians thought that giving advice on a daily limit sent out the wrong signals saying that it was okay to drink daily, when repetitive drinking without a rest in between was dangerous. What is your view about that?

Anne Milton: I am going to sound repetitive. My view about that is that we should keep an open mind on that because, as Mark Prunty described, this is a complex picture. There are unintended consequences. There are dangers, if you give people a daily allowance, because they think it is something they can save up for the weekend. Understanding human behaviour is a critical part of how we do that. We need different messages for different groups of people. I would say we should have no hard and fast rules. Local measures will be very effective. When going back to some of the areas that have a large tourist trade, where a lot of people go for hen nights or stag nights-Blackpool, I know, has that-you may be putting out different messages in towns like that than you would do for schoolchildren. Mark, do you want to add to this?

Dr Prunty: With regard to the daily guidance, the levels, the benchmarks, that have most recently been planned in Canada and previously in Australia, the evidence base for the risk is based on regular daily consumption and that level is low risk for these range of harms. That also needs to be placed in the context that the vast majority of people do not drink daily and have drink-free days. The core evidence around which the harm and science is most robust is about daily consumption. In a sense, we need to make sure that that message is credible. It can be described in weekly terms, but there is a concern about saving up. Previously, there was also a concern about encouraging twice a week drinking in that you may interfere with some of the potential beneficial effects. The 1995 report made it very clear that there was a range of reasons why the shift went from weekly to daily.

Q94 Stephen Mosley: It is on those potential beneficial effects that I want to push you a bit more. The 1995 "Sensible Drinking" report did conclude that the "moderate consumption of alcohol confers a protective effect against a number of series diseases, including coronary heart disease", stroke, gallstones and so on. They highlighted a number of benefits. Do the Government still believe that there are any health benefits from drinking alcohol in low quantities?

Anne Milton: I am saying this with extraordinary caution because anything that is said in this report needs to be placed in the context of the extensive harm that alcohol can cause. There is, possibly, evidence to suggest that it remains true for older adults. However, a number of experts and research books recently have raised some questions about the robustness of that body of evidence. The Government need to talk about the harm that alcohol causes us. There are plenty of people who will rush to the belief that alcohol is going to provide them with some health benefits, while resisting the rush to the fact that alcohol causes some harm. It is important that all we do in public health is based on the best evidence available, because it is only if backed-up by scientific fact that the Government’s messages remain credible. That credibility is terribly important. We have to tell the truth, which is difficult in a complex area like this, and where there is questionable evidence in this instance about any possible health benefits.

Q95 Stephen Mosley: We noted at our last meeting on 12 October there was a degree of disagreement about the so-called benefits. One of the witnesses said that the cardiovascular benefit was overplayed. You were talking about the evidence changing. How much has the evidence changed since that "Sensible Drinking" report was published and are there any plans to look at it again?

Anne Milton: Do you mean the 1995 report?

Stephen Mosley: Yes.

Anne Milton: It has remained good for a long time. We constantly look at it. As I said at the beginning, what is important for the Department, as it is important for Public Health England, is to remain open-minded and receptive to any evidence. We must also remain perceptive to challenge. If somebody comes along and says that there is research that we have not heard of that will demonstrate that we are wrong, then we should look at it again. Maybe you want to come in on this, Mark.

Dr Prunty: I saw the transcript of that discussion. There was one issue about the scale of the evidence supporting the benefits. It is true that the number of studies has increased and multiplied. There have been major reviews which have looked at the methodology underpinning those studies and questioned their robustness. The evidence has been accumulating in that direction. In terms of reviewing that further, the major well-controlled studies are out there, and there have been various reviews of that. There is still evidence of the health benefits, particularly for coronary heart disease, but it is certainly true that the concerns about how robust the methodology is and whether there are other confounding factors has strengthened considerably, particularly in the last five to 10 years. There has also been increasing consensus that many of those benefits are likely to be achieved by other methods as well, such as diet and exercise. Certainly, the British Heart Foundation has come to the conclusion that equal or greater benefit may be accrued by diet and exercise, to which the 1995 report did refer.

Q96 Stephen Mosley: From a public health perspective, you strongly believe that you should concentrate on the problems that alcohol can create rather than any other potential benefits fro m the public health perspective.

Anne Milton: If there is absolutely clear and unarguable advice that there were health benefits to drinking, the Government should tell the truth. That is what the Government should do. The message to get across the harm alcohol causes is far more difficult than the belief that alcohol might cause you some benefit.

Q97 Pamela Nash: Following on from Stephen’s question, since the 1995 report , has there been any additional and stronger evidence on the particular effects of alcohol consumption on women?

Anne Milton: Women do have greater risks of long-term health harms when drinking at similar levels to men above the lower risk levels. Women have been catching up, which is of concern. Patterns of drinking in young women have, without a doubt, changed. But, still, women drink much less than men on average and suffer far fewer health problems. I do not think that we could point to one particular bit of evidence. That is where we have ended up. Probably, there has been a concentration on the harms for pregnant women, in particular, and NICE produced guidelines in 2007. Mark, do you want to say something?

