Health Committee - Minutes of EvidenceHC 132

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Oral Evidence

Taken before the Health Committee

on Tuesday 17 April 2012

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Andrew George

Dr Daniel Poulter

Mr Virendra Sharma

Chris Skidmore

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston

________________

Examination of Witnesses

Witnesses: Professor Sir Ian Gilmore, RCP special adviser on alcohol and Chair of the Alcohol Health Alliance, Eric Appleby, Chief Executive, Alcohol Concern, Professor Alan Brennan, Sheffield Alcohol Research Group, and Dr John Holmes, Sheffield Alcohol Research Group, gave evidence.

Q1 Chair: Good morning. Thank you for coming to join us. Could I open the session by asking each of our witnesses in turn to briefly introduce themselves, starting with Eric Appleby?

Eric Appleby: I am Eric Appleby. I am the Chief Executive of Alcohol Concern. I was from 1990 to 2004 and I have recently come back to the job in the last few months.

Chair: Congratulations.

Professor Gilmore: I am Ian Gilmore. I am a physician by background with an interest in liver disease. I chair the Alcohol Health Alliance, a coalition of more than 25 organisations who are concerned about the health implications of alcohol, and I still represent the Royal College of Physicians on alcohol issues.

Professor Brennan: I am Alan Brennan, Professor of Health Economics and Decision Modelling at the university of Sheffield with a team that have been looking at modelling minimum unit price and its effects.

Dr Holmes: I am John Holmes, a public health research fellow at the university of Sheffield, working on the Sheffield alcohol policy model.

Q2 Chair: Thank you very much. As you know, the Committee has announced that it is doing this review of alcohol policy-deliberately, as the Government announced their Alcohol Strategy a few weeks ago. It was notable that that document was a crossGovernment document led by the Home Office but involving, obviously, the Department of Health. Would you open the session-perhaps each witness in turn-by telling us, first of all, how you reacted to the general principles set out in that strategy, and, secondly, whether you think it right that this is a policy that should be led from a Home Office perspective or from a health perspective. How would you deal with the emphasis in terms of the problem we are trying to solve? Is it a social problem or is it a health problem?

Eric Appleby: My initial reaction to the strategy was one of welcoming it. It is a significant step forward from anything we have had before. That was, overall, the response, and particularly because the strategy has looked at tackling consumption through price and availability-perhaps less so through marketing-which we know are some of the key triggers there. I think it could have gone further in terms of the issue of treatment. There is more that could be done and said on that.

As to the question about the location of the strategy, the key thing for us is that there is a strategy that has some teeth and that will have an impact. Health is clearly an important part of it. To go back in terms of the emphasis of it, clearly the headlines are around binge drinking. It is a problem and an unsightly problem. In health terms, however, the bigger problem is not so much the binge drinking but the longterm, more hidden perhaps, middleage and middleclass sort of drinking. In health terms, the most significant costs are hospital admissions, the vast majority of those being the chronic longterm impact of drinking on things like strokes, cancers, hypertension and all that sort of stuff. As I say, I am reasonably relaxed about where it is located as long as it does the job that it sets out to do. We know that these things tend to get passed around Government Departments, so I would not want to make a big deal of it. As I say, the important thing is that it does the job it sets out to do.

Professor Gilmore: I would very much echo that. The overall impression is a positive one as far as the strategy is concerned. For the first time it really does accept the evidence as to the main drivers of the alcohol problems we are seeing in society, particularly price, availability and marketing. Clearly it is stronger in solutions in some of those areas than others. I think it does lack specific targets and ambition in some areas-the areas concerned with marketing are weaker. I would like to have seen a lot more said about treatment services, but we can come back to the detail of that.

I do not mind too much how it was framed. What I mind about is how it measures up to what I think it requires in order to reduce our per capita consumption and the concomitant harm. I very much agree with Eric Appleby that the emphasis is on binge drinking, but what we are more interested in is the impact on everyone’s drinking. For example-and we may get on to talking about hospital admissions-Liverpool Primary Care Trust data show that 90% of hospital admissions related to alcohol are for chronic conditions. They are not for people falling over in Lime Street when they are drunk, but for chronic conditions. In many areas the strategy does measure up to making an impact on those areas, and if it helps politically to have it framed in a particular way, then I have no specific objections.

Q3 Chair: But does it follow from what both you and Eric Appleby have said that the definition of the ambitions in the document, which focuses on alcoholfuelled violent crime, binge drinking and alcoholrelated deaths, is focused more on a social policy issue and you would want to see the emphasis shifted more in the direction of longterm morbidity caused by unnoticed alcohol consumption?

Professor Gilmore: That is fair. As I say, if it does the job then I do not mind quite in what terms it is couched, but it is stronger perhaps in areas that relate to crime and social disorder-licensing-than it is perhaps in some of its ambitions concerning health and, in particular, treatment. So, yes, I would accept that, but we would have preferred it to have been framed more in terms of the health challenges and potential health benefits. None the less, there is a lot there that gives us something to work on.

Professor Brennan: It is important to say that the economic effects of alcohol go across various different aspects. In our modelling efforts about the impact of minimum unit price, we have looked at the impact on health harms-hospital admissions and alcoholrelated deaths. But crimes-and they are important, and I think it is important that that is acknowledged as part of the strategy-and also workplace-related harms, such as absence from work and unemployment caused by harmful drinking, are important economic aspects. The policies underlying the strategy, particularly as to pricing and licensing, are aligned well with the reviews of evidence nationally and internationally that we have undertaken about what works in terms of alcohol harm reductions.

Q4 Chair: Focusing on the question of policy objectives, though, it is odd, is it not, that against the background of declining overall alcohol consumption, there is perceived to be an increasing problem of alcoholrelated morbidity?

Professor Brennan: That is quite a complex thing to untie. There has been a recent reduction in reported alcohol consumption, but from quite a high level that has been going up over many years. Certainly in relation to these chronic health harms, where people drink substantially and over time that results in illnesses like cancers; a shortterm downturn does not turn off that lagged effect around health harm. So the damage that is being done to livers and other parts of the body is part of that complex picture.

Q5 Chair: Do you accept the evidence that there is now declining alcohol consumption or do you regard that as a blip related to the recession or some other factor?

Professor Brennan: I have not studied it in great detail so I would not like to say that I do not accept it, but certainly it has been short term compared to the very longterm trends.

Dr Holmes: To follow on that, alcohol consumption peaked in 2005. In 2005 we were drinking more alcohol per person per year than we had been at any other time in the last hundred years. So, yes, we have seen a small fall from that peak, but in no way are we back down at what might be considered low levels in an historical context.

Returning to the original questions, I think the strategy is a big step forward and I would echo what Ian and Eric have said. From a public health perspective, there is a lot in there which is evidence based and could be considered a good example of evidencebased policy making. In terms of whether it should be led by the Home Office or the Department of Health, a lot of the attention, obviously, went on minimum unit pricing. Minimum unit pricing will have some impact on binge drinking and it will have an impact on alcoholrelated crime, according to our modelling, but there are other things in the policy which will also have an impact on the binge drinking. There is a lot in there about controlling the availability of alcohol, looking at the density of alcohol outlets in city centres and looking at the impact of introducing a public health consideration into the licensing objectives. While the focus has been on minimum pricing-and perhaps the biggest impact of that will be on health outcomes-there are plenty of things in there which, the evidence suggests, will have an impact on binge drinking.

Q6 Andrew George: Can we say that the liberalising of licensing hours has been a complete failure? In other words, are we coming to a conclusion now-and is this universally accepted by all four of you-that we need multiple Government interventions for the good of the individuals who are otherwise vulnerable to all the things that alcohol can do to them?

Professor Gilmore: We have to accept-to quote the bible on this topic-that "alcohol is not an ordinary commodity". If it is left to personal choice as an entirely libertarian issue, we will run into problems. It is a drug. It is a drug of dependence. It is a psychoactive drug. It happens to be legal. We do not want to make it illegal, but it does require different handling from soap powder and other things that may be dealt with otherwise by the free market. Yes, we certainly need to consider it differently and we do know that availability is a key factor. Availability was clearly increased in the last strategy of 2004 when licensing hours were relaxed. A lot of things changed around the same time, so it is very hard to blame one individual strand, but it has often been said that the vision of the Prime Minister of the time of turning England into a winesipping, continental cafe culture did not work.

If we look at the statistics, for example, of the admissions to St Thomas’ hospital in the month of March before and the month of March after that change in policy, there was a huge increase in alcoholrelated admissions and alcoholrelated presentations. Overall, increasing availability is not in the interests of health, and regulation-admittedly the minimum regulation which then always has to be balanced with individual freedoms-is not an area where we can sit back and leave it all up to individual personal choice, because we are dealing with a drug of dependence.

Q7 Andrew George: I wonder whether Professor Brennan or Mr Appleby want to comment on whether there were any beneficial outcomes from that experiment with the liberalisation of licensing hours. Can we draw a conclusion from it that there is something about the British psyche or culture that is different to the continental-that we are too immature in comparison with our continental counterparts, that we do not disperse at night, arm in arm, discussing Plato-

Chair: Unlike the Greeks.

Andrew George: Maybe some of us do-fairly incoherently probably-but in fact we go out and slug nine bells out of each other.

Valerie Vaz: They do that as well.

Andrew George: Is it that we, in Britain, are culturally different, incapable and too immature to cope with too much freedom and access to this particular drug?

Dr Holmes: There has been evidence over the years, looking at different drinking cultures in different countries. Traditionally, the Scandinavians had what we called the dry drinking culture where they did not drink as often but when they did they drank in quite an explosive fashion and got very, very drunk, whereas the Mediterranean countries had what we call a wet drinking culture, where they drank all the time but did not necessarily get particularly drunk, and Britain was somewhere in between. There is increasing evidence that that distinction is breaking down. Things like globalisation are changing it. You can obviously see how the different environments-which alcohol those countries were able to produce historically-determined those, but obviously that distinction has broken down. Increasingly, there is evidence that the continent is starting to drink in this British way, where young people increasingly drink to get drunk.

Q8 Andrew George: So we have exported our problem, have we?

Dr Holmes: You could argue that. Whether it is exported or someone else has exported it, I am not sure. The general point is that, as Ian said, there is no real evidence to suggest that increasing licensing hours will lead to a more relaxed drinking style. The evidence-and it is fairly limited on temporal availability-is that longer licensing hours and more days of sale lead to higher levels of consumption, more harmful consumption and more harms related to alcohol. There has not been a high-quality evaluation of the Licensing Act, but what there has been has certainly not suggested there have been beneficial effects.

Q9 Andrew George: Would you agree, Mr Appleby?

Eric Appleby: I would not disagree with anything that has been said. As to the first part of your question about the licensing changes, I do not think you could say they were an unqualified success. Things change, as Alan has been saying. The drinking culture changes over time and, as Ian has said, it is no ordinary commodity. We have a number of pressures on people with drinking-cultural and commercial-so it does need regulating, but things do change. I think one of the things we are learning is that-and what we have always had did not necessarily seem to work anyway-we have to keep a constant process of reviewing and changing the regulations that we put in place and the way we do this. Even if you look at it now, the major concern is about drink bought from supermarkets as opposed to pubs, whereas a while ago it was pubs we were worried about. This is a constant process of reviewing what we have and how we need to regulate it. I do not think leaving it either to a market or to a cultural assumption is enough.

Q10 Andrew George: Do you all think it is appropriate that the Home Office should be taking the lead on this policy area, or do you think it should be driven by a concern about health-in other words, the Department of Health driving this policy? Have the Government got it right, that in fact the primary concern is antisocial behaviour and that the policy must be driven by addressing those issues rather than the concern about the health of those who are drinking?

Professor Gilmore: From my point of view, what matters is outcomes. Clearly alcohol cuts across many areas of Government and it is not for me to tell Government how do its job. What I am interested in is the output and what impact that has on my primary concern, which is health. If I had turned left rather than right out of the school gates I might have been a police officer now and I would have been arguing from a crime and disorder point of view. It all depends on where we are coming from, but they are clearly all important. I cannot argue that health should have primacy, although I do think that the general public would put health very high up.

One of the striking features of alcohol is the damage it does to third parties, and we often do not make enough of that. There is hardly a family that has not been touched by some member having alcohol dependence or being a victim of violence or whatever. Health has to be up there, but how it is framed does not matter to me so much as what Government puts out in the end to help society to improve its health.

Q11 Chair: Does Professor Brennan want to comment on that?

Professor Brennan: Yes. I have two points on what you have been asking. I would come back on the licensing point to agree with what John said. I would have preferred it if some more substantial research had been done on the effects and evaluating the Licensing Act last time. In particular, there are quite a few data sets that do collect how many people are drinking what, but mostly they are crosssectional data sets so they are different people each year who are surveyed. Having a longitudinal survey in which you could see how people change their patterns of drinking would be a very powerful tool for evaluation of alcohol policies. It would have been really powerful in the licensing and will probably be even more powerful as a tool in the coming strategies.

Q12 Dr Poulter: Professor Gilmore, I have a question for you. You outlined earlier-I think quite rightly-that 90% of admissions to hospital were often linked with more chronic alcohol abuse. On that, in terms of connecting chronic conditions with alcohol abuse, traditionally the focus has been on liver disease, which is your specialty; but do you think there is a broad enough long-term evidence base-for example, with other conditions, certain types of cancer and the like-in terms of how the data is collected to say that alcohol is a part of this admission and a part of this illness, or do you think the evidence base at the moment is focused largely on illnesses that have almost a direct correlation purely with alcohol?

Professor Gilmore: The evidence base is quite strong for the impact of alcohol on conditions such as cancer, high blood pressure, heart disease, strokes and so on. The socalled alcoholattributable fraction for different diseases has been very well worked out. What is less well worked out is how we code illnesses when patients come in and out of hospital. There has been an improvement in coding along with payment by results, and so on, but I think it is still not well done. I am concerned at the move to change the way that hospital admissions are measured so that only if alcohol is part of the primary diagnosis will it be captured. I think there is a real risk of losing the impact of alcohol on health if we do that. If it is done, it is very important that we continue to capture also the data on secondary diagnosis, because we know that coding is still poor. Yes, the impact of alcohol on other diseases-on cancer, breast cancer and the like-has been very well categorised, but we do not always put that evidence into practice.

Q13 Dr Poulter: So it is well documented. There is good medical evidence for it.

Professor Gilmore: Yes.

Q14 Dr Poulter: But in terms of linking that with hospital outcomes, admissions and policy, the coding that is used in hospitals may underreport the impact of alcohol on that particular admission.

Professor Gilmore: Absolutely. There are huge differences. If you look at deaths directly related to alcohol, you are talking of about 5,000 or 6,000. If you are looking at attributable fractions, you will be up to about 40,000 deaths a year. It can make a huge difference when you take into account the alcoholattributable fraction of other major diseases.

Q15 Dr Poulter: I have one other quick question of clarification. You made the point earlier about 90% of admissions being alcoholrelated, but you also talked about when licensing laws were extended and expanded. I presumed you were saying that the attendances at A and E at St Thomas’ increased during that time to do with alcohol in that year-those MarchtoMarch comparisons you gave earlier-and they would be not only the chronic disease picture that you painted but also the localised incidents of people on that particular night drinking too much and presenting at A and E but perhaps not being admitted to hospital later on.

Professor Gilmore: It was both. They looked at related attendances at A and E and hospital admissions, and there was a rise in both. So it is likely to affect both acute presentations and chronic conditions.

Q16 Valerie Vaz: How do you measure it? What is the timeline in relation to someone who has started drinking alcohol and it then becoming a chronic condition?

Professor Gilmore: How do we define "acute" and "chronic"?

Q17 Valerie Vaz: Yes. How do you define it?

Professor Gilmore: That is a difficult one. It tends to relate to the actual medical condition you have had. In other words, if you have cirrhosis of the liver from alcohol, even if you fall over and break your ankle that would be counted as an acute episode-if you had the chronic condition-and vice versa. It relates to whether the condition is one that requires longterm exposure to alcohol.

Q18 Valerie Vaz: Can you give a time estimate on that?

Professor Gilmore: No, I cannot. I do not think there is a time definition. It is related more to the episode. If it is a chest infection from lying in the gutter when drunk, it would be acute. Acute presentations tend to be related to the complications of being drunk, whereas the chronic ones tend to be those related to longterm consumption.

Q19 David Tredinnick: Sir Ian, you talked about codifying illnesses earlier on. Has any work been done on whether there is any different impact from the consumption of different alcoholic drinks? I put it to you that it has long been held that gin is a depressant, whereas people say that if you drink vodka you are less likely to get a hangover. I do not drink whisky, but I think that whisky is alleged to have certain characteristics too. Is there any evidence of relative harm from consuming particular spirits?

Professor Gilmore: There has been a lot of work looking at the supposed beneficial effects or less detrimental effects of different beverages-the health benefits of red wine as opposed to other colours of wine, and so on. You can find some research to suit whatever case you want to put on the day. The reason is that there is probably virtually no difference. What really matters to your body is the amount of alcohol you take in. Some people may find that they have a headache the next day after sherry and not after gin or vodka. We know that there are incredible innate differences between individuals in the way their bodies handle alcohol and there may well be individual differences in the way we handle different sorts of alcohol, but the bottom line, so far as your body is concerned, is how much alcohol you have taken in, both acutely in order to get drunk and chronically to sustain permanent damage. We know it is actually quite hard to get drunk on weak beer, whereas it is very easy to get drunk on shots of spirits. That is because you can get in more spirits in a short time and there is a limit to the volume of beer you can drink, but if you find you get the beer in, the effect of the alcohol will be the same whichever way you have taken it.

Chair: It’s "Bad luck, Bordeaux."

Q20 Rosie Cooper: There are difficult questions here and confused messages that the public hear. It can almost be seen as a circular argument, in the sense that we hear-there are various stories-it is better that you drink in a controlled environment, that is, in a public house where people can see that you get drunk and restrict your intake of alcohol, but earlier we were talking about the increased licensing hours. If you regulate that, then surely people are going to go back and drink more in an unsupervised place. How would you help policymakers and the general public understand and how would you help us help people to make the right choices?

Dr Holmes: The point is to retain the focus on the key driver of alcoholrelated harm. It is not where you drink or who you drink with, but how much you drink. That is where the focus needs to remain. As I said already, we are drinking at historically very high levels. Yes, we can do other things as well, but fundamentally we need to bring that level of consumption down, particularly for those people who are drinking at the heaviest levels. That is unrelated to where they drink, accepting the fact that prices in the off trade are substantially lower and cheap alcohol is highly available to a greater degree than it is in the on trade. I am assuming we are going to be getting on to that shortly.

In terms of which place to drink is more or less risky, it depends who you are. If a 19yearold man goes out drinking in a pub, he is probably at a higher risk of getting into a fight than a 50yearold woman who goes out drinking in a pub, but that 50yearold woman is probably at more risk of harm from drinking at home because she is at a time of life where she is at greater risk of the various chronic diseases you can get from drinking. So I do not think it is helpful, when you are giving out broad public health messages, to talk about where drinking is safe. The only point when it probably is relevant is ensuring that pubs are well run, that they abide by their licensing conditions and that they are not places that are conducive to violence.

Eric Appleby: The thing we have not been very good at has been the messages. We have what were originally called "Sensible drinking guidelines", which, when they were framed, were relatively straightforward, but the world has changed since then-the strength of drinks, the size of servings, and all that. It is now very confusing for people. The strategy talks about reviewing those. The important thing is reviewing how we communicate them, because I think you will find that the science has not changed very much. It is about how you communicate that and how you can get the message across to people of the true nature of the issue. It is a very loaded subject. Nobody wants to be told that they should drink less than they are currently drinking. We have this spectrum between, at one end, a sort of fatalism about drinking, "You cannot do anything about it. People drink. It just happens" and a denial at the other end, "Yes, I have my bottle of wine with a meal every night. I do not get drunk. I do not cause anyone any problems. There is nothing wrong with that," except 20 years down the line when you end up in one of Ian’s hospital beds.

For policy makers, it is a difficult one. What we need to do is look at ways in which we can produce messages and produce medical evidence about what alcohol will do to your body over a period of time if you drink in this sort of way and get those messages across. We do love a bit of a headline, which is one of the reasons why we hear so much about the whole binge drinking thing. It is an important topic and a problem in certain areas, but we overdo the pictures of drunken youths and do not do quite enough on some of the more evidencebased underlying messages about the nature of alcohol and what it does.

Q21 Dr Wollaston: Can I move on to the question of minimum pricing and ask-perhaps starting with Dr Holmes-about how strong you feel the evidence is to support minimum pricing?

Dr Holmes: It is probably better if Alan talks about the strength of our evidence. He is the technical expert on our team.

Professor Brennan: Thanks, John. The key ingredient in a minimum price policy is obviously the price. From a public health evidence perspective, the evidence is absolutely completely overwhelming that if you increase prices people drink less alcohol. If you talk to the man in the street they are not convinced that that is the case. There are two recent systematic reviews, one of 132 studies and another one of 112 studies internationally, all showing that when prices increase people decrease their consumption, and not by as much as the price increases. If you put prices up 10%, consumption might fall by 5%, for example. That is really important.

The work that we have done modelling the effects of minimum price has had to look in detail at what people are drinking in England-or Scotland, when we have analysed Scotland-how much they are paying for it and what the different beverages are. All of that is taken into the account so that when we have done our analyses we have said, "We know exactly what market share is currently made up of things that are less than, for example, 40p per unit." If we assume that the prices for all those products were to increase to exactly that possible proposed minimum, then there would be price increases happening for all those products and all of the people that buy those products would face those price increases and reduce their consumption. So when we have done our modelling we have taken account of that kind of heterogeneous purchasing and consumption pattern across the population.

The key advantage of minimum pricing, from a targeting perspective, is that it is, in the data, the harmful drinkers who tend to drink more of the cheaper alcohol. Compared to putting general prices or general taxes up, putting a minimum price means that it is the harmful drinkers who are disproportionately affected by the policy. Those are the kinds of analyses that we have done.

Q22 Dr Wollaston: One of the criticisms sometimes made of minimum pricing is that it will not help with the wealthier longterm chronic home drinker. Is there any evidence that people on relatively higher incomes change their behaviour with a policy like minimum pricing?

Dr Holmes: There is no specific evidence looking at the impact of minimum pricing on those on high incomes but there is evidence looking at what people on high incomes spend their alcohol money on. It is very clear that, right across the income spectrum, people who are drinking at harmful levels are price responsive and that they drink cheap alcohol. For instance, we have had a look at the spending diary data from the Expenditure and Food Survey and found that in all income groups about 80% of alcohol units are purchased in the off trade and, of those units, in all income groups, more than half of the units bought by harmful drinkers were below 50p a unit. So even in the highest income group, half of harmful drinkers’ alcohol spending is on cheap alcohol. That makes sense because, while we talk about high incomes, it is only those at the very, very top of the income spectrum who disregard price. The remaining 95% are price sensitive and still look at the price of their supermarket shopping.

Q23 Chris Skidmore: A bottle of wine is far cheaper now than it was, say, 20 years ago. You can pick up a bottle of wine in Tesco for a fiver. A minimum price is not going to affect that and it is the middleclass drinking-what Eric and Sir Ian said about the half a bottle a night for 20 years that then rebounds to end up in cirrhosis of the liver-that minimum pricing, surely, is not going to touch.

Dr Holmes: The evidence suggests that those who are drinking at harmful levels are buying that cheaper alcohol. No, a £5 or £6 bottle of wine is not going to be affected. But if you are buying your wine at Asda and you are buying three bottles for £10, it will be affected. If you are buying a £4 bottle of wine it will affected. Harmful drinkers do not only drink wine. They drink cheap ownbrand spirits which are certainly affected. They drink super-strength ciders and beers. They buy the beers sold in packs of 24, which are almost exclusively sold below 50p or 40p per unit.

Professor Brennan: But you are right. It is not the case that a minimum unit price would stop everybody drinking alcohol or stop all alcoholrelated harm.

Q24 Chris Skidmore: I was interested in the 90% of admissions in Liverpool that Sir Ian mentioned being affected by the longterm chronic conditions of cirrhosis that might not only affect those on low incomes, but those on the medium to higher incomes that this strategy will not touch. You will still have those admissions.

Q25 Dr Wollaston: That was the question, whether or not it will impact on that 90% as well as on the group that most people would accept it would have an effect on-or people would see that there could be an effect on-the young binge drinkers on a low income. Are you confident that the modelling is there to show that it will impact this 90% as well?

Dr Holmes: It is worth pointing out that, as I have said before, minimum pricing will have an impact on young binge drinkers. But young binge drinkers do not buy as much cheap alcohol as older people simply because they tend to drink more of their alcohol in the on trade, which is largely not sold at prices which will be affected by the policy. Some of it is, but largely it is not. The biggest impact from this policy is on those older people, not people necessarily with higher incomes but people of a higher age. This is not a policy which is targeted at young binge drinkers. This is a policy which is targeted at people of all ages who drink at harmful levels.

Q26 Dr Wollaston: Do you think there will an impact on health inequalities?

Dr Holmes: The evidence on this is a bit mixed. There is evidence that those on lower incomes suffer a greater risk of harm per unit of alcohol than those on higher incomes. A policy which reduces consumption in all income groups should have a bigger impact on the health outcomes of those on lower incomes because it will reduce their risk of harm by a greater amount.

Q27 Dr Wollaston: Can you clarify why they are at greater risk of harm if they are on a low income?

Chair: I do not understand that.

Dr Holmes: It is a bit unclear. Partly it is to do with other confounding factors, things to do with other aspects of their diet, other health behaviours, the environments in which they drink, their access to medical services and the quality of those services and, because of their other health behaviours, their body’s ability to deal with the alcohol. There are lots of reasons which you could broadly consider as social exclusion arguments which mean that people on lower incomes are at greater risk of harm from alcohol than people on higher incomes.

Professor Gilmore: I would echo that. It is a big health inequalities issue. It is the poorest who do disproportionately suffer harm from alcohol. The reasons are complex, as we have heard, but I am sure that consumption coming down in general would have a disproportionately beneficial effect on the poorer.

Q28 Dr Wollaston: Coming back to the point that Chris touched on earlier about the level of the minimum price, if you want to impact on people who are buying a £4 or £3 bottle of wine, is there any evidence, in your view, about where the level should be set and whether or not we should coordinate that with Northern Ireland and Scotland?

Professor Brennan: It is clear that there is a kind of accelerating level of impact. If you were to set a minimum price at an extremely low level, like 20p-I think it is something like that-0.1% of the market is covered and you are basically doing nothing. As it rises up, the level of impact accelerates because you have two effects going on that multiply beneficially, which is more of the market being covered and people facing a higher relative price change for the alcohol that they were buying. For example, in our modelling a 40p minimum price was reducing consumption by 2.4% nationally, but a 50p minimum price was something like 7.6%.

Dr Holmes: It was 6.7%.

Professor Brennan: Okay. So there is about two and a half to three times more impact on a range of different measures from 50p compared to 40p. There is a lot of coverage in that range across the market share. There are a lot of products sold at those levels.

Q29 Dr Wollaston: Can I ask you to clarify what it would be at 45p? That is the level that is being discussed for Scotland. What would be the reduction?

Dr Holmes: It would be 4.3%.

Q30 Dr Wollaston: Is that estimated to translate into reductions in alcoholrelated deaths for each of those?

Professor Brennan: As to alcoholrelated deaths, for 40p we estimated a reduction of 1,190; for 45p, 2,040; for 50p, 3,060.

Q31 Dr Wollaston: Over what time period is that?

Professor Brennan: That is the annual level of deaths, but that is once the policy has been in place for a considerable period of time, so accounting for the fact that there is this lag effect, those chronic diseases will not immediately disappear in year one.

Q32 Chair: What is the considerable period of time?

Professor Brennan: I think 10 years was how we were modelling things.

Professor Gilmore: If I could come in there, in countries that have increased the price and reduced consumption, you see a drop in deaths from liver cirrhosis within 12 months.

Professor Brennan: Yes, you will see that.

Professor Gilmore: We know it takes 10 years to get cirrhosis in most people, but the impact is seen much quicker. That is probably because there are quite a few people-hopefully not round this table-teetering on the brink and were they to suddenly reduce their consumption they would slip back into the safety zone. So although what Professor Brennan says is absolutely true, none the less you do get very real health benefits in the short term.

Professor Brennan: And they accumulate.

Professor Gilmore: Yes.

Q33 Valerie Vaz: I am quickly going to ask-you may not be able to answer this question-whether you have any comparisons with other EU countries and in particular what the EU Commissioner said, that EU rules will not apply if countries want to have a minimum pricing level. I am trying to get you, I suppose, to say that there is not any prohibition to doing it because other countries have done it, and if you have the evidence for that.

Professor Brennan: I have nothing to say as to the legal side of things. I do not think minimum price has been implemented in many European countries but it has in some of the Scandinavian ones. John might know.

Dr Holmes: I am not sure that is correct. I think it is only in Canada that they have had it properly implemented. Do you want to talk about the Canadian evidence?

Professor Brennan: Yes, I could. There is a recent paper by Professor Stockwell in the journal Addiction. Canada has had a minimum pricing policy for quite some time and its differential in different states has changed at different time points. It is quite clear that when they have changed their minimum price there has been a direct impact on consumption. Once they have had this policy for a while and they ratchet it up a little bit, or put it down, consumption follows quite quickly in terms of decreases and increases.

Q34 Andrew George: I want to follow up exactly on that point, the international comparisons-obviously you have reallife examples in Canada-and, therefore, where there have been problems in the north with the Inuit, whether the ratcheting up of prices had a clearer impact in that area. Also, you have adopted a modelling approach and clearly you have been advancing that and evangelising, if you like-if you do not mind me saying so-the potential benefits. To what extent has that been peer reviewed by colleagues in other academic institutions who have confirmed that your modelling appears to be robust?

Professor Brennan: I would not say I am a natural evangelist. A cautious and evidencebased approach is what I would say. Certainly the modelling work has been peer reviewed-the original work that we did for the Department of Health-and then the work that we did for the National Institute for Health and Clinical Excellence goes out to peer review in itself and is now published in peerreviewed journals such as The Lancet. I am perfectly happy that it has had real detailed scrutiny by many people. There is a separate question which is "It is only modelling" and there are two ways to look at that. The way that I look at that is that modelling is not only modelling. Modelling is a synthesis of all of the available evidence in an integrated, sensible and coherent way. We pull it all together to answer the questions that policy makers have.

Q35 Andrew George: As to the example of Canada, you said that there were differential approaches-in different provinces, presumably. I wonder whether you could say anything about the northern territories, where there were particular problems with alcohol.

Professor Brennan: I do not have much to say on that in terms of health harms. I have been looking more at the price elasticities and the effects on consumption.

Q36 Chris Skidmore: In addition to a minimum pricing strategy, there are also the attempts to remove 1 billion units from the marketplace by 2015. I would be interested to get your views on-if you have done any modelling-how effective that might be. As a backofthepaper calculation, roughly £42 billion was spent on alcohol in 2010. If you take that as a 40p minimum pricing, I make that about 17 billion units. I know that is not accurate, but if you are trying to reduce by 1 billion, that is going to effectively reduce consumption by 6%, which is twice as effective as the minimum pricing. I do not know if you felt that was also the case, that, by taking units out, it would have an even more dramatic effect than minimum pricing overall.

Professor Brennan: There are two separate things. We have not done any formal modelling yet of the reduced 1 billion. It would be very interesting to put it in. As John said earlier, it is the units of alcohol that cause the health harm, so there is no doubt in my mind that that approach will have benefits. As to the relative benefits against minimum price, in a way the two kind of relate to and counterbalance each other. If you have 40p per unit but there are fewer units in your beer or wine, then that interlinks.

Professor Gilmore: I think you are referring to the pledge in the Responsibility Deal. If 1 billion units are taken out over this time period, then we would expect to see some benefit. However, Eric and I were talking on the way down here-we have been around this field for a decade or more-and remember the pledges to get labels with unit information on them 10 years ago. If we get some extra added value from the pledges of the Responsibility Deal that will be a benefit, but we should not rely on that as an alternative to minimum unit price.

Q37 Chris Skidmore: In addition to the Responsibility Deal and the minimum unit price you have duty, which obviously-it was announced in November 2010-will be rising at 2% above inflation each year to 2015. I am interested in the concept of the ABV where you have the 2.8% for lower strength alcohol and then, for higher strength alcohol, 7.5%. I was interested in your views on whether you felt that was the right parameter to be set-that with a lower cost you could charge less duty on drinks under 2.8% and higher duty on 7.5%. To me, personally, 7.5% seems quite high and you could have had a far narrower parameter, but that itself is a lever that will surely help to change the marketplace and reduce units overall.

Professor Gilmore: Absolutely. We need every tool in the box. We have not been helped by the fact that you cannot charge more duty on 15% wine than 5% wine, for example. The regulations are through Europe, so we need to look at all these ways of influencing price. Minimum unit price, on the face of it, seems the fairest and most targeted way of doing it because it will impact on the heaviest drinkers and will also have a disproportionate effect probably on underage drinkers. We need to look at all ways of modulating price. It is a complex area and a lot of the other measures around marketing and licensing are particularly important. I am pleased that the strategy has acknowledged that treatment for people with alcohol problems-who have the problems now-does work. Also, it is fair to say that I do not think the strategy goes far enough in saying how to improve that treatment. There are lots of good things out there. There is QIPP evidence on alcohol care teams in hospitals that really save money and reduce hospital admissions that does not come through in the strategy. There are NICE tools for treatment of alcohol problems that do not come through, so I hope that the Committee will be looking at those aspects too.

Q38 Dr Wollaston: I have one final question about the evidence for ending multibuys. How strong is the evidence from Scotland that that has an effect?

Dr Holmes: I am looking for a piece of paper which has some numbers on it. Because what we are interested in here is reducing consumption among harmful drinkers, we will not know the extent of the impact on those drinkers in Scotland until, maybe, 18 months after the policy was brought in because that is when the survey data, which looks at the impact on different groups, comes out. We have, however, seen some very early data from Nielsen on alcohol sales. I cannot find my piece of paper, but it does say-I think it was brought in at the start of November last year-that, compared to the previous November’s sales, sales of wine and beer were substantially down. Wine and beer are heavily discounted and sold in multibuys, so that is what you would expect. They also compared the change in sales in Scotland in that period with the change in sales in England in that period. Again, there was not the same change in England. It is very early evidence-we do not know who it is impacting on-but there is evidence that that policy did have an impact on consumption.

Q39 Dr Poulter: On the issue of corporate responsibility and corporate and consumer responsibility deals, which is quite an important area, there is evidence that this can work in some areas of policy-for example agriculture, supporting British farmers. However, what you have there is a tiein with the consumer wanting to support the objective. This is a little bit difficult to achieve with alcohol where, as we have already heard, the consumer wants to drink a lot and often get drunk, for example. That is the objective, in many cases, of the consumer. So there is a behavioural change issue to tackle.

Looking at the history of the alcohol industry, despite these very laudable intentions on Government policy with extending the licensing hours-which was a laudable intention but did not achieve responsible drinking-and looking at the fact that supermarkets had been responsible for multibuy deals and the cutprice alcohol deals and encouraging preloading, is it not the case that there is a risk that relying purely on corporate responsibility and consumer responsibility, unless substantial behavioural change is also indicated, is not going to be effective on its own? Also, in many respects, what minimum price alcohol pricing will help to do is encourage and engender that responsibility by forcing the supermarkets and the drinks industry to look at how much alcohol they have in their products because, thus far, they have not taken responsibility themselves.

Professor Gilmore: I will hand over to Eric in a second, but I would agree with that entirely. It is very difficult to get away from the conflict of interest of industry. There are areas where they can make a contribution, making sure that existing regulations as to serving underage drinkers and people that are drunk and so on are adhered to, but I have always had concerns about industry getting round the table to discuss how you produce a public health strategy for alcohol because you cannot get away from the conflict of interest. The same applies to supermarkets.

Eric Appleby: Absolutely. I echo that entirely. As Ian says, there are things the industry can do, but, at the end of the day, industry’s first responsibility is to their shareholders and to making profits which, by and large, means selling more drink. Clearly, there are responsibilities the industry has and they should live up to them. Put crudely, they need to live up to them but I do not think there should be any deals involved. It is a responsibility that they have.

Professor Brennan: Can I add in one thing on that? It depends on how the policy is implemented, but when we first modelled minimum price we assumed that the Government were not taking any of the extra spending that consumers were putting in directly as an extra minimum unit tax in any way. So the off trade retailers are having their prices put up and they make more money. There is an incentive on the retailers for minimum unit price to exist.

Q40 David Tredinnick: I am listening to Dan and to you and making notes at the same time. I am going to ask you questions about advertising, but, following on from what Dan is saying here, and we are looking at the impact of pricing on reducing consumption, should there not be a much greater emphasis-and I speak as someone who has worked in the advertising industry-on tackling the fashion of over-consumption? We are starting to see this now with some advertisements showing the results of car smashes after a night out on the booze or girls being drunk in the street and they can either go home looking nice or they can go home in a complete state, bleeding and things like that. Do you think that as well as this pricing strategy we need to have a much more powerful driver changing behaviour through other methods?

Professor Gilmore: Clearly the answer to that is yes. As we have said before, we need to use every lever we have in the system. What we do know is that public health campaigns on their own tend not to produce much behaviour change but often do when combined with regulation. For instance, there was a big seat-belt campaign. Nobody actually changed their habits but when regulation came in people accepted it because they had been softened up. There are many opportunities for that. I will perhaps hand over to Eric, if he wants to add to that.

Eric Appleby: Yes. It is this business of needing both the carrot and the stick. Drink driving is a very good example of that. The breathalyser and the "Don’t Drink and Drive" campaigns appear to have the effect. We do need more powerful advertising about the impact. It goes back to the messages, as I was saying before, but we need to look more at advertising-promotion-of drink as well. In particular, I am concerned about the issue of alcohol adverts getting out there and having a better prevetting system. What happens at the moment, often, is some quite unacceptable alcohol adverts get put out and the complaint process takes a while. It is some time before people can get the advert withdrawn, during which time some of the damage has been done. There are some very recent examples of that. Alcohol Concern did some work about young people and drinking and a particular product called Frosty Jack’s, a very cheap white cider which was being sold in 3 litre bottles, which is what young people were drinking because it was the cheapest. Its advertising-its website-were frankly scandalous but it was out there. We complained and eventually the website got withdrawn, but not before a lot of people had seen it. A stronger prevetting of adverts would help.

Professor Gilmore: Could I come back? I had forgotten the other point I was going to make. Clearly we would like to change the culture. The drinks industry says again and again that it is not about price and that we need to change our culture, but price changes culture. It has been that differential between the on trade and the off trade that has driven us from a nation, 10 or 20 years ago, that drank in pubs to a nation that drinks at home because it is cheaper. So we can change culture by levers such as price, availability and marketing as well as by some nebulous trick that we have not yet discovered.

Q41 David Tredinnick: Could you not also argue that, socially, it is a very bad idea that people should be drinking at home? It would be much better if they were drinking in properly regulated pubs. There is a greater issue here, which perhaps we are not going to get on to, of the price differential between on premises and off premises. We are losing so many pubs. We have lost some in my constituency. They are closing all the time. It is a tragedy that people have to drink on their own or at home when they should be socialising in groups. Surely that has benefits too.

Professor Brennan: My take a little on the strategy is that it has not looked at the option of having a minimum unit price in pubs and bars, which is something which is plausible and feasible and we have also modelled. I have interpreted that in my own way to be saying that the Government are keen, in a sense, to redress the balance of affordability between the two sectors. That is helpful to me in my new year’s resolution, which is to go to the pub more.

Q42 David Tredinnick: Moving on slightly, the Government, while acknowledging that there is a link between advertising and alcohol consumption, are not proposing to follow Norway’s example and have a ban on alcohol advertising. It says it would not be a proportionate response. Do you think that is fair, and what evidence is there on the links between advertising and alcohol consumption? You touched on this earlier.

Professor Gilmore: I chair a science group that supports the European Commission Alcohol and Health Forum. They commissioned us to do a piece of work on marketing and young people and the conclusion, quite clearly from reviewing the literature internationally, was that children start drinking younger and, when they do start drinking, they drink more because of the influence of advertising. I have no doubt in my mind that it is important. I, personally, would like to have seen more in the strategy, tougher action on advertising. Dr Wollaston has given us a perfect example in her Bill on marketing. I find it remarkable still that they are showing advertisements for alcoholic beverages in films that are rated for 12yearolds. If there is any situation where you know you have to be 18-to get into an 18 film-yes, show them a product suitable for 18 plus, but to show it for people of 12 is beyond my capacity to understand. So there are still areas where we could beef up the strategy on advertising.

Q43 David Tredinnick: Are there any meaningful comparisons to be drawn between the alcohol industry and the tobacco industry, which has seen significant changes in advertising policy over the years?

Professor Gilmore: They are clearly, in many ways, different and the end point is different. We are not seeking eradication of alcohol, whereas we are seeking the eradication of tobacco products. None the less, there are very clear comparisons, often indeed in the way the industry promotes their products and the way the industry is moving into developing countries when developed countries start taking tougher action. Certainly I think we should be looking at following the examples, for instance, of health warnings on bottles. That is an obvious example. I would personally like to see a ban on broadcast advertising, as they have in France. I would personally like to see a ban on sponsorship at sports events, as they have in France.

Q44 Chair: Do you have a general view in your mind of the proportion of the alcohol consumption that causes no health problem?

Professor Gilmore: This is a-

Chair: I understand that this will not be evidence based. I am looking for an impression.

Professor Gilmore: You can come and see me afterwards, Chairman, if you want. There are great difficulties and this is the nub of the problem of the health messages to the general public. Everyone is different and probably responds differently to alcohol. If you take 100 very heavy drinkers the majority will never get cirrhosis of the liver, but we cannot yet tell you which group you fall into. There are those individual differences. Then there is the fact that for different diseases the threshold is very different. If you stick within socalled safe limits then there are certain diseases you are virtually guaranteed not to get, whereas there are other conditions, like some forms of cancer, where drinking well below safe recommended limits will significantly increase your risks. I am afraid that, at the moment, you cannot generalise and say you will be totally safe if you stick to such and such a level. But I do welcome the recommendation in the strategy that guideline advice is revisited. It should be possible to personalise that more than we have at present and to try to get round some of the understandable confusion in the general public.

Q45 Chair: The reason I ask the question-and then I will go to Virendra-is this. We started off this morning’s evidence session by focusing on what the problem is. We acknowledged that there is binge drinking and the lawlessness problems associated with that. There is a defined group of people who definitely drink more than is healthy for them, and that has longterm consequences for their health. But there is a danger, in those two identifiable problems, that that discussion is moving on to a general theme that alcohol is bad, which for the majority of responsible users-in my perception at least-is not true.

Professor Gilmore: No, but you will get the maximum health gain by shifting the whole population consumption curve down. So we are looking for maximum public health gain, not only to get the very heavy drinker to drink a bit less. If everyone drinks a bit less, even those drinking within the current recommended upper limits will get a health gain too. An awful lot of hypertension, for example, is caused by alcohol and there is an impact within recommended limits. If someone has hypertension and they are drinking up to the upper limits, they will get health gains from reducing it. While we do not want to be killjoys, none the less there will be a bigger benefit than only targeting the very heaviest drinkers.

Eric Appleby: Can I add to that? We talked about messages and the guidelines and everything. It seems to me that one of the problems we have is that we are not very good at talking about alcohol. At one end it is a bit of a joke: going down the pub and getting drunk is comfortable and jokey. At the other end, talking about real problems is almost a taboo subject. In between we are not very good at having that conversation about the dichotomy, if you like, that alcohol is quite enjoyable and we like it but it also carries harms. Having this conversation about managing risk is something we just do not do, and people tend not to want to do. It is instigating that conversation which is to some extent what is needed.

Chair: That is a much broader issue in the whole discussion of health policy. David wants to follow through and then Virendra.

Q46 David Tredinnick: To what extent does exercise mitigate the impact of alcohol consumptions at different levels? If a person exercises regularly, is their body then able to process out the alcohol at a better rate? Has anything been done on this?

Professor Gilmore: I am not aware of any evidence on that. I would be surprised if exercise mitigated the adverse impact of alcohol. I do know that if you try and run off your hangover the following morning it is dangerous and people sometimes die of arrhythmias-

David Tredinnick: I will not be doing that.

Professor Gilmore: -of the heart, secondary to trying to clear their head the next day. I do not know of any evidence. What is interesting is that health messages relating to alcohol seem to be best wrapped up in general health and lifestyle messages. We reviewed this recently in another report from the European Commission on alcohol in the workplace. People seemed to take on the messages about alcohol better if they were part of general lifestyle advice-weight, exercise and alcohol-rather than preaching to them about alcohol. That is where I see the link between exercise and alcohol.

Q47 Mr Sharma: I am, I think, one of those very few individuals here who does not drink in the pub or at home. Do you not think that, with this trend of it being cheaper to drink at home, when you bring your drinks home-you drink and smoke in the presence of the young children-you also encourage the young children to drink and that it is better to stick to the pub? Second, there is the community spirit-when you go and drink in the pub with friends and other community people, that brings the community spirit as well. Do you not think that this pricing trend of cheaper wine that you take home is also causing social damage to the local community and to society in general?

Eric Appleby: What is clear is that children learn and take messages from their parents and it depends what those messages are. It is not so long ago that we were told that drinking in pubs was bad news for children because it was forbidden and was something behind closed doors-it was forbidden fruit and they could not wait to get their hands on it-so we should be introducing our children to drinking at home as a gentle introduction, a glass of wine here or there. Now we are having the debate the other way round. Probably the answer has to be that it is what messages you give. If you drink at home socialising with some friends, one drink each and enjoying that, then children will see that, or they may see you going to the pub and coming home roaring drunk. It is very much about what parents show to the children. Clearly that is why a lot of what we are talking about here is important. It is not only about the health of middleaged people, if you like, but also their drinking as parents and what the next generation is going to do.

Q48 Valerie Vaz: I want to follow up on the advertising industry. £800 million is spent on advertising. What are the targets you see in the Responsibility Deal that could possibly counter that? If there are not, clearly, say so, or if there are.

Eric Appleby: I am racking my brains. I do not recall anything in the Responsibility Deal so far which is going to make much of an impact on that. I have to say that in the strategy I was slightly disturbed to see talk about promoting advertising that promotes positive socialising-or something along those lines.

Q49 Chris Skidmore: It is page 23. It recommends the "Drinkaware’s ‘Why let good times go bad?’ campaign and we expect to see more campaigns such as this in the future."

Eric Appleby: Sure. I have nothing against Drinkaware’s "Why let good times go bad?" campaign.

Chris Skidmore: I was going to follow up to ask if you agreed with that particular statement.

Q50 Valerie Vaz: Can you answer the question?

Eric Appleby: There is a very fine line here. The advertising rules say that you should not advertise alcohol in such a way that suggests social success, either individually or as a group-positive socialising. It is dangerous. In my own view, again, I would prefer to see us go towards the French approach which is that you can advertise alcohol on a factual basis rather than in any other way. Unfortunately, I spent an evening on Sunday at Wembley watching a game sponsored by Budweiser and sitting opposite signs which said, "Great Times Are Waiting". I am not sure that I think that is the sort of advertising we want. Yes, of course, I enjoy drinking and everything but it feels to me that we still have a bit of a culture of advertising there which suggests that the more you drink the more you are going to enjoy yourself, I am afraid.

Professor Gilmore: I have some slight concerns about "Why let good times go bad?" because it is normalising going out and drinking to have a good time. One of the concerns is that people who do not drink are still considered odd-"What is wrong with them? Why do they not drink?" I think it is very regrettable that Heineken is the official beer of the Olympic Games.

Q51 Rosie Cooper: I have had constituents contact me about foetal alcohol syndrome, as I used to know it. I think it is called foetal alcohol spectrum disorder now. Do you have any estimates of the number of cases annually and why there is, essentially, a lack of good information out there about it-if and how we can improve that-and, I suppose, is the message very clear that if you are pregnant you should not drink at all?

Professor Gilmore: The message here is difficult because we do not have strong evidence on very light consumption during pregnancy. In the absence of evidence either way, the safest message-and this is what the Chief Medical Officer some years ago concluded-was to advise women not to drink at all. That is certainly the advice that the Alcohol Health Alliance would concur with. The problem is if you want to be evidence based, you have to be consistent. If somebody says, "Is there evidence that taking one glass of wine a week when I am pregnant is going to damage my baby?" then you have to say to be honest and say, "No, we do not have that evidence." But we do not have the evidence that it could not. By extrapolation from the fact that heavy drinking undoubtedly does damage the baby, the safest thing for women is not to drink at all.

Q52 Rosie Cooper: Do you know the number of cases a year?

Professor Gilmore: I cannot give you those data. The problem there is that we still do not fully understand what that spectrum is. We know babies that are obviously severely damaged, where their features are abnormal and they have brain damage. The numbers are, mercifully, fairly small, but there is clearly a tail and a lot of interest in whether inattention hyperactivity syndromes in children are linked to alcohol exposure in utero. We certainly know from animal work that the foetus is very sensitive to alcohol. At the moment, we have to work on a precautionary principle, but it is certainly an area where there is the need for more research. Until such time, the public health message is "Do not drink if you are pregnant". That would be an ideal starting message to have on labels.

Q53 Rosie Cooper: Absolutely. I used to be Chair of the Liverpool Women’s hospital and pregnant ladies who come in are confused about those messages. But if you see the results when it goes dreadfully wrong, then-

Professor Gilmore: Absolutely.

Q54 Rosie Cooper: Can I move on almost into the public health field? The Government feel that Health and Wellbeing Boards will be instrumental in improving approaches to tackling alcohol problems. Do you agree with that? If you do, how do you think they will do it? Do you think alcohol will have a high enough priority in the huge amount of work that they are going to have to do?

Professor Gilmore: It is certainly a risk. With the major changes in the NHS, with public health going into local government, with clinical commissioning groups out there commissioning services from hospitals, there is bound to be a risk that alcohol will fall through the gap, both in preventive terms and in treatment. It should not, but we do not yet know how strong those connections are going to be. It will need a strong national steer, both from Public Health England and from the National Commissioning Board, to make sure that it does not get squeezed out. We know, historically, when money is tight, that the immediate or the urgent takes precedence over the important and public health has a tendency to be squeezed out.

Q55 Rosie Cooper: I am a person who totally believes in the idea of a Health and Wellbeing Board, but in the construct we have now I am not sure it has the powers and the tools to enable it to deliver. Is there any help and advice you could give them-or give us, even-about making sure that this does not fall through the net?

Professor Gilmore: I know the Royal College of Physicians have been looking very hard at the structure of Health and Wellbeing Boards, clinical senates and commissioning groups so we will submit evidence, I think, trying to encourage better links to make the system work.

Eric Appleby: I think the principle of Health and Wellbeing Boards is great and the potential to have a real impact is huge. I share Ian’s concerns about whether it will actually happen. Looking at the strategy, this is an area where the strategy is, unfortunately, perhaps at its weakest. When it starts talking about treatment, it defers to the drug strategy. It says "We have a drug strategy". Payment by results refers to the drug strategy again, where in fact there are specific alcohol pilots going on. I think there are not the levers there to try and push the appropriate commissioning of alcohol services.

Earlier, Ian talked about admissions and the changing of the criteria. The one real alcoholfocused outcome target we have is alcoholrelated hospital admissions. If that is going to dictate the future purchasing plans, if you change that so only primary diagnoses get picked up, then you are going to miss the 90% of hospital admissions because they are chronic, they are long term and what you do in the first year is not going to have a huge impact on that. So there are number of things. There are good things in the strategy. The introduction of health checks is great. I like the fact that it has highlighted the effectiveness of IBA-identification and brief advice-and particularly liaison nurses in hospitals. It has highlighted some good things, but I do not think it has done very much to push them further and encourage people to pick them up and do them.

Q56 Rosie Cooper: Can I ask a very quick question about the brief advice? Do you believe that that intervention is effective and there is enough of it?

Eric Appleby: I believe it is effective. There is not enough of it.

Q57 Chair: It is one or the other, presumably. It is either effective, in which case we want more, or ineffective, in which case it is not a sensible intervention.

Eric Appleby: It is effective and we want more.

Professor Gilmore: Effective and more-cheap, good value.

Professor Brennan: It is effective. In seven clinical trials and meta-analysis all the evidence shows that it is-surprisingly, to me-effective. People really reduce their consumption after the brief intervention. It is also, from a health economic perspective, clearly cost-effective. That was another part of the report that we did for NICE.

Rosie Cooper: That is a large circle to join up, is it not?

Q58 Chair: Can I stand back from it for a second? In your initial responses to the first question you did say that you felt that the strategy was weak on service delivery. You have come back to that point in response to Rosie’s question. I wonder if you feel there is a clear view and, if so, where it is to be found, about what "good" looks like in terms of service delivery to people with alcohol problems.

Eric Appleby: Yes, there is. NICE have produced an excellent document-guidelines-and they have backed that up with an audit tool which is almost like a beginner’s guide. It takes you through what-

Q59 Chair: Obviously it is a continuously evolving picture, but there is a clear view about what "good" looks like and what we should be looking for is effective rolling out of the strategy as defined by NICE.

Eric Appleby: Absolutely there is, yes. There is a spectrum and IBA-early identification-is one end of the spectrum. At the other end of the spectrum you have to do things because people are dying, but, again, it is the bit in between that sometimes we miss out.

Professor Gilmore: Right at the far end, with the heavilydependent patients that unfortunately are often considered "no hopers", treatment is still effective and cost-effective. We only remember the ones that come back and not the ones that do well. It is very good that the strategy acknowledges that treatment works but it perhaps has not identified fully the levers that people can use locally to implement good care.

Q60 Chair: No doubt, along with all the other conditions-longterm chronic conditions-these services rely on greater integration of primary and secondary services with social care and so forth.

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Q61 Valerie Vaz: Is there anyone it is not effective on? Is it effective on young people, for instance?

Professor Gilmore: Funnily enough, the early studies suggested that brief interventions were less effective in women than in men, but I am not sure whether that has been substantiated. It is not my area of expertise. Now brief interventions have been looked at in A and E departments, general practice and criminal justice settings and it seems to have a significant impact in all the settings in which it has been looked at.

Q62 Valerie Vaz: And also on young people?

Professor Gilmore: I cannot answer that, I am afraid. We will send in some evidence.

Q63 Valerie Vaz: Does anyone know?

Eric Appleby: I am not sure.

Professor Brennan: I am not sure. It is clear that they are slightly less cost-effective in women than in men. That is because men are drinking slightly more at harmful levels and benefit more from the advice, marginally. But both are still very costeffective compared to other interventions.

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Q64 Dr Poulter: We have touched upon the need to ensure that interventions are effective, incentivised and prioritised. A traditional problem with the QOF payment for GPs is that it has been very much process focused and focused on data collection, which, of course, is important, but what we are interested in is outcomes and improving outcomes for patients. In relation to QOF payments and the issue the Chairman talked about of having a more integrated, communityfocused care, is it important that GPs are incentivised to make sure that they focus on effective interventions rather than only on data collection, in order to make alcohol policy effective?

Professor Gilmore: I am not an expert in the GP contract or indeed how to incentivise GPs. We welcome the fact that alcohol has got into the health check, but it would be better embedded in the system if it was in QOF. As well as early identification, it has to be linked clearly to a mechanism where it goes on to provide the brief advice.

Eric Appleby: I would second that. It is very important. There is a perverse thing that goes on-you will know better than I probably-that GPs are one of the more resistant groups to implementing this, and I have never quite understood why that is, but to embed it, the more incentives there are the better.

Chair: Gentlemen, thank you very much. You have answered a wide range of questions and given us plenty of food for thought. Thank you for coming.

Examination of Witness

Witness: Chris Sorek, Chief Executive, Drinkaware, gave evidence.

Q65 Chair: Welcome. We shall try to make you feel at home, even if we ask you, hopefully, some piercing questions. Would you like to begin the session by introducing yourself and your organisation?

Chris Sorek: My name is Chris Sorek. I am the Chief Executive of Drinkaware. It is an independent charity that was formed in 2007 following an agreement between Government and the healthcare community, which Ian Gilmore was part of, as well as industry. We are fully funded by the drinks industry. We have a unique governance model that brings together five members of the alcohol industry, five members of the public health community and three independents-that includes the chair-so that everyone can sit around the table and have a discussion about information, education and what changes behaviour in the United Kingdom around alcohol.

Q66 Chair: Thank you very much. We would like to begin by probing a little, if we may, the nature of the Drinkaware organisation and then moving on to the substance of the issues. The Alcohol Strategy refers to the fact that there is a review going on-or a review planned-of the Drinkaware structure and I would like to start by understanding where that process is, how it came about and what factors need to be taken into account in that review.

Chris Sorek: In 2007, when Drinkaware was formed, it was said that by 2009, there would be a review of Drinkaware. At the time that review went through at the end of 2009, an addendum to the memorandum of understanding that originally set up Drinkaware was established and signed by the drinks industry and by the Government. Basically, what that said in 2009 was that Drinkaware would be funded at a higher rate than had been done in the past: more industry partners would be brought on board-stakeholders would be brought on board-and would raise the amount of money that Drinkaware would have made available to it to about £5 million per year. The addendum to the memorandum of understanding also recommended that in 2012 an audit be conducted again of Drinkaware and its activities and that would then move into a review of what Drinkaware’s activity should be from 2013 onwards. It has all been part of a process that was established between Government, industry and the public healthcare community.

Q67 Dr Wollaston: Following on from that, it strikes me that having five industry representatives on your board is quite a heavy representation. I am interested that in 2009 the agreement was signed by the drinks industry and by Government but obviously not signed by the health representatives. Or is that not the case? Did they sign up to it as well?

Chris Sorek: My understanding-it was before my time-is that in 2007 the agreement was initially prepared and created with the input from the public healthcare community, Government and industry, but that the Drinkaware Trust, which was at that time part of the Portman Group, was being spun out. That agreement-the memorandum of understanding-was to be signed between Government and industry to make Drinkaware an independent charity.

Q68 Dr Wollaston: Is there an argument that perhaps you need fewer industry representatives on this board? There is inherently a conflict of interest for the industry whose main obligation is to their shareholders.

Chris Sorek: The way it is currently set up is that there are five members from the public healthcare community as well as five members from industry, so there is an equal balance there, along with three independents.

Q69 Dr Wollaston: Should it be an equal balance, though?

Chris Sorek: All I am suggesting is that it currently stands that way. The review that we are going through is going to take a look at our governance structure, our organisational structure and what we need to be in the future as we go forward. I am saying that all these things are going to be considered in terms of the review process as we go forward.

Q70 Dr Wollaston: Can I ask perhaps for your personal opinion? Do you feel that there is inherently a conflict of interest for the industry to be involved?

Chris Sorek: As the chief executive and having worked for three and a half years with the board as it stands, there has never been any conflict of interest or anything where the board from the industry side has ever said, "You must do this or we will pull out," and there has never been anything saying, "You must do this because this is what we want." They have never said that. As a matter of fact, I have seen nothing but cooperation between the two. I can tell you, quite honestly, as I have said in the past, in public and in Parliament as well in previous evidence, that I would leave the organisation if I felt I was being told that I had to do something by industry-or, for that matter, by the public healthcare community-because I work for an independent charity.

Q71 Dr Wollaston: So you would not have had any discussions with the drinks industry prior to coming to this Select Committee meeting today?

Chris Sorek: None.

Q72 Chair: Can I ask about your personal background? Before you took this job, had you come from a drinks industry background or from a public health background or from neither?

Chris Sorek: Absolutely none of the above. My background is that I started off as a journalist. I went from being a journalist to working for Ogilvy in AsiaPacific. I eventually went through that process and set up Ogilvy’s operations in AsiaPacific for about 11 and a half years. I then moved to New York where I handled work for one of Y&R’s subsidiary companies, which is an advertising agency, on their global clients, working with consulting groups around the world. I then went to the Red Cross in Geneva where I headed up their communications and issues management programme for three and a half years. I established them on the internet as well as other things. I then moved from there to reestablish the SAP brand, came back to the United Kingdom to work on De Beers and the "Blood Diamond" movie and worked with people like Nelson Mandela and the presidents of Botswana and Namibia about blood diamonds and what was going on at that time because of my experience with the Red Cross. After that I eventually came over to Drinkaware to take over the chief executive job there.

Q73 Valerie Vaz: I want to drill deeper into this. It may be that you can correct this, but on Wikipedia you have your full members as Bacardi, Carlsberg, Diageo, Heineken, InBev UK, C&C Group, Molson Coors Brewing Company and Pernod Ricard. I do not see any healthcare people on there. Is that right, or do you want to correct that for us?

Chris Sorek: I would say that that has to be corrected because those people are not on the board. They are stakeholders.

Q74 Valerie Vaz: They are full members, yes.

Chris Sorek: There is no full membership. They are just stakeholders.

Q75 Valerie Vaz: Could you explain the governance structure? You mentioned £5 million. Where does that come from?

Chris Sorek: It comes from the drinks industry.

Q76 Valerie Vaz: Totally from the drinks industry?

Chris Sorek: Totally from the drinks industry. It is about £5.2 million.

In 2009 there was a new business plan put together for Drinkaware going forward because Drinkaware needed to be funded at probably a higher level, but also to get more people from the industry side involved within Drinkaware. At that time the business plan that was developed was based on income that is derived from the alcohol sales, for all intents and purposes, but it is delivered in three different categories. One is going to be the on trade, another the off trade and then you have producers. There is a banding structure that goes through that business plan, from A through, I believe, K, and it is based on how much money they make from alcohol. That determines how much money they give to Drinkaware. It was agreed that would be the most equitable way to go forward. The people that you mentioned there are some of the industry stakeholders. In terms of the public health community and their relationship with us, it varies based on whether or not we are dealing with local people in terms of local organisations, where we give out grants, or at regional level or, in some cases, within the devolved administration.

Q77 Valerie Vaz: Taking you back to the governance structure, who is actually sitting round the table? What do you do? What is your day like?

Chris Sorek: It is very busy.

Q78 Valerie Vaz: Yes, but I need to know who is making the decisions and how the decisions are coming out.

Chris Sorek: As it turns out, in terms of the strategy, the board-

Q79 Valerie Vaz: First, who is sitting on the board?

Chris Sorek: On the board sits Derek Lewis, who is the chair, an independent, Alex Hunter, an IT specialist, an independent, and Helen Humphreys, an independent from a communications industry background. You then have five members of the public health community, which include Dr Nick Sheron and Dr Michael Wilks. Does everybody know who-

Q80 Valerie Vaz: No. You need to tell us who they are.

Chris Sorek: Dr Nick Sheron is one of the top liver specialists in the country. Dr Michael Wilks is one of the top forensic specialists. We have Gill Valentine who is from the University of Leeds-and now University of Sheffield. She will be Pro-vicechancellor for there but she is a human geographer. I cannot remember everyone on the board unless I mentally "look" around the table. Give me a second. There is Professor David Foxcroft from Oxford Brookes, who is a chartered psychologist, and we have one open position which was previously filled by Alan MaryonDavis of the Royal Society for Public Health, who has retired and now moved on to our Chairman’s role and, because of that, he has resigned from our board. On the industry side you have Benet Slay, who is from Carlsberg UK now-formerly from Diageo-Mark Hunter who is from Molson Coors, Ted Tuppen CBE from Enterprise Inns, Carolyn Bradley from Tesco and Nick Grant from Sainsbury’s.

Q81 Valerie Vaz: You know what the debate has been raging about recently. How do you set your strategy and your policy? I know you said there is no interference from them, but surely not doing anything is just as bad as being interfered with. There is a huge debate raging about the effects of alcohol, is there not?

Chris Sorek: There is a huge debate.

Q82 Valerie Vaz: What do you do? I am confused about how you influence what is going on.

Chris Sorek: I appreciate that. We carry out campaigns that are aimed at consumers across the country, the entire United Kingdom. Our strategy is focused on three target audiences: parents and under 18s, young adults 18 to 24, and adults 25 to 44 years old.

Q83 Valerie Vaz: What were your campaigns?

Chris Sorek: The campaign that we are currently running now for parents and under 18s is a programme called "Talking to your kids about alcohol". That campaign, which was recently launched, is basically made up of two parts. One is a parents’ brochure, but there is also a digital campaign that is aimed at parents of under-18s-basically 10 to 14-year-olds-to get them to have a conversation with their children about alcohol. A lot of parents think that they can have that conversation. When we first did the research about it, we found that 80% of all parents said, "Don’t worry about it. I can talk to my kids about alcohol." Then they took a look at this interactive video-if you go on to our website you can see it-of a young child talking to their parent in the kitchen while they are having lunch or tea. They look and there is a wine bottle there, and they say, basically, "Can I have some of this?" That interactive video allows the parent to decide on what is said next, "Yes", "No" or "End of conversation," and then it trees down into number of other parts of it. This has all been approved by our independent medical panel. As it goes through that entire thing, it eventually gets down to a point where it gives parents advice.

The interesting thing about that campaign so far has been that, out of all the people that have seen it, which is well over 300,000, 40% of the parents, after they have seen it, feel, "I really cannot have that conversation with my children right now because I do not know enough." They stay on our website and they go to other parts for parents and the information that we give to them about how to talk to your children about alcohol. That is currently one programme that is going on. It is counterintuitive to see that people do not feel confident after seeing the video, but it tells us that parents who think they have a plan probably need to have more support and we provide that information to them. That is one area.

There are two other areas. One we have just mentioned, "Why let good times go bad?" which is aimed at 18 to 24-year-olds. That campaign was an agreement that was originally signed between the last Government and the drinks industry to conduct a campaign that we eventually took over, aimed at 18 to 24-year-olds, to bring down the level of binge drinking and nightlife issues that were out there. The bottom line is that in this last year’s campaign we found that we were able to reach about 850,000 young people. Out of those 850,000, the total population that saw and recalled our campaign, which was about 27%-which is roughly double the industry average of people recalling any campaign-8 out of 10 young people took on our tips, which is great, because they said they would employ those tips to mitigate the issues regarding having a good night go bad, which, to your point, was what was the result of that. We also know that 56%, after they had seen the campaign, interacted with the campaign and were going to change their drinking behaviour. Granted, these are claimed behaviour changes, but that is still a fairly substantial number-a high number-for young people doing that.

The last area that we work on is with adults, which is the 25 to 44-year-olds, although it goes even higher than that, because we have about 350,000 people coming to our website on average per month. These are unique visitors. Most of those people come to our website and usually go round and get information from different places, but we have a specific campaign aimed at adults that is targeted to bring them to a website that is called MyDrinkaware. [The witness showed illustrations of website pages to the Committee] The MyDrinkaware part of the website is a tool and basically-you were talking about brief interventions before-this is a brief intervention. People come in and sign up. Out of the 250,000 people that have come on to the MyDrinkaware part of the website, over 108,000 have already started using this. Out of that 108,000 only 30% are active users and I will tell you why only they are active in a few seconds, but-

Q84 Valerie Vaz: Do you know the demographics of the people who are using it?

Chris Sorek: We do have some demographics. We are restricted from going into too much detail because of data protection, but we do know that, out of those people that have come-the 30% of the 108,000 that are really on board with MyDrinkaware-that 30% stay with it and use the tool to reduce the amount of alcohol they are drinking. We know that, out of that, 30% have seen a reduction of between 5 to 3.9 units. But if I could just show you this for a second because you were talking about-

Q85 Chair: Can I interrupt a second, Mr Sorek? Purely at a practical level, in terms of evidence to the Committee, we have to publish the evidence and so if you could refer to it rather than point it out, that would be easier.

Chris Sorek: Sure.

Andrew George: We could have them sent to us.

Chair: Could we have them sent to us?

Chris Sorek: Yes.

Q86 Valerie Vaz: I appreciate all that, but I want to ask your view, or the group’s view, on an advertising ban. Has that ever been discussed and would you ever consider it?

Chris Sorek: First of all, as an organisation, we are proscribed from talking about policy or lobbying. So we have no voice in issues about advertising, licensing, availability and things like that. There is a reason for that.

Q87 Valerie Vaz: How do you fit into the Department of Health then?

Chris Sorek: How do we fit into the Department of Health? We coordinate-

Q88 Valerie Vaz: Do you fit in at all?

Chris Sorek: We coordinate very closely with the Department of Health, the Home Office and the Department for Education.

Q89 Valerie Vaz: How do you do that without influencing policy? What are you doing when you are talking to them?

Chris Sorek: We provide information and education to consumers. We do not talk about policy. We provide them with research and information. I can only say that it resonates extremely well with consumers. When I started in 2008 we had maybe 40,000 or 50,000 people coming to our website every month. We are now having an average of about 340,000 to 350,000. Quite honestly, we have become more and more popular for people to come to and view the information on our website.

Q90 Valerie Vaz: So comparing with what is happening in Europe, like France and Norway, you do not consider that would be a route, a tool?

Chris Sorek: Not necessarily, no, because we are really focused on the United Kingdom and the consumers in the United Kingdom.

Q91 Dr Wollaston: Is it not a measure of the lack of genuine independence that you cannot actually say that the single best thing you could do would be to, say, remove the advertising? Even the WHO have commented that it becomes meaningless, given the disproportionate spend on advertising compared with the spend for Drinkaware. There is such a disproportion that the greatest effect would be for you to campaign to have a drop in advertising but you cannot do so because your terms are set partly by the board itself and because you need industry signup to it.

Chris Sorek: No. I am sorry, it is not disingenuous. It was an agreement made by the public health community, Government and industry to have this organisation set up that would only focus on providing information and education-just the facts-about alcohol to consumers. It has been that way since 2007.

Q92 Dr Wollaston: Do you feel that when you review what Drinkaware is all about that the fundamental change should be that you are allowed to lobby on reducing advertising?

Chris Sorek: That would be something that would be taken up-I am sure will be discussed-in the review potentially, but it would be also something that the board will have to take up and vote on.

Q93 Dr Wollaston: Would the board have to agree to it? In other words, would you have the drinks industry having to sign up to something that is fundamentally against their interests? In other words, that is a conflict of interest, surely.

Chris Sorek: We are speculating. All I can say is that whatever proposals the review brings up-

Q94 Dr Wollaston: But it is not speculating. It is a very serious point, is it not? The point is being made that there is such a huge disproportion in the spend on marketing and the spend on Drinkaware that levelling that playing field or significantly reducing advertising would have the single greatest effect.

Chris Sorek: The Alcohol Strategy suggests already-within the strategy it talks about this-that Drinkaware should be increased in scope and funding. How that happens is still something that needs to be proposed to the board and then the board has to take that decision. I cannot answer for the board.

Q95 Dr Wollaston: But are the turkeys going to vote for Christmas?

Chris Sorek: I am sorry?

Q96 Dr Wollaston: Are the drinks industry going to accept that one of the roles of Drinkaware could be to campaign against advertising?

Chris Sorek: It could be, but that is a decision that would have to be taken by the board.

Q97 Chris Skidmore: You mentioned that you could not make any decisions on policy, that you could not raise issues of policy.

Chris Sorek: We do not comment on it, yes.

Q98 Chris Skidmore: You do not comment on issues of policy, but the title of your press release on 23 March was, "Alcohol strategy must address Britain’s hidden binge drinkers" and your own comments said, "We are concerned however that while young adults sprawled on pavements after a night out on the town grabs headlines, Britain’s hidden binge drinkers present a worrying trend", and you go on quite convincingly. I do not disagree with your statement but that is clearly an attempt to influence policy. Therefore, you have a very grey area of which you are saying, on the one hand, "We cannot talk about policy. We cannot talk about banning advertising", but, on the other hand, you are very willing to talk about issues of policy in terms of hidden binge drinking which may or may not be convenient because then it deflects from young persons drinking, which, in terms of the alcohol industry, is far more valuable than hidden binge drinking. Do you not think that there is a grey area?

Chris Sorek: In fact, we provided the information that we felt needed to be placed in the public domain, which was a comment by Drinkaware about the Alcohol Strategy. That was that, for all intents and purposes, the Alcohol Strategy has a very high focus on binge drinking. What we wanted to do is to bring to the attention of the public, through the media, that most of the binge drinking, as you heard from the previous panel, happens at home and among adults and not among 18 to 24-year-olds. Clearly, that is an area that needs to be addressed because that is where chronic alcohol-and eventually acute alcohol-issues occur.

Q99 Chris Skidmore: I agree with you and I agree with the press statement, but my point is that the press statement there is a clear attempt to try and influence policy. Why not put out a press release saying, "The Government need to look at advertising in the run-up to the Olympics, and whatever European football cup there is, and the effect that advertising might have on young people’s drinking habits in the future"? Why not put out a press release on that as well? That is simply asking for more information rather than policy.

Chris Sorek: I appreciate that. The reason why we took the position that we did in terms of the release we sent out was that if you focused only on the issues around binge drinking and 18 to 24yearolds, in fact you missed the majority and the biggest issue that needed to be addressed, which is the people who are 25-plus who are overdrinking, at home usually. That is the only reason we put it out, so that it would not be forgotten within the discussion that was going to happen afterwards.

Q100 Chair: Mr Skidmore’s point, surely, is that that is addressing a policy question. By putting out the press release you did, you are saying that the Government are right to focus on binge drinking and the social consequences of binge drinking but they should not forget in their policy the middleclass drinking issue that leads to longterm health consequences. That is a comment about the Government’s objectives as defined in its policy paper, is it not?

Chris Sorek: It was as defined within the Alcohol Strategy. Rereading the Alcohol Strategy, the initial parts of it are very much focused on the social harm that is caused by 18 to 24-year-olds who are binge drinking. In fact, all we were trying to do was to make sure that, within there, there was a balanced view that 18 to 24yearolds are clearly an issue but so are people who are drinking and bingeing at home.

Chair: We have probably covered the point, have we not?

Valerie Vaz: Yes, fine. We can move on.

Q101 Chair: I think so. I wanted to come on to the attitude of Drinkaware to minimum pricing. You make the comment, "While price is one of many factors that influence drinking, at the source of behaviour change is tackling people’s attitudes." Do you believe that price has an important impact on people’s attitudes? Do you think those are alternatives, or are they the same thing?

Chris Sorek: As the previous panel said-and we fully agree with it-there are a number of tools in the toolkit. Pricing is one of those things. There are other issues as well. Those are things that the previous panel discussed in more detail and with a better understanding than we would. We are looking at the demand side. You may be able to raise the price and change availability but changing people’s demand for alcohol-changing their behaviour as to why they want to drink and what they are drinking-is something that we are focusing our attention on. What we are trying to do is reduce the amount of alcohol that parents give to their children. If they followed CMO guidance you would not see the average age of first drink at 13.8 years. You would see it at 15, which is what CMO guidance says. That says that there are quite a few parents who are giving alcohol to children at a much earlier age. If you take a look at what we are doing with adults, we are trying to talk to them about units and unit guidelines. What they will then do is reduce the amount of alcohol they are drinking on a daily basis, which is one of the reasons why MyDrinkaware, I believe, has become so successful.

Q102 Dr Poulter: I am a doctor by background, as are other members of this Committee, and I was not aware that your organisation was in existence, I have to say, during my medical practice, which is interesting, in one way. You have a number of interesting initiatives and it is good that the number of hits on the website have gone up. But it is almost, it appears to me, that it requires people to recognise they have a problem with alcohol and to stumble upon or realise that they want to have a look at your website or find it in the first place. Many people with alcohol and drinking problems do not recognise the problem that they have in the first place.

One thing we have not talked about so far-and it would be interesting to hear your views-is how you interact as an organisation with local authorities who are being given responsibility for public health, or at least 40% of the public health budget. It seems to me that if we want to engender behavioural change, working with schools and local authorities in their public health role is a key challenge and a way of getting into communities in a way that has perhaps been more difficult to do in the past.

Chris Sorek: If I can go back to your first question first, people, I would say, do not stumble on to Drinkaware. As a matter of fact, whenever they put in "alcohol", "alcoholrelated illness", "health and alcohol" or any of those search items into Google we always come up number one in terms of we are the place where people come to. As a matter of fact, Eric Appleby’s predecessor, Don Shenker, basically said to me, about 18 months ago, that we are the de facto consumer source for information about alcohol. I am simply saying that people come to us for a number of different reasons and on a regular basis.

Q103 Dr Poulter: Absolutely, but the point is that if I were an alcoholic it is very unlikely that I would recognise my own problem; I would not necessarily want to admit I had a problem or recognise it. My spouse, my family or my friends may recognise I had a problem, but it is unlikely that I, myself, would want to access or stumble across your website, which is the point I was getting at.

Chris Sorek: From that perspective, as an organisation, we focus on prevention. There are people like Addaction and others that focus on dependence issues. Our remit, again, is that it stops at the point of getting into dependence. That is something that we turn over to another organisation rather than ourselves. We do prevention and education work. We do not get into dependence.

Q104 Dr Poulter: But do you not think that is a difficult dividing line? For example, somebody who has an unhealthy relationship with alcohol-for example, the binge drinker-may not necessarily be a chronic alcoholic, yet that person may not recognise that going out and drinking far too much one night a week or two or three nights a month is a problem. So although we may recognise that here, they may not recognise that as a problem. It may well be it relies upon them to recognise the problem to access your website rather than dealing with the issue of engendering behavioural change. A general awareness of alcohol needs to be rather more nuanced than that, raising awareness in schools, working with local authorities and so on. I would be interested in teasing out how you do that.

Chris Sorek: To give you a bit of an idea-and I will not belabour you with a lot of different things-I have here unit measure cups. We are talking about local authorities and what we are giving out. We have given out approximately, I believe, somewhere in the neighbourhood of 500,000 or 600,000 of these unit measure cups over the last few years. Many of these go to the NHS-PCTs in the past-and to GP surgeries. We have given out more than 400,000 of these things in Scotland alone.1 We also have free fact sheets that are being downloaded all the time, available to everybody across the country. Those are being used by local authorities. As a matter of fact, recently I was in Northern Ireland at the launch of "My Name is Katie". That is a programme aimed at parents where they have basically lifted our parents’ brochure material, put it into a local environment and then renamed it as "My Name is Katie". They reprinted it almost verbatim. For all intents and purposes, what we are able to do is provide information free of charge to everybody across the country, including all local authorities. If you take a look at how our resources are being used, I can only say that our resources are being used across the entire United Kingdom on an ongoing basis and every year we spend probably close to about £300,000 or £400,000 doing nothing but supplying those types of resources to local authorities.

Q105 David Tredinnick: Can we see your glass? Would you mind passing it round?

Chris Sorek: Sure. [The witness passed the item to the Committee]

Chair: I am not sure how they record that in Hansard, but they are aware of that.

Q106 Rosie Cooper: You started off by telling us that Drinkaware provides information and education for consumers. But in the exchange, just then, with Daniel you said you deal with prevention and somebody else deals with addiction. Is that right?

Chris Sorek: Yes-dependence.

Q107 Rosie Cooper: My confusion is that you deal with prevention yet tell us you are not able to say, "Reduce alcohol advertising because that would help prevention." You then tell us you are not able to say, "Increase the unit price of alcohol because that will help prevention." So I do not get you at all.

Chris Sorek: The issue that you are talking about is that there are different people doing different things-different parts and different tools within the toolkit, as I mentioned. Our role is to provide information and education. Others are out there, including people like Alcohol Concern-I know Eric Appleby and what they are doing over there-and their job is to lobby and talk about policy around unit pricing and things like that. They would not be talking, necessarily, about prevention. They will talk about advertising and we will not. Addaction, who I know very well, will be talking about dependence issues and they take over from that perspective. We are trying to provide information and education to consumers and so hopefully, over a period of time, will prevent them from going into a dependence-

Q108 Rosie Cooper: The best information you could give them is not to drink excessively and not to watch adverts, and that the price should be increased, and you are telling us you cannot give it. I am genuinely confused, in the sense that I do not know what you are for beyond-and I am not trying to be difficult-being a fog, a means of confusing or jumbling up the messages and almost being a human shield where criticism can bounce off, saying "We are doing something" when the big thing that you could be doing, you tell us, you are not able to do.

Chris Sorek: All I can say is that the campaigns we have been running over the last 18 to 24 months have been somewhat successful in terms of what they are doing. They are showing the green shoots of behaviour change, which is our intention. It is going to take time and many people working at it from a number of different directions. It is the same reason why you would not see, for example, to answer your point, Alcohol Concern running a campaign the same way we would be doing and talking to people about alcohol. It would not happen. You would not see Addaction doing the same thing. Everybody plays a role in this, so we are all part of the solution in terms of trying to change behaviour.

Q109 Rosie Cooper: You talk about green shoots. When I was a student we would apply gibberellic acid to increase the growth rate. All you have to do is turn the lights on and say, "These are two or three things you can do which will really help you not to get in this mess," and you are saying they are beyond you, but then you also include yourself in the prevention zone. It does not make sense.

Chris Sorek: We are in the prevention zone because we are talking to consumers directly about the facts relating to alcohol and alcohol misuse. When you talk about reducing advertising, availability or licensing, those are things that are all on the policy side and there are people talking about those things. We all work together to solve the problem. It is not just a supplyside issue. It is a demand issue. It takes more than simply changing the rules about availability or pricing. It also means changing people’s attitudes towards the demand for alcohol.

Q110 Rosie Cooper: I think you should all join up together with a common message to reduce advertising and increase the unit price. Let us get on with it and start really saving lives and helping people.

Chris Sorek: It is something that, again, within the sphere of what we are doing-

Chair: It is a matter for the Committee.

Q111 David Tredinnick: Going back to Dr Wollaston’s point earlier about the scale of the amount of money going into advertising versus the amount of money going into your organisation, I hear what you are saying and the way that your organisation has grown from small shoots to slightly larger shoots, but in terms of proportion of effect I would suggest to you that there is a massive difference in the resources that you have and the resources of the drinks industry. For that reason, your impact is disproportionately less.

Chris Sorek: I am not going to disagree with that. In some cases it would be great, and part of the review process is to take a look at what size we should be, what we should be doing and, as we go forward, how best to make behaviour change happen. It is definitely one of the questions that we are asking within the review.

Q112 David Tredinnick: Going to the point which was made just now about attitudes, there seems to have been a fundamental shift in attitudes, certainly from my generation, where people went out to have a few drinks and one or two might have had too many, to getting into a state of complete intoxication being the starting point for doing anything-"I am going out to get drunk tonight." It is the attitude, the behaviour, that has to be adjusted and pricing is part of that. Somehow we have to get at those attitudes, do we not?

Chris Sorek: I would agree. I think that changing-

David Tredinnick: I am sorry, I did not express that very well, but I was thinking on my seat, as it were.

Chris Sorek: Changing people’s attitudes is probably one of the most important things we need to do in this country. Years ago, during my first time in the United Kingdom in the late 1970s and early 1980s-when I was working here-going out and getting drunk, at that age, was seen as losing face. People would think less of you. That has changed and there has been a cultural shift. As to what has changed those things, we are still trying to find more insights about to figure out how we might be able to address that. There are a number of things that we are looking at too. For example, we do know that with young people there are more 18 to 24yearolds out of work and those 18 to 24yearolds out of work have a slightly different attitude towards drinking to get drunk than those that are working. We need to address those people.

Q113 David Tredinnick: If we could get these glasses into public houses or get them given away as freebies in stores, it would be brilliant because one of the problems a moderate drinker has, I think, is trying to assess how much alcohol they are having in all kinds of hostelries where all the glass sizes are apparently different. I know we have statutory measurements for pints and half pints but certainly the measurements in glasses are confusing to interpret.

Chris Sorek: I can tell you that I gave one of these glasses to a senior member of Government probably about six months ago and, at that time, she said to me, "I cannot wait to show this to my husband and talk about how much alcohol we are drinking." So you could say that it is across the board. But I can say that this has had an effect in Scotland where we passed out almost 400,000 of those over the last three years.

David Tredinnick: Illustrating the impact of different strengths of wine and beers is very important.

Q114 Chris Skidmore: Very quickly on unit labelling, the Government are consulting on labelling at the moment and I want to pick up what Drinkaware’s own position is. Obviously the industry is committed to this 80% coverage of labelling by 2013 under an enhanced selfregulatory framework, although the previous selfregulatory framework meant that only 15% of drinks were labelled with the overall number of units per drink. Does Drinkaware have a position on unit labelling? Do they agree with the industry’s approach or should we be moving towards a tougher regulatory framework that does not rely on selfregulation?

Chris Sorek: What I can say is that I believe any information you give to consumers so they understand how many units are there is going to be extremely helpful. That is the reason why these glasses are really important in some respects. But it is also for people who know-for example, we have started running a campaign with the British Beer and Pub Association and the Wine and Spirit Trade Association members where they will put up posters within their stores or pubs. Basically, it says there are two units in a pint of beer and two units in this kind of glass of wine, two units in another drink and then one unit in, say, a 25 ml pour of spirits. The issue is to get people to start understanding what units are about and also what unit equivalents are, so once they start making that connection between units and unit equivalents they will have a better understanding and, hopefully, reduce the amount of alcohol they drink. Any labelling that does talk about units is great. Our name is on the labels basically as a voluntary agreement. It is not something that is specified. It is a voluntary agreement-

Q115 Chris Skidmore: Would you prefer it to be?

Chris Sorek: I am thrilled that our name is on there because it draws more people probably to our website to get more information about alcohol.

Q116 Chris Skidmore: Would it not be more effective if every single bottle of drink had Drinkaware’s logo and website on there?

Chris Sorek: They pretty much do. The only ones that do not are probably wine bottles, and we recognise that that is clearly an issue we would need to address. But that is something that we would address through a different forum.

Q117 Dr Wollaston: Have you produced a similar glass for wine, because I know one of the issues, particularly for wine, is the-

Chris Sorek: It is on the glass there.

Q118 Dr Wollaston: The trouble is, of course, that people do not drink their wine in beer glasses. People drink their wine in wine glasses. I have seen the beer mats that Drinkaware produces and they very often lead to an impression that there are two units of alcohol in a glass of wine when in fact, very often, there are three in a glass of wine. A real issue, particularly for women drinkers, is assuming that they are drinking less than they actually are. I wondered if you have an equivalent one in an actual wine glass-type glass.

Chris Sorek: We do not, although I have to say that, late last year, we did run a campaign that was aimed at women and drinking at home and wine. As it turns out, it was so popular that 15,000 consumers requested glasses, literally at the speed of the click of a finger, through the promotion that we were running. We are looking at it as something we can do. It could be, potentially, in a wine pourer, something that you would-as in many cases you have, for example-stick inside a bottle and you could literally dial up or dial down the amount of units, or, based on your ABV, how many units you would be getting out of there so it gives you an idea what is going on there. We are currently looking at something along those lines that might be helpful for somebody to use at home. That makes a lot of sense.

Q119 Dr Wollaston: I know you do not feel you are able to comment on policy, but certainly when you go to the continent, for example, and you are given a glass of wine at lunchtime it comes in a very small glass. Over here we are given a glass of wine in a huge glass. Does Drinkaware have a view on how important the size of the glass is?

Chris Sorek: As it turns out, we do mention in virtually every one of our releases or communications with the public that smaller measures are available. As a matter of fact, on our website when you look at our drinks calculators, or even on the ones that we pass out that are basically wheels, that are paper-and we passed out probably close to 5 million of those over the last three years-they do have 125 ml, a smaller measure, and then it goes up to 175 ml and then 250 ml. It gives you an idea of how many units you are getting in each one of those and also how many calories you are getting too.

Q120 Dr Wollaston: Again, that is very important. At the moment the glass says that Drinkaware recommends that you drink no more than two to three units or three to four units, depending on whether you are a man or a woman. But at one point you were saying this was the recommended daily allowance, so you were referring to it almost like a vitamin, that people should drink this quantity. That was changed following complaints. Does Drinkaware regret that that was there at one point?

Chris Sorek: In fact, yes and no. There were three screens that went with that view that you are talking about and in each one of those screens it kind of led you through-because it is one of those things that changes on your website fairly quickly so you read through them-and, as you get to the end, it does say, "Now regularly means" and it gives the definition of "regularly". So we have changed it to be clearer. We have done that.

Q121 Dr Wollaston: But do you not think it was a rather catastrophic error to refer to alcohol as a recommended daily amount?

Chris Sorek: Mark Bellis did the research on that. He was the one that brought it up and, as it turns out, out of 93 different mentions of the correct mention of the unit and unit guidelines on the website, that was the only one that was wrong and we changed it as soon as we found out.

Chair: We have probably covered the ground. You are, to a degree, as has been drawn out in the discussion, David dealing with Goliath. I hope you have not felt like that this morning.

Chris Sorek: Absolutely not.

Chair: Thank you for coming.

Q122 Dr Wollaston: Can I ask one final question?

Chris Sorek: Sure.

Q123 Dr Wollaston: You stated that Drinkaware spends £5.2 million. As a matter of record, what is the total spend on advertising, marketing and sponsorship <?oasys [pc10p0] ?>through the internet, film and all the different media? What do you estimate is the total spend on alcohol marketing, advertising and sponsorship?

Chris Sorek: I do not know.

Q124 Dr Wollaston: You do not know?

Chris Sorek: I do not know, and the reason why-

Q125 Dr Wollaston: Should Drinkaware not know that?

Chris Sorek: These are companyconfidential bits of information and it is not something that they share with us, and nor would I expect them to share them with us as a charity. I have asked the question and I have seen numbers bandied about that are basically extrapolations from US data, but I cannot say what that actual number is. I can tell you that it is a lot more than what we have.

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Q126 Dr Wollaston: What would you estimate it is?

Chris Sorek: We are in the single digit millions and I am sure they are in the triple digit millions. What that number is, I just do not know.

Q127 Dr Wollaston: Have you made an estimate yourself?

Chris Sorek: No.

Q128 Dr Wollaston: Have you not done so from reading the literature or talking informally to colleagues?

Chris Sorek: I have talked to them and everybody has a slightly different view of what that number might be. I really cannot tell you what it is. I have no idea. I wish I did.

Chair: Thank you very much for coming.