Evidence Based Policy? Dipsomania!
By Keir Liddle
If you spend enough time around me, and are unfortunate enough to start a discussion on politics with me, you will likely hear me claim that many politicians’ response to calls for evidence-based policies are more akin to calls for policy-based evidence: that is to say that politicians sometimes seem as if they don’t so much want to follow the evidence, but rather cherrypick the evidence that best suits their political position, or supports the new policy they want to push through.
With this column, which will likely be fairly irregular depending on what arises in the political sphere, I intend to sift through some of the policies being put to parliament (Westminster and Holyrood) and look at the evidence base from them. I may also from time to time explore the claims of political think tanks, NGOs and other lobbyists – particularly if scientific claims are being made.
The first subject I have chosen to tackle is minimum alcohol pricing, which has already attracted a degree of controversy and debate with a few people convinced that the policy will fail to have any major impact on health or issues with anti-social behaviour.
One of the key issues appears to be around personal choice and individual responsibility – essentially, a stance that the government has no business interfering in it’s citizens lives at this level: a reaction against a perceived nanny state, if you will. Ideologically, I don’t wish to comment on this, but personall,y I have always felt that individualist arguments like this fall down psychologically. We are beset by external influences that exert social pressures on us and extol us to do this, that, and buy the other thing (for an overview of the weapons of influence and the psychology of persuasion you could do worse than seek out Robert Cialdini’s work). Why else would the alcohol industry spend 45 times as much on advertising their products as the UK government spends on alcohol education? Now, I feel a little churlish complaining about the influence alcohol advertising exerts on people, given that alcohol adverts tend to be among the more inventive ones out there — but they do exert a remarkable influence upon us. Perhaps not in the case of discriminating between brands of booze, but in making booze itself something we want.
In terms of health, there are rising public concerns in many countries about the harmful effects of alcohol use on society; this having lead to an increased focus on the potential of public health interventions. Long term alcohol use is responsible for several illnesses that affect the liver and associated systems, and it increases the risk of chronic disorders like oesophagael cancers. Acute intoxication is also associated with adverse events such as road traffic accidents, falls, and anti-social behaviours like assaults. It is also a contributory factor for risky sexual behaviours, and thus increases the risk of HIV transmission and unwanted pregnancy.
There is also an economic aspect to alcohol abuse, as it leads to reduced job performance. In 2006/07 alcohol attributable admissions to hospital in England alone were 800,000, and the total yearly cost to the NHS is around £2.7 billion a year. Clearly, alcohol overuse and abuse is a major concern that needs to be addressed. So when it comes to addressing alcohol abuse, what is thought to be the best way to go about it?
In 2009, Anderson, Chisholm and Fuhr identified nine target areas to tackle excessive and damaging alcohol consumption:
1. Information and education
2. Health sector response
3. Community programs
4. Drink Driving policies
5. Addressing the availability of alcohol
6. Addressing the marketing of alcoholic beverages
7. Pricing policies
8. Harm reduction
9. Reducing the public health effect of illegally and informally produced alcohol
Target areas 1 and 3 represent inexpensive means of tackling alcohol related issues. However, they do not appear to notably affect consumption levels or health outcomes, and as such are not really considered effective or cost effective strategies to pursue a reduction of harm.
Target area 2 generally comprises brief health sector interventions for hazardous alcohol use, and these have been greatly studied. The cost effectiveness of such interventions is low as they involve addressing individual “problem drinkers” rather than applying a population-level strategy or intervention. The effectiveness of such approaches also depends on the individual problem drinker being treated.
Target area 4 has been shown to be very effective in high income countries: anti-drink driving advertising campaigns coupled with measures such as roadside breath-testing have been quite effective, and there is the assumption that such benefits could be seen in lower income areas also.
Target areas 5 and 6 are tackled by reducing access to retail outlets for specified periods of the week and implementation of a comprehensive advertising ban. These have the potential to be very cost effective countermeasures but only if they are fully enforced.
Targert area 7 involves policies relating to alcohol price. Consistent evidence shows that the consumption of alcohol is responsive to an increase in the final price which causes it to decrease. Tax increases, although unpopular, represent a highly cost effective way of dealing with alcohol related issues in countries with a history or tradition of heavy drinking. Tax increases have to be mitigated against encouraging individuals to begin production illegally or evade taxation by importing alcohol from abroad which is target area 9.
In April of this year, Purshouse, Meiser, Brennan, Taylor and Rafia published a paper that modelled epidemiologically the effects of alcohol pricing policies on health and health economic outcomes in England. They found that general price increases were effective for the reduction of consumption, health-care costs and health-related quality of life losses in all population subgroups. Minimum pricing policies were found to maintain this level of effectiveness for harmful drinkers, while reducing the effects on consumer spending for moderate drinking. They interpreted this as implying that minimum drinking policies, coupled with discounting regulations, warrant further consideration because both strategies are estimated to reduce alcohol consumption and thus the related harms arising from excessive consumption.
In short, it seems that minimum alcohol pricing is supported by evidence from health and epidemiological research, and is in fact evidence-based policy, not policy-based evidence.
Anderson, P., Chisholm, D., & Fuhr, D. (2009). Effectiveness and cost-effectiveness of policies and programmes to reduce the harm caused by alcohol The Lancet, 373 (9682), 2234-2246 DOI: 10.1016/S0140-6736(09)60744-3
Purshouse, R., Meier, P., Brennan, A., Taylor, K., & Rafia, R. (2010). Estimated effect of alcohol pricing policies on health and health economic outcomes in England: an epidemiological model The Lancet, 375 (9723), 1355-1364 DOI: 10.1016/S0140-6736(10)60058-X