Dr Prunty: It is clear that the protective effects are less apparent in women. They have a lower risk of coronary heart disease, which is the main disease that we are talking about. We also have evidence that alcohol contributes causatively to breast cancer, which is an issue with low levels of consumption. Women are at risk of coronary heart disease at a lower level but for a shorter period of time, because they tend only to be at risk post-menopause of developing these problems. If anything, the evidence has become somewhat clearer that the protective effects apply more clearly to men than to women. Let me put it that way.

Q98 Pamela Nash: The Scottish Chief Medical Officer’s advice t o pregnant women is that no alcohol is safe at any time du ring pregnancy and there is no safe limit. Could you explain why that differs slightly from the advice given in England ? Do you think that the mixed messages on alcohol guidelines for women who are pregnant are causing confusion among the public?

Anne Milton: It is terribly important for all those in the health sector, politicians and Chief Medical Officers to try and get the messages on line. In an area which has complicated messages, where the public are resistant to take them up, then clarity is absolutely critical. There is no doubt about it that pregnant women or those who are trying to conceive should avoid drinking. If women choose to drink, they should not drink more than one or two units of alcohol once or twice a week and should not get drunk. Our Chief Medical Officer will reiterate that. I cannot answer for the Chief Medical Officer for Scotland. You will have to ask him yourself.

Q99 Pamela Nash: What effect do you think mixed messages to t he public are having?

Anne Milton: Both sets of advice are based on the underlying message that women who are pregnant or trying to conceive should avoid alcohol and not get drunk. As I say, the Chief Medical Officer for Scotland is answerable for his own advice. I cannot answer for him. I do not want mixed messages out there. I hope that Ian Gilmore will read the transcript of this evidence session and feel that the Government are taking good and scientific advice on all that they do, but people persist in beliefs and they will persist in saying things in their own way. The Chief Medical Officer for Scotland can do what the Chief Medical Officer for Scotland is allowed to do.

Pamela Nash: I will take that back.

Q100 Stephen Metcalfe: We heard from some of our previous witnesses that they did not want to see the recommended guidelines increased. Do you believe that they should be decreased in the light of the more recent evidence that has come through, particularly linking drinking alcohol with cancer? If you were to go through that process of reviewing the guidance, what would that process be? Would it only be based -I appreciate there is a lot in this question- on the scientific evidence or would voter attitudes have an input into that as well?

Anne Milton: The Alcohol Strategy is going to involve us in looking at everything we do with regard to alcohol. That is a cross-Government strategy. If the Government produce a guideline, we have to demonstrate on what evidence that is based. If that guideline differed from what the evidence backed up, that would be clear, and we would then have to answer for why we had given advice that conflicted with the scientific evidence. We are in the process at the moment of looking at everything around alcohol. I do not believe that there is currently any evidence available that would suggest that we ought to alter those guidelines.

There are two issues. There is scientific evidence about what is low risk, but one must not forget that in anything that concerns risk there is a sliding scale. There is not a point at which your risk suddenly alters. It differs from person to person, age group and so on. Also, we have to be clear that a complex message is got across clearly. Altering guidelines can cause problems in terms of getting across messages. I do not know whether you want to add anything, Chris?

Chris Heffer: You made a point about voters’ preferences. If I can be slightly civil servicey, we always talk of people rather than voters. We are not allowed to give the Minister anything that is political in that perspective.

Anne Milton: That is an important point to make.

Chris Heffer: Given that we are in 2011, one could see merit in engaging the public in some of this approach, whether that is understanding some of the terminology used or what is their appreciation of risk. Two or three years ago, we changed phrases like "lower increase in risk", given feedback on that. I think you have talked about labelling units and simplicity at times as well. If there is to be a message on a bottle, it would be helpful if that was part of the consideration rather than leaving a fairly long list of things to communicate, which is tricky to do in a small space. If you are going to do a marketing message and have some evidence, expertise and engagement on what that might be, it would seem helpful if you are going to do that; otherwise, as the Minister said, the scientific principles would be on the same basis to start with.

Dr Prunty: A small technical point, which the Canadians are looking at, is that one of the benchmarks is the cause of mortality. The unknown causes of mortality will already have been incorporated in assessing the risk for that guideline. You learn more about it, but the risk of death from breast cancer, for example, which we did not know about or were not sure about, will already have been picked up in the causes of mortality, which is the main factor that drives setting the benchmark, alongside the fact, which is the issue Chris has raised, that no single condition below those levels has a very substantial risk. It is those two things together that reinforces low risk.

Anne Milton: Maybe the challenge for the week is whether we can get this through to Members of Parliament.

Q101 Chair: On that point, Minister, Dr Prunty and Mr Heffer, I thank you for your attendance.

Anne Milton: It is our pleasure.

Q102 Chair: We would be grateful if you can leave your graphics and the other documents that you promised us.

Anne Milton: Certainly, and, if there is anything else that the Committee wants, we are very happy to supply it.

Chair: Thank you for a frank exchange this morning.

Prepared 3rd November 2011