Thursday, June 5, 2014

Prohibitionist Electioneering

A four-point "call for action on alcohol", issued today, has been signed by the heads of general and specialist groups of doctors and nurses, academic researchers and the heads of the Anglican, Catholic, Methodist, Presbyterian and Salvation Army churches.
It calls on the incoming government after the September 20 election to implement Law Commission proposals from 2010 to raise alcohol taxes by 50 per cent, impose a minimum price for alcohol to stop price discounting, and phase out alcohol sponsorship and advertising except for "objective product information".
The 50 per cent tax hike would result in a 10 per cent increase in retail prices of alcoholic drinks. National Addiction Centre director Professor Doug Sellman, who organised the statement, said such a price increase would cut consumption by 5 per cent.
The Herald embeds their full statement, available here.

They open with a quote,
"If alcohol were a communicable disease, a national emergency would be declared." 
Later, they write,
The argument is often heard that policies to slow the supply of alcohol through increasing price or reducing physical availability diminish personal freedom and autonomy of "ordinary New Zealanders". It is time we moved from the self-interested and sometimes destructive "freedom to" (... drink as much as you want; supply alcohol to your children's friends; promote and sell alcohol anywhere any time) and consider the "freedom from" the harms caused by heavy drinking.
Those two together do get to the crux of things. The expansionist view of public health deems personal consumption decisions as akin to a communicable disease, puts no value on that individuals derive consumption benefits from alcohol, and largely ignores existing regulatory constraints including:

  • If you're at a bar, and you're intoxicated, the bar can face pretty substantial penalties for continuing to serve you. Maybe you can drink "as much as you want" at home, but you can't do it in a licensed venue. I'm not sure what the prohibitionists will come up with to ban people from getting drunk at home, but I'd be surprised if they didn't come up with something. 
  • The latest round of regulatory changes prohibited you from serving alcohol to your children's friends if they're minors unless you have a permission note from their parents. 
  • You cannot promote alcohol in advertising on television outside of the watershed hours; you cannot sell alcohol outside of the permitted and constrained hours that vary from venue to venue and jurisdiction to jurisdiction. 
The market's already pretty heavily regulated. But all of those existing regulations, they never count for much. It's the next set of regulations that will make us the Shining City on the Hill. 

Back to their missive:
The 'sophisticated' alcohol culture promised twenty-five years ago by advocates of the liberalising Sale of Liquor Act 1989 has turned out to be an increasingly endemic heavy binge drinking culture in New Zealand [De Bonnaire et al 2005; Wells et al 2006]. The cost of alcohol harm is estimated to run into billions of dollars, money that would be much better spent on community benefits.
Ok. First off, here's the time path on per capita alcohol availability. Here's just how bad things have gotten since liberalisation in 1989. It's really terrible. You might want to cover your eyes and peek through the cracks in your fingers.
Can you see the huge per capita increase in alcohol consumption that came about because of liberalisation? It's there. Just squint a bit more.

Heavy drinking or binge drinking? The WHO reports [discussed here] that 5.6% of drinkers (4.5% of the population) consumed at least 6 standard drinks on at least one occasion in the last 30 days. So roughly one person in 20 had the equivalent of six 330 mL Tui, or just under two 500mL bottles of Epic's Hop Zombie Double IPA.* Even at that low a threshold, only one in twenty are drinking that much at least monthly. 

The WHO report lets us benchmark New Zealand internationally. Sure, there are other measures of everything within NZ, but the WHO figures at least run a common measure across different countries allowing for international comparisons. Why might international comparisons matter? 

Here are some of the countries lauded by Alcohol Action NZ. Quoting from them:
  • Scotland’s parliament has legislated for a minimum price per standard unit of alcohol of 50p, to eliminate ultra-cheap products, although this is now being challenged in various courts by the alcohol industry.
  • The whole of the USA has a minimum drinking age for alcohol of 21 years.
  • Ireland has off-licence trading hours of 10.30am - 10pm Monday – Saturday, 12.30 10pm on Sundays. California has a blanket closure of on-licences at 2am.
  • The South African government has recently formulated legislation to ban all alcohol advertising and sponsorship, in even more stringent fashion than has existed in France for more than 20 years, although is now bracing itself for attack by the alcohol industry during the upcoming parliamentary process.
  • Most countries of the world have a blood alcohol concentration (BAC) drink-driving limit of 0.05 or less, including Australia. Countries with a BAC of 0.02 or 0.03 include Sweden, Norway, Poland and Japan.
  • Norway has resisted the influence of the European Union in maintaining strong regulation of alcohol in the face of trade agreements.
Ok. So Scotland, Finland, the US, Ireland, South Africa, France, Australia, Sweden, Norway, Poland and Japan are singled out as being super-awesome anti-alcohol campaigners. Let's check some outcomes.

First, let's look at age-standardised prevalence of alcohol use disorders. The WHO puts New Zealand at 3.4% prevalence, lower than all countries in the Western Pacific Region other than Brunei (1.7%), Japan (3.3%), Malaysia (2.3%), and Singapore (0.9%). See p. 320 of the appendix. Were New Zealand in Europe, we'd be much lower than average: we're lower than any European country other than Italy (1.2%), Malta (3.2%), Netherlands (1.3%), Romania (2.6%), Spain (1.4%), Tajikistan (0.8%), and Turkey (2.6%).

And how about those super-great campaigner countries? France (6.0%), Finland (7.7%), Ireland (7.3%), Sweden (9.9%), Norway (8.7%), Poland (8.7%), and Scotland (UK is 12.1%, no separate Scottish figure) all have worse rates of alcohol use disorders. Similarly, the USA (7.8%) and South Africa (5.4%) are worse than NZ. Only Japan (3.3%) is slightly below the NZ rate. If we fully replicated the experience of those countries with policies lauded by Alcohol Action NZ, we'd have worse rates of alcohol use disorders.   

Ok, maybe our problem isn't with alcohol use disorders. It's that nasty binge drinking. Let's look at at the prevalence of heavy episodic drinking in the WHO figures. The table at page 312 of the appendix puts NZ at 4.3%. Why is this lower than the 4.5% listed above? Because it's age-standardised: some differences in drinking across countries depend on demographic differences. Let's again compare NZ with our neighbours, with Europe, and with those countries whose policies are lauded by Alcohol Action NZ.

In the Western Pacific Region, Brunei (0.5%), Cambodia (1.2%), Kiribati (2.4%), Malaysia (0.3), the Philippines (1.6%), Singapore (4.2%) and Vietnam (1.3%) have lower rates; 13 countries including Australia, China, and Japan (18.4%!!) have higher rates.

In Europe, Turkey (0.2%), Tajikistan (1.0%), and Andorra (4.2%) have lower rates. Every single other country in Europe has higher rates of heavy episodic drinking. Every single one. 

Among those countries lauded by Alcohol Action, France (29.8%), Finland (35.9%), Ireland (36.5%), Sweden (24.3%), Norway (12.6%), Poland (5.4%), Scotland (UK figure of 27.1%), the USA (16.2%), South Africa (9.8%), and Japan (18.4%) ALL have higher rates of heavy episodic drinking. Every one of them. 

If we look at the WHO figures, it is utterly, utterly absurd to claim that New Zealand is some kind of binge drinking outlier. The Ministry of Health uses a different standard for potentially hazardous drinking and have higher figures; they also report that rates of hazardous drinking are declining, and especially among younger cohorts. MoH puts hazardous drinking rates at 19% of drinkers, with 80% of the population being drinkers. So 15.2% of the overall population. Even if we use that figure instead of the WHO one on heavy episodic drinking, we still get a lower rate than most of the countries lauded by Alcohol Action.

Fundamentally, how we stand relative to other countries shouldn't matter much: if a policy is cost-effective it should be implemented. But we have to define cost-effectiveness comprehensively, taking due account of the costs the policy imposes on individual consumption. And, that countries with lauded policies tend to have worse drinking outcomes than we do might just give us pause.

Previously:



* I only chose this one because I happened to have a bottle in my office supply.

4 comments:

  1. I love the first quote you have from them, "If alcohol were a communicable disease, a national emergency would be declared."

    We should have a competition to see who can come up with the silliest example to insert such as, 'If alcohol was radioactive, a national emergency would be declared.' (plus most of us would be dead).

    ReplyDelete
  2. if alcohol were a black hole, maybe.

    ReplyDelete
  3. Someday, someday, I will have an "office supply." In fact, it might be the one driving force behind me eventually starting my own business!

    ReplyDelete
  4. "If we fully replicated the experience of those countries with policies lauded by Alcohol Action NZ, we'd have worse rates of alcohol use disorders"

    "And, that countries with lauded policies tend to have worse drinking outcomes than we do might just give us pause"

    Or, maybe, countries with poor alcohol-related outcomes have enacted policies to (try to) reduce consumption?

    I don't think it affects the broader point (I think a minimum price is probably not the way to go, and the pro- side of the argument seems to be poorly anchored in evidence, and more akin to a moral panic) but I'm struggling to see how the evidence you've given here supports your conclusion, without some kind of before-and-after analysis of the impact of the policies in the variously mentioned countries.

    It's like saying 'alpine countries have more avalanche control measures' BUT 'alpine countries have more avalanche-related deaths and damage' THEREFORE 'avalanche control leads to WORSE OUTCOMES'.

    Now, I would not be surprised if analysis of these policies did show a minimal impact on binge-drinking and alcohol related health effects, and significant negative impacts in terms of reduction of non-harmful consumption. But a list of countries that have these policies, next to their (Current? Recent?) levels of binge drinking and alcohol use disorders, tells us damn near nothing about how effective those policies are.

    ReplyDelete

As I randomly delete anonymous comments, please use a handle. Comments on older posts go into moderation; sorry if there are delays in hoisting your comment from the moderation pool.