In this issue> Alan Maryon-Davis puts down the blue pencil> Martin McKee on making the invisible visible> What the Lancet Countdown report is missingThe magazine of the

UK Faculty of Public Healthwww.fph.org.uk

Winter 2017

Through a glass darkly How alcohol harms continue to challenge us

THE FINAL WORD

‘ ’ The Lancet Countdown report on health and climatechange is a formidable document but downplaysthree vital factors: inequality, consumption andgrowth, says Ian Gough

IT SEEMS churlish to criticise the LancetCountdown report on health and climatechange. It provides a comprehensiveframework to chart the impacts of climatechange on health across the world, bringstogether research on adaptation, mitigation,finance, policies and politics, and compilesa formidable but not too numerous arrayof indicators to plot all this. My concern isthat it downplays three critical issues:inequality, consumption and growth. Inequality: the major contributors to climatechange have been the rich – mainly centredin the global North but with rapidly risingnumbers in the South. The World Bankcalculated that if the 40 million drivers ofSUVs in the US converted to averageEuropean cars, the emissions saved wouldenable all 1.4 billion people in the worldwithout electricity to be connected withoutraising the overall CO2 envelope. Consumption: the widening disparitybetween countries’ territorial andconsumption-based emissions. The formerare produced within a country’s borders,and the latter refer to emissions bound upin all the goods and services consumed,including imports. With the globaloutsourcing of production in the past fourdecades this disparity has grown: UKconsumers are responsible for some 80%more emissions than our waning territorialemissions would suggest. Growth: the idea of massively decouplingeconomic production from harmful

environmental impacts including globalwarming. Such decoupling is urgent but isunlikely to be sufficient if endlesscompound growth is not questioned.

What might all this imply for climatechange and public health? First, we need tokick-start an attack on unearned wealth andincome, deliver decent and safe retrofittingof housing, starting with social housingand fuel-poor households, and introduce‘social tariffs’ for electricity, gas and water(lower tariffs for the first units consumed).

Second, we need to rethink the idea ofnecessities and luxuries for a carbon-constrained era. The Lancet Countdownreport’s advocacy of ‘co-benefits’ – policieson pollution, transport and food that serveboth health and climate goals – isimportant here. We could go further: forexample, increase VAT on luxury productsharmful to health and the environment,and reduce VAT on necessities with co-benefits. We should consider too howessentials such as water, energy, transportand housing could be delivered within acitizenship framework, analogous to healthand education, rather than left to

increasingly unregulated markets. Third, we need to challenge the idea of

unending growth. One gradualist way ofrethinking this could be via work-timepolicies. We know there is a closerelationship between average hours of workand emissions, so reducing paid work-timebecomes not just a social and economicpolicy but a climate policy. A four-dayweek and less stressful work would likelyalso facilitate improved physical and mentalhealth – becoming another co-benefit.

This radical programme raises many issues:in particular, who is to decide whatconstitutes ‘luxuries’ and ‘necessities’? Howcan this be squared with consumerautonomy and ‘choice’? How far caninequality be restrained in the light ofplanetary boundaries? In my book I advocatethe way that forums of citizens couldaddress these big issues, informed by radicallocal initiatives such as Transition Towns.

But at some stage our reliance onworthwhile co-benefits must becomplemented by confronting thecontribution of inequality, consumption andgrowth to ill-health and climate change.

Ian GoughVisiting ProfessorCentre for Analysis of Social ExclusionLondon School of Economics

Ian’s latest book, ‘Heat, Greed and HumanNeed’, is published by Edward Elgar

We need to challengethe idea of unendinggrowth‘

‘Information

ISSN – 2043-6580

Editor in chief Alan Maryon-Davis

Production and commissioningeditorRichard Allen

Editorial boardAndy BeckinghamStella BotchwayMatthew DayDavid DickinsonRachel JohnsFrances MacGuireHelen McAuslaneSally MillershipThara RajLeonora Weil

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All articles are theopinion of theauthor and not thoseof the Faculty of Public Health asan organisation

UP FRONT

WINTER 2017 3

FROM THE PRESIDENT

WelcomeLCOHOL is still our favouritedrug. In Bad liver and a brokenheart Tom Waits sang: “I’ve

drunk me a river since you tore meapart.” We drink to forget, to drown oursorrows, to be sociable and to celebrate.Tom Waits also sings: “I don’t have adrinking problem unless I can’t get adrink.” In Billy Wilder’s film The LostWeekend we get the image ofalcoholism the industry would like us tohold – “One’s too many and a hundred’snot enough” – the alcoholic is diseased,deviant, alcoholism an addiction, abehaviour divorced from the regularexperience of the rest of society.

The alcohol industry has learnedgreatly from the lies, the obfuscationand deception of the tobacco industry.They have hired their merchants ofdoubt to challenge the science, to resistnew laws in the lobbies, to battle agreedlaws in the courts, within nations andinternationally. They have invented theace denigration for the public healthcommunity – calling us ‘nanny state.’They have learned to play down harm,delay and escape regulation. Bans onalcohol advertising and promotions,controls on availability, all resisted orintroduced grudgingly. They havecreated token agencies, marginallyfunded, to show how responsible they are.

And the alcohol industry has been ableto hide behind the notion, rarelycontested, that a little alcohol is a goodthing. Doctors, lawyers, journos andpoliticians have colluded with this. The J-shaped curve has been a cosy defence.But we also have the normal distributionof alcohol consumption. Severe alcoholdependence on one side, teetotal on theother, the majority in between. Societalharms – violence, accidents, poor mentalhealth, poor relationships, absenteeism,poor productivity, as well as theburgeoning range of clinical conditions –can be moved, for better or worse, byshifting the level of consumption acrosssociety.

Modelling has shown a minimum unitprice (MUP) for alcohol woulddiscourage harmful consumption, withlittle impact on social or occasionaldrinkers. But MUP was opposed anddeflected successfully by the industry forover 10 years. We congratulate theScottish public health lobby on therecent momentous decision toimplement MUP in Scotland. We predictconfidently that Wales will follow. It’sdifficult to understand why it should stillbe such a problem for England.

Ironically though, our preoccupationwith MUP has seen the tax escalator foralcohol removed, and the real price ofalcohol continuing to drop. The alcohol-related harms are now particularlymanifest in health losses. The number ofpotential years of working life lostthrough liver disease now approachesthat caused by coronary disease and hasovertaken breast and lung cancer.Hospital episodes for liver disease in thefour nations of the UK are goingthrough the roof. Nearly double inEngland since the Licensing Act. Over amillion hospital admissions a year causedby alcohol – contributing to the ‘winterpressure’ all year round.

The UK has a big drink problem – weneed to do something big about it.

And Tom Waits has come off thebooze.

John Middleton

Up Front 3

Interview with Martin McKee 4

Special feature: Alcohol harms 6

Take it to the min 6

Harms to others being investigatedand measured at last 7

Lager louts grow up into ageing drinkers 7

Debate: Are the drinking-in-pregnancy guidelines too strict? 8

Social drinking 9

Antisocial behaviour: a chance for treatment 10

You don’t have to drink to be affected by it 10

Cheap at the price 11

Responsible parties 12

Why drugs make a poor mixerwith drink 13

Helping young people makebetter choices 13

Reducing harm by having a sayin licensing 14

Alcohol labels fail to informconsumers 14

Books & Publications 15

Endnotes 16

Noticeboard 19

The Final Word 20

Contents

Public Health TodayThe magazine of the UK Faculty of Public Healthwww.fph.org.uk

Winter 2017

What was the original concept forPublic Health Today?We wanted a livelier publication thanhitherto – a bit more user-friendly, withcontributions coming from outside and notjust the ‘official FPH message’, type ofthing. We wanted it to be broader thanthat.Why did you want to be editor?I was in my last year as President. I leapt atthe idea because I’d done a fair amount ofwriting in the past; I was an NUJ memberand vice-chair of the Medical Journalists’Association; I’d edited a magazine calledHealth Education Journal; I’d contributedlots of articles to all sorts of publications;and I’d also done a regular column for athing called Public Health News publishedby the Chartered Institute of EnvironmentalHealth. I thought this was a way that Icould be involved in FPh after mypresidency rather than just fall off the cliffedge which is what happens to a lot ofpresidents when they get to the end oftheir three years.What have you enjoyed about therole?The themes are different for each issue, soI learn a whole load of stuff when we haveour editorial meetings. They are always abit of a mad dash – a one-hourteleconference. It’s a very jammed agendabut lots of good ideas get thrown around.

I love the fact that it’s a vital process – it’senergising.

I also like working closely with theProduction Editor, the planning process,commissioning and checking the articles,the copy editing, the proof reading andthen finally seeing the finished product.The whole process from beginning to endis really very satisfying.

I’ve also enjoyed writing the editorial bit.It’s been a great opportunity to introduce

the special feature topic and a chance toadd my own spin on things. I think futureeditors would appreciate having that. Any particular challenges orproblems you’ve had with the role?Obviously you can’t pay people tocontribute, so sometimes it’s a bit of anissue to get them to deliver on time. Oneslight disappointment is that we haven’tgot more advertising in, because I think themagazine could pay its way if we couldjust get more advertisers – people running

conferences and courses, masters coursesin particular, book publishers, public healthconsultancies. I always wanted to expand itto 24 pages on a more permanent basis tomake it a more substantial magazine. Thatof course means more time, more staff;we’ve always been strapped for internalresources in that sense. That’s beensomething of a disappointment, but itcould still happen. Moving it partly onlinecould help because that would cut downon the postage bill which is a big expense.I think the magazine could have a healthyfuture if it’s managed properly.What has Public Health Today donefor the world of public health?I’d like to think it has helped bring peopletogether into more of a public healthcommunity. Perhaps it has also helpedsome public health people who have gonethrough the training programme and areworking in local public health departmentsor academia to be a little more aware ofothers outside the field who contribute tothe public's health in all sorts of differentways. We always try to broaden it out andget contributions from a wide variety ofsources, so that people realise there’s awhole wider organism out there trying toimprove the health and wellbeing of thepeople.

Interview by Richard Allen

The whole processfrom beginning toend is really verysatisfying‘

‘A

That’s enough – Ed.After eight years as Editor-in-Chief of Public Health Today, Alan Maryon-Davis hasdecided this will be his last edition at the helm. Here he shares his memories

What would you regard as your proudest achievementso far?The people I’ve been able to support at an early stage in theircareers. There’s quite a large number of people all over Europe thatI’ve been able to support and mentor and many are now in quitesenior positions. Also, being able to bring people together toachieve a lasting legacy. In terms of scientific achievement, I wouldpoint to our research on the concept of ‘precariousness’ – that aprecarious existence, whether in relation to income or employmentor food security or housing tenure, has a major impact on health.

And your next big challenge?Corporate determinants of health – understanding the ways in which global corporations shape our lives. Not just the tobacco industry, although the fight against the tobacco industry has definitely not yet been won. The new Philip MorrisFoundation is an example of how we need to be continuallyvigilant. But more than that, the way artificial intelligence and

social media are shaping the way people think and behave. The evidence that foreign powers are deliberately trying to createdivisions within societies, for instance supporting both whitesupremacists and black resistance movements in the US at thesame time. We need much more understanding of things like these.

You’re renowned for your prodigious energy andoutput. What drives you to keep up such an incrediblepace?Well there’s such a lot to be done out there. I don’t want to soundtoo pious, but I do believe strongly in speaking out in the face ofinjustice. I always think of Edmund Burke’s saying that all that’srequired for evil to succeed is for good people to remain silent. I get very annoyed when people say that commenting on thingslike inequality and social determinants is “too political”. I think weneed to ask who is defining these things as political. We can bringthe evidence to bear. Public health has a hugely important role inmaking the invisible visible.

What keeps you awake at night?Jetlag. I travel an enormous amount. Nine flights in the next 10days. It’s a completely crazy life – but I work with some veryinteresting people and hopefully we do make a difference.

Finally, how do you relax?Well, that is a problem – it’s a pretty relentless schedule. I do go to the gym in hotels as far as possible. I enjoy classical music and read a lot. And there’s always BBC iPlayer. Documentaries and histories mainly. Basically, anything with Alice Roberts or Lucy Worsley.

Interview by Alan Maryon-Davis

WINTER 2017 5

INTERVIEW

4 PUBLIC HEALTH TODAY

INTERVIEW

Martin McKee CBE is Professor of European Public Health atthe London School of Hygiene and Tropical Medicine. He iscurrently research director of the European Observatory onHealth Systems and Policies and is Immediate Past Presidentof the European Public Health Association. He has publishedmore than 1,020 scientific papers and 44 books

We bring the evidence to bear, says McKee

‘Making the invisible visible’There’s such a lot to bedone out there. I don’twant to sound too pious,but I do believe stronglyin speaking out in theface of injustice‘

‘How did you first get into public health?I qualified in medicine at the age of 22 and was moving rapidlytowards an academic career in internal medicine. The work I wasdoing was very much focused on lab research. At the same time Iwas seeing patients in Belfast in the early 1980s with scurvy andberiberi, and the impact of poverty was very obvious. It was alsovery clear that the research I was doing on small peptides was notof much real value to them. I became quite disillusioned, and so Imade a move.

I’d always been interested in issues beyond medicine. I’dseriously considered doing politics, philosophy and economics atuniversity. But I came from three generations of medics in myfamily, and there was an expectation that I’d do medicine. I’vebeen fortunate in being able to combine it with work on thepolitical and economic determinants of health.

When I did the masters at the London School I did anattachment with Leila Lessof in Islington, and she set up a postwhich allowed me to come back from the training scheme inNorthern Ireland and work half-time at the London School withNick Black.

So how and when did you start getting involved in theEurope scene?I had always been very interested in the history of Europe. I’dtravelled extensively as a teenager on Interrail, including countrieslike Romania and Bulgaria – about 20 European countries by thetime I was 21. Money was available at the time for new seniorlecturers to develop links with Europe, and I was encouraged toapply. That was in 1989 and on 9 November the Berlin Wall felland suddenly Europe got a lot larger. Because I knew the countrieson the other side of the Iron Curtain reasonably well I was able toimmediately build connections with colleagues, particularly in whatwas then Czechoslovakia and Hungary. By the mid-1990s I had

started working in the former Soviet Union.

What have been the main issues you’ve worked on?My work on the collapse of communism led me into researchingthe health effects of rapid social, political and economic transition.Following on from that, David Stuckler and I looked at the healtheffects of the global financial crisis in 2008, subsequently lookingat economic, social and demographic change worldwide, inparticular urbanisation and trade liberalisation. As a result of that, I now lead the health systems part of the Prospective UrbanRenewal Epidemiology Study, working with Salim Yusuf atMcMaster. We’re following up 300,000 people in 25 countriesworldwide to try to understand their changing experience ofhealthcare and what we can do to overcome the barriers andeconomic costs they face, with a focus on hypertension.

What do you think the impact of Brexit will be onpublic health in the UK and Europe?It’s a complete disaster. There’s going to be much less moneyaround – even the most optimistic predictions talk about a £15billion-a-year hit for the economy. There’s going to be far fewerworkers, not just in the NHS but in a whole range of other areaslike agriculture. Many government departments are already bucklingunder the strain, and there’s a real danger of government failure.

In research terms the UK has always punched above its weight –in large part because scientists from other parts of Europe havecome to the UK to work – and that will be missed. Informalcollaboration is going to be even more important. Much can bemanaged on the basis of personal relationships, but clearly loss ofaccess to things like Marie Curie scholarships and Erasmus fundingis going to be a problem. Unfortunately, the British government’sposition is that we can have our cake and eat it, but they haveabsolutely no feasible proposals as to how this could come about.

CONNECTIONS: A remaining section of the Berlin Wall

AROUND 63% of Europeans report thatthey have experienced negative effectsfrom other people’s drinking. In the UK,the figure is higher at over 70%. These arethe headlines from the recent ReducingAlcohol Related Harm (RARHA) study*which surveyed alcohol consumption andharm in 19 European countries.

Alcohol-related harms to the drinker arewell documented. But it is only recentlythat attempts have been made to measurethe negative effects of alcohol on someoneother than the drinker. The RARHA surveyasked about harms respondents hadexperienced over the previous 12 monthsand which they associated with someoneelse’s drinking. The eight measures rangedfrom items such as ‘woken at night’ to‘involved in a traffic accident’. Theinclusion of lesser harm with more seriousharm explains the headline-grabbingfigures. For policy purposes, it is moreuseful, perhaps, to tease out some of thedetail of the findings.

Looking at the four items that measured‘more serious’ harm, across all countries,14% reported they had been ‘in a seriousargument’, 3.3% had been ‘harmedphysically’, 6.8% had been a ‘passengerwith a drunk driver’ and 1.7% had been‘in a traffic accident’. For the UK, thefigures were higher: 17%, 4.6%, 3.6%and 1.5% respectively. Along withBulgaria, Estonia, Lithuania and Romania,the UK had the highest percentage ofrespondents reporting any of the eightharms measured and also reporting arelatively high prevalence of ‘more serious’harm. As might be expected, women weremore likely than men to report harm; butcompared to most other countries whereexperience of harms decreased with age, inthe UK, there was little difference acrossage categories.

It is also important to consider people’sviews on the extent of negative effect fromothers’ drinking. The UK was in the topfive countries for prevalence of beingnegatively affected ‘a lot’ by others’drinking, with 10.1% reporting ‘beingwoken at night’, 5.8% ‘felt unsafe in apublic place’, 9.8% ‘annoyed by vomit,urine or litter,’ 5.8% ‘verbally abused’,6.8% ‘in a serious argument’, 2.5%‘harmed physically’, 0.4% a ‘passengerwith a drunk driver’ and 0.7% ‘in a traffic

accident’. Nearly 9% of UK respondentsreported having been affected ‘a lot’ by aknown heavy drinker, largely family,relatives or household members.

It is difficult to gather good informationin retrospect regarding negativeexperiences in childhood. With thatreservation, RARHA results found that forall countries, 9.1% of men and 13.4% ofwomen said they had been negativelyaffected a lot by living with a heavy drinkerduring childhood or adolescence. In theUK, the figures were 6.1% and 13.3%.

These findings – a small selection fromthe RARHA report – highlight the natureand extent of perceived harm from others’drinking. Much remains to be done toimprove measurement of harm and toimprove understanding of the experienceof harm from the perspective of thoseaffected. Even within the UK, we canexpect considerable differences at regional,community and social group levels. But theimportance of the findings for policy andpractice emerge clearly from the report andthe case for further examination of ‘harmto others’ is well made.

Betsy ThomProfessor of Health PolicyDrug and Alcohol Research CentreMiddlesex University

* Reducing Alcohol Related Harm.Comparative monitoring of alcoholepidemiology across the EU. Synthesisreport (2016) https://tinyurl.com/ybft574w

SPECIAL FEATURE: ALCOHOL HARMS

WINTER 2017 76 PUBLIC HEALTH TODAY

SPECIAL FEATURE: ALCOHOL HARMS

FOLLOWING the biggest and best DryJanuary to date, 2018 is shaping up to bea Big Year in the battle to reduce theharms caused by Big Alcohol.

The Big Red-letter Day is Tuesday 1 May,when minimum unit pricing (MUP) finallyarrives in Scotland – five long years (and abruising battle with the Scotch WhiskyAssociation) after being enacted by theScottish Parliament. The breakthroughcame last November when the UKSupreme Court unanimously ruled thatMUP does not contravene laws oncompetitive trading and is therefore legal.

As well as Scotland, Wales is also well onthe way towards MUP with a clearstatement of intent. And Northern Ireland isready to press ahead just as soon as it canget back to properly devolved government.

So, yet again, as with the ban onsmoking in enclosed spaces, England is the

last part of the UK to embrace a potentiallymassive step forward for public health.Despite constant pressure from the AlcoholHealth Alliance (which includes FPH) – butbolstered by covert and much strongerpressure from Big Alcohol – theGovernment is refusing to budge from itswait-and-see-what-happens-in-Scotlandpolicy.

This leaves us with another five years’

delay, hundreds of avoidable deaths andthe interesting prospect of busloads ofrollicking bootleggers pouring across theCheviots, laden with bulging suitcases ofWhite Star cider.

Meanwhile the Scottish Government andthe National Institute of Health Researchhave put in place an impressive evaluationpackage covering pretty well every angleyou can think of – consumption, health,crime, jobs, family budgets, socialattitudes, the wider economy – with a

special focus on dependent drinkerscomparing Scotland with north-eastEngland. It will be a fascinating quasiexperiment – unless of course Englandwere to have a sudden change of heartand join Scotland with the same MUP, inwhich case there’ll be a sizeable bunch ofvery disgruntled researchers tearing uptheir spreadsheets in frustration.

In this edition of Public Health Todaywe’ve tried to capture a range of issuesfrom alcohol policy to front-line practice.We consider the impact of alcohol onfamilies, on older people and a pan-Europestudy of harm to others. We investigatethe crime dimension, and the complexinteractions of alcohol with depression. Welook at licensing and fiscal initiatives. Wedebate the Chief Medical Officer’sguideline on drinking in pregnancy. Andwe cast a beady eye over the shadyinfluence of Big Alcohol on labelling andmarketing. Lots for you to sip and savour.

Finally, just to say that, after eight yearsof editing this magazine, I’ve decided tomake this my last wielding of the bluepencil. If you think you’d like to give it awhirl, do get in touch. Goodbye andthanks for reading.

Alan Maryon-DavisEditor-in-Chief

This leaves us withthe prospect ofbusloads of rollickingbootleggers pouringacross the Cheviots‘

‘

Harms to others beinginvestigated andmeasured at last

Lager loutsgrow up intoageing drinkers

IT WOULD have been inconceivable, 30years ago, for older people to be sufferingthe consequences of alcohol misuse intheir own homes. In the 1980s, it wasyounger people staggering home from thepub, often incurring the wrath of the law.

Perhaps what we are now seeing as apublic health problem is those babyboomers who were the lager louts of themid- to late-20th Century. This populationof post-war hedonists now has higherlifetime and current rates of alcohol misusethan any other generation.

It is not the marital, occupational andlegal consequences of alcohol-related harmthat our society needs to tackle. The focusshould now be on retirement,bereavement, social isolation, multiplechronic physical problems such as pain,interaction of alcohol with prescribed drugsand an increased likelihood of alcohol-related brain damage. These are verydifferent problems from those usually seenby substance misuse and addiction services.

The challenge is to manage thiscomplexity in a way that also looks at age-sensitive matters in service delivery, such assensory and cognitive impairment, mobilityproblems, dignity and stigma. It often seemsthat older people with alcohol problems areat the bottom of the commissioning ladder.

In 2015/16, 55-74 year-olds formed 45%of alcohol-related admissions to hospitalsin England. The number of alcohol-specificdeaths in people aged 50 and over hadrisen by 45% over the previous 15 years.This contrasts with no increase in numbersfor the 15-49 age group.

There is strong evidence for minimumunit pricing to reduce alcohol-related harm.We also know that age-specificinterventions delivered to older peopleresult in similar, if not better, outcomes inimproving health and social function.

Sadly, there remain only pockets of goodpractice in integrated care for older peoplewith alcohol misuse. One success story is inthe London Borough of Southwark wherethere is a strong partnership between thelocal authority and mental health services.

We’ve dropped the ball in commissioningservices for older people with alcoholproblems. Let’s pick it up and run with it.

Tony RaoConsultant Old Age PsychiatristSouth London and Maudsley NHSFoundation Trust

Take it to the minThis is a pivotal year in the struggle against alcohol harms as minimum unit pricingfinally launches in Scotland. The results could be fascinating, says Alan Maryon-Davis

Take it to the minThis is a pivotal year in the struggle against alcohol harms as minimum unit pricingfinally launches in Scotland. The results could be fascinating, says Alan Maryon-Davis

SPECIAL FEATURE ALCOHOL HARMS

WINTER 2017 9

SPECIAL FEATURE: ALCOHOL HARMS

8 PUBLIC HEALTH TODAY

THE alcohol industry has long been at theforefront of developments in marketing. In1876, the Bass Triangle became the firstregistered trademark, and the iconic‘Guinness is good for you’ campaign,launched in 1929, has a good claim to beone of the most influential advertisingcampaigns of the 20th century. There areplenty of people who still believe that, byroasting barley at a slightly highertemperature than usual, stout is imbuedwith additional health-giving properties.That is impact which marketing executivescan usually only dream about.

The rise of social media in the late 2000sproved no exception to this trend. Havingalready invested heavily in digitalmarketing, major drinks producers wereamong the first to recognise the changingtide represented by the emergence ofFacebook and, later, Twitter and Instagram.In 2011, Diageo (producers of Guinness,among other brands) agreed amultimillion-dollar deal with Facebook,building on what it claimed was a 20%increase in sales the previous year as adirect result of Facebook promotions. Sincethen almost all of the major brands havemoved into the social media space, andincreasingly place digital interaction at theheart of wider marketing strategies.

Social media presents an array of newopportunities to drinks producers, and a

swathe of problems for regulators. Inparticular, social media exchanges thetradition of broadcast advertising, in whichone message is viewed by a large numberof people, for interactive engagementmarketing. This blurs the line betweenbrand-developed material and user-generated content, allowing consumers toact as brand ambassadors through actionsranging from uploading videos to simplyliking or sharing a post. As a consequence,

an enormous amount of material can passbelow the regulatory radar.

The rhythm of social media marketing isalso different. Posts are targeted andscheduled to reflect the patterns of workand leisure across different consumergroups. Again, this poses tangibleproblems for regulation. In April 2017, forinstance, a complaint was raised with theAdvertising Standards Agency (ASA) abouta post for a Bristol nightclub which usedpseudo-pornographic imagery to advertise

a drinks promotion. In fairness, the ASAruled the advert contravened itsregulations; however, the ruling came inAugust – four months after the advert wasplaced on Facebook, which was for anevent the following week.

In reality, our current system ofadvertising regulation was established in apre-digital era. Although alcohol advertisingis subject to some stringent rules, these areincreasingly hard to enforce in an age ofmulti-platform social media marketing. Weneed a comprehensive review of existingsystems to bring regulation into the modernage. This may conclude, as many publichealth campaigners would prefer, in acomprehensive ban on alcohol advertising.It may, by contrast, establish new limits onhow social media can be used or whotakes responsibility for material appearingon brand timelines. It may simply tacklethe increasingly thorny problem of how toregulate online sales of alcohol.

Whatever the result, it is clear that whatwe have in place is not fit for purpose, andit is surely not a matter of if, but when,there is an overhaul.

James NichollsDirector of Research and PolicyDevelopment Alcohol Research UK and AlcoholConcern

Social drinkingThe current system of advertising regulation was designed in a pre-digital era, so it struggles to deal with alcohol promotions on social media, says James Nicholls

We need a review ofexisting systems tobring regulation intothe modern age‘

‘

People needsimple, clearmessagesBACK in 2014 directors of public healthin the north-east of England wereconcerned that, in a region with highalcohol consumption, they needed tosend out a clear message about thedangers of drinking during pregnancy.The existing guidance left the publicconfused and in the interests of claritythey advocated delivering a messagethat it’s safest not to drink at all duringpregnancy.

In January 2016, the chief medicalofficers (CMOs) decided to adopt thesame precautionary approach: that, inthe absence of evidence that smallamounts of drinking during pregnancywas safe, it were best to advise nodrinking at all. They did, however,address concerns relating to womendrinking before being aware of theirpregnancy, stating that the risks werelikely to be low if only small amountshad been consumed and advising that

women consult their midwife or doctorif they had concerns.

I believe women have a right to knowthat alcohol passes through theplacenta to their unborn child, andthere is no guarantee it isn’t doing anyharm. Women are used to beingadvised to stop eating certain foodproducts and to stop smoking whenpregnant. The suggestion that weshould compromise on alcohol probablysays less about the risks and more

about the wider role it plays in society. My experience working as a

communications professional in publichealth leads me to believe that we aregenerally excellent at getting thescience right, but sometimes not sogood at turning that science intosimple, compelling messages. It isalways a compromise, and the resultscan often be messy, but I strongly

believe that while what you say isimportant, what people understand iswhat really matters.

In the north-east we have beenpromoting the ‘0 for 9’ message forover three years, and its simplicity isclearly cutting through with the public.In a survey of over 2,000 adults in theUK carried out in late 2017, only 41 percent of women were able to correctlyidentify the new CMO pregnancyguidelines. However, I believe that thesimplicity of the new guidelines will seethat figure increasing, because in thenorth-east awareness now stands at 52per cent of women.

My big concern is that theGovernment and its agencies aresingularly failing to effectivelycommunicate the new alcoholguidelines; we’re being kept in the darkthroughout every stage of our lives.That is unforgiveable in a society wheredrinking, sometimes to excess, is thenorm.

Colin ShevillsDirectorBalance North Eastbalance.grtest.co.uk

DEBATE: Are the drinking-in-pregnancy guidelines too strict? Clare Murphy says womenneed information not judgement, while Colin Shevills says total abstinence is simpler

No evidence ofharm from low-level drinkingTHE shift to a policy of advising abstentionfrom alcohol in pregnancy was not borneof changes in the evidence-base – thereremains no evidence of harm at low levels.

The change was apparently spurred bythe guideline group’s concerns thatprevious guidance “may have been read asimplying a recommendation to drinkalcohol at low levels during pregnancy”.The basis for this anxiety? An unpublished,unavailable presentation to the groupbased on a discussion with some newmothers. It doesn’t feel like a goodevidence base for an evidence-based policy.

The group was clear its advice was basedon the need “for clarity and simplicity”, abit like how you might talk to a child.Because what ultimately underpins the chiefmedical officer guidelines is a lack of faith inwomen’s ability to understand informationand their capacity to make their own

decisions, based on the available evidence.For some, it is irrelevant whether small

quantities of alcohol in pregnancy areharmless. Is it such a hardship to forgoalcohol for nine months for your baby’ssake? Isn’t such a policy entirely benign? Toimply, however, that the evidence sayssomething it doesn’t is not benign.

For one, it adds to the growing climateof anxiety around pregnancy today, with

women’s behaviour increasingly scrutinised.It was extraordinary to see a recent surveyin the Journal of Public Health asking thepublic if they supported the abstinence-only approach – as if pregnant women’schoices are a legitimate target forjudgement and sentiment a suitable basisfor health policy.

In this climate, scientists too increasinglyposition themselves not as truth-bearers

but public health messengers. Despitefinding no evidence of harm from low-leveldrinking in pregnancy, studies frequentlyconclude with calls for greater scrutiny ofwomen – whether pregnant or potentiallypregnant (you just need a working wombto require monitoring), including thedevelopment of alcohol ‘biomarkers’ toassess whether women are lying. AScottish hospital is working on just this.

Pregnant women today are heldaccountable for a whole manner ofnegative outcomes in their offspring on thebasis of little or nothing. The discussionaround alcohol – but above all obesity – inpregnancy is a case in point. This is notbenign. It is dangerous.

And what’s really tragic is that calls forold-fashioned, society-wide public healthinitiatives which genuinely could improvethe health of babies – such as thefortification of flour with folic acid – havebeen completely drowned out.

Clare MurphyDirector of External AffairsBritish Pregnancy Advisory Servicewww.bpas.org

NO

YES

THE Antisocial Behaviour, Crime andPolicing Act 2014 introduced the civilinjunction and criminal behaviour order(CBO). This replaced, and represented astep-change from, the antisocial behaviourorder (ASBO). These powers may appear tolie some way outside the public healthdomain; but they can help public healthteams support a challenging client groupand enhance the commissioning of alcoholtreatment services.

The orders allow courts to banbehaviours, such as visiting a location, andimpose positive requirements to encouragechange. They are appropriate for peoplewhose antisocial behaviour is due toalcohol problems, and the requirementscan include ‘treatment’ interventions, suchas support and counselling or alcohol-awareness classes.

Public health teams now haveresponsibility for alcohol treatment. Thesenew orders offer an opportunity to discuss and develop responses totreatment-resistant clients who may behaving a significant impact on localcommunities.

Alcohol Research UK (ARUK) is currentlyfunding a project to help community safetyand alcohol treatment staff to developalcohol-focused positive requirements. Thisproject has been very well received. Over100 staff from local authorities acrossEngland and Wales have contributed, andthree regional workshops were over-subscribed.

Evidence of the positive impact of theseorders has been identified. For example,Bedford Borough Council has published a

case study of a woman who received aCBO as a result of her drunken behaviour.It highlighted the positive outcomes andcost savings that can be achieved by jointworking – £45,000 in one year in that case(www.bedford.gov.uk/pdf/CaseStudy_ASB.pdf).

The key message from those consulted isthat work is required to enable alcoholtreatment services to support these orders.This offers an opportunity to engage awide range of partners in discussion aboutthe shape and focus of services.

Senior police officers, police and crimecommissioners and community safetymanagers should work with public healthcommissioners to design servicespecifications and contracts that supportinvolvement in positive requirements.Alcohol services should be designed to bepart of the process that leads to a CBOfrom the earliest possible point. This wouldinvolve offering specific positive treatmentrequirements, but also:n community outreach alongside policeofficers and neighbourhood wardens.n offering a speedy, even proactive,response to individuals at high risk ofreceiving orders. n attending multi-agency meetings withthe client where the behaviour is discussed.

If public health teams wish to learn moreabout the ARUK research and potentialtraining, please emailmward@alcoholconcern.org.uk

Mike WardSenior ConsultantAlcohol Concern

SPECIAL FEATURE: ALCOHOL HARMS

WINTER 2017 1110 PUBLIC HEALTH TODAY

Antisocial behaviour:a chance for treatment

A SPECTRE is haunting the alcohol industry– the spectre of price regulation. InNovember, the Supreme Court confirmedthe legality of the Scottish Government’slegislation for minimum unit pricing (MUP),bringing to an end a five-year dispute. TheIrish Government is in the process ofpassing MUP into law. In October, theWelsh Government announced its plans toimplement the policy. For the WestminsterGovernment, officially at least, MUP is“under review”.

So why is price regulation needed foralcohol? Accounting for income growth,alcohol is 60% more affordable in the UKtoday than in 1980. Drink is particularlycheap in supermarkets and off-licences,where the average price of beer is lowertoday than in 2001, even though theoverall prices have increased by 52%.Strong white ciders, overwhelmingly drunkby underage and harmful drinkers, containthe equivalent of 22 shots of vodka for aslittle as £3.49.

This is deeply worrying, becauseaffordability is one of the key drivers ofconsumption and harm: cheaper alcoholinvariably leads to higher rates of deathand disease. Alcohol is responsible for21,000 deaths and 1.1 million hospitaladmissions in England each year, and liverdisease is now one of the leading causes ofpremature death in the UK.

The World Health Organization and theOrganisation for Economic Co-operationand Development recommend raising taxeson alcohol to reduce its harmful impact onhealth and society. A meta-analysis of 50academic studies found that doubling therate of alcohol tax is associated with a35% fall in alcohol-related mortality, andreductions in the number of trafficcollisions, sexually transmitted diseases,crime and violence.

In the wake of the financial crisis, the UKgovernment introduced the alcohol dutyescalator, raising tax on alcohol by 2%above inflation each year between 2008and 2013. This encouraged falls in therates of consumption and alcohol-relateddeaths. Yet this progress has stalled, withtax on beer cut by 16% and tax on ciderand spirits cut by 8% in real terms since2012.

In any case, much of the most harmfulalcohol is sold so cheaply that taxes would

have to be raised dramatically in order tofully address it. Moreover, alcohol taxes arelevied on businesses, not consumers, andso retailers sometimes choose to absorbthe cost of higher taxes rather than raisingprices on the shelves.

A more direct and targeted way ofdealing with cheap alcohol is minimumunit pricing, which sets a ‘floor’ price perunit, below which it is illegal to sellalcohol. For example, an MUP of 50pwould require a typical pint of beer to beat least £1 and a bottle of wine to be noless than £4.50.

Evidence from Canada, which operates asimilar policy to MUP, shows that higherminimum prices are associated with lowerconsumption, hospital admissions anddeaths. Modelling by the Sheffield AlcoholResearch Group suggests that a 50p MUPin England would reduce hospitaladmissions by 22,000 each year and save525 lives.

The recent momentum behind MUPshould therefore be a cause of excitementfor the public health community, and itcomes as no surprise that alcoholcompanies are fearful. By raising the priceof alcohol we can reduce its toll.

Aveek BhattacharyaPolicy AnalystInstitute of Alcohol Studies

Cheap at the priceAlcohol is more affordable than it was 30 years ago, but the recent push forminimum unit pricing should help to redress the balance, says Aveek Bhattacharya

Strong white ciderscontain theequivalent of 22shots of vodka for aslittle as £3.49‘

‘

You don’t haveto drink to beaffected by it

WHEN you hear the phrase “alcohol harm”what is the first thing you think of? Damageto your liver? Drink-driving? Antisocialbehaviour? What about the impact on thedrinker’s family? While problematic alcoholuse can detrimentally affect individuals, itcan also have a devastating impact onthose closest to them. Families affected byalcohol often suffer in silence, feelingashamed of their loved one’s drinking andstigmatised as a result, or they see heavyalcohol consumption as a ‘normal’ part ofboth society and family life, so don’t realisethere’s a problem or that support is outthere.

Support for families has been proven tobe effective and can take a variety of forms,from one-to-one work with professionals topeer support groups, from structuredinterventions to information leaflets. As isoften the case, however, support varies alot locally; it is excellent in some areas, butminimal in others, if it exists at all.

At Adfam, we passionately believe thatfamilies deserve support in their own right.No-one should have to suffer in silencebecause of the actions of those closest tothem. Support for families should be wellresourced, available in every area, and wellpromoted so that families know it is thereand how to access it.

We should be motivated, not only by theclear moral argument for supporting fellowcitizens at times of need, but also by thebeneficial consequences and savings forsociety as a whole. Properly supportedfamilies can themselves support their lovedones through the challenges of life andhopefully into treatment and recovery. Every£1 invested in support for families affectedby substance use gives £4.70 in value backto society (https://tinyurl.com/ycca6o52).This includes through improving the healthand wellbeing of both family members anddrinkers.

For more on how we improve life forfamilies affected by substance use, to finda local support group or for resources forboth families and practitioners, visitwww.adfam.org.uk

We also lead the Alcohol and FamiliesAlliance(www.alcoholandfamiliesalliance.org). Whynot join us?

Oliver StandingDirector of Policy & CommunicationsAdfam

SPECIAL FEATURE: ALCOHOