Living in an age of (Welsh) lifestyle diseases

There’s nothing like a well-worn cliché for undermining your opponents. “Isn’t this all a bit nanny state?” is one I get quite a lot. Although most of us have never been any nearer to a nanny than watching Mary Poppins, we’re immediately wary of the suggestion that someone might boss us about like children and force us to swallow some unpalatable medicine (spoonful of sugar or otherwise).

So just how did we get to this point where advocates for public health are caricatured as infantilising busybodies? The roots of the problem lie in the massive changes in the nature of the threats to our health over the past two hundred years. Throughout the 19^th Century and most of the 20^tth Century, public health was about things that happened to us, like infectious diseases. The answers were about things like vaccines and clean water. But for the last 30 years or so, public health has often been more about things we do to ourselves, like overeating, not exercising, smoking and drinking. And the answers have been harder to find, or at least more uncomfortable to voice.

Tomorrow: Fat is a Welsh issue Lee Waters asks what we can do about the our obesity epidemic.

We live in an age of so-called ‘lifestyle diseases’ that are, to a large extent, the result of the way we live. As the Welsh Government’s recent Green Paper on a Public Health Bill for Wales noted, this is what Wales’ major public health challenges look like:

• More than half of adults are overweight or obese
• Only a slow decline in smoking
• Alcohol consumption remains high

The question arises, with so much ill-health now linked to our own behaviour, whose responsibility is it to change our ways? To what extent can or should the state interfere in things we do to ourselves and which bring consequences for ourselves? As the Green Paper pointed out:

“There is a fundamental balancing act between governments intervening to address challenges to health and wellbeing, and an individual’s freedom to ultimately live their lives in the way they choose…The more intrusive an intervention is considered to be, the stronger the justification needs to be in terms of the overall population benefits it would help to deliver”.

One example of what could be called an ‘intrusive intervention’ is the proposal by the UK Government for a minimum price for alcohol in England and Wales of 45p per unit. For those not in the know, a unit of alcohol is 10ml of pure ethanol. There are around two and a half units in the average pint of beer and around ten in a bottle of wine. So the Coalition’s plans mean a bottle of wine would cost around £4.50 or more, and a pint couldn’t be sold for less than about £1.12. Anyone who’s been in a pub recently will see straight away that this will do no harm whatsoever to sales in your local. What it will do is end price promotions like Tesco’s offer last year of 2 litres of cider for £1.74, or 21p a unit.

The plan has been backed by the Welsh Government, which, like Alcohol Concern, supports setting the baseline price at 50p per unit rather than 45p, but it’s not without its critics. Mirroring John Stuart Mill’s famous dictum that “the only purpose for which power can be rightfully exercised over any member of a civilized community is to prevent harm to others” the Institute of Economic Affairs have been quick to condemn:

“It is preposterous to suggest minimum pricing for alcohol. Alcohol consumption should be a matter of personal responsibility, not of state control. It should be up to consumers to decide when and where they want to drink and how much”.

But with healthcare publicly funded, and almost all of us relying on public services to look after us if we become unwell or infirm, can government legitimately take action to stop us harming our own health? And is it only ourselves we are harming? Many people would argue that heavy drinking does in fact harm others, and that the public sector often ends up paying the price for our drinking habit:

• Around £70 billion in costs to the Welsh NHS each year – and not just the obvious costs of casualty on a Saturday night, with alcohol-related inpatient costs for the over 50s dwarfing those for alcohol-related A&E admissions
• Social services
• Policing
• Street cleaning
• Anti-social behaviour
• Towns centres avoided by non-drinkers – 45% of adults in Wales say they avoid their town or city centre at night because of alcohol-related trouble
• Absenteeism from work
• Impact on drinkers’ families

“But isn’t this really a cultural issue, not a financial one?” I hear you say. Don’t we need to be changing the way people think, not hitting them in their pockets? That’s certainly what a lot of the major drinks companies would like us to believe. The alcohol industry’s social responsibility body the Portman Group (made up of nine of Britain’s biggest alcohol producers) has stated that “it is only through education, coupled with targeted interventions against misusers, that we can ultimately change the drinking culture”. Putting aside the curious notion that we would want to intervene “against” someone with an alcohol problem, the facts just don’t support the Portman Group’s approach.

In 2011 researchers at Bangor and Glyndŵr Universities concluded that there is “little evidence that health education campaigns on their own are effective in influencing the population’s drinking behaviour”. Conversely, they did find evidence that alcohol industry sponsored campaigns to promote sensible drinking – the kind of “please enjoy responsibly” slogans we’re used to seeing on bottles and billboards – are “ineffective or counter-productive”. The reasons for this are not hard to see. As one American blogging mum pointed out, the healthy drinking message is generally lost in the alcohol marketing it rides on:  “According to Kellen, this was his Drink Responsibly pose”.

Like it or not, all the evidence is that controlling the price of alcohol is one of the most effective ways to reduce consumption and change the drinking culture. The team at Bangor and Glyndŵr came to the following very clear conclusion:

“Consumption of alcohol is highly sensitive to changes in price (or, to be more accurate, affordability). When the price of alcohol drops, more is consumed; when alcohol becomes more expensive, less is consumed”.

The major alcohol producers and retailers are plainly worried that minimum pricing will hit their off-trade sales, and are working hard to kill the proposals. But despite all the industry noise about penalising moderate drinkers, a minimum price of 50p per unit will cost anyone drinking within the recommended guidelines around 28p extra per week. That’s less than the price of a daily paper or a pint of milk. It’s a small price to pay for a healthier relationship with alcohol in this country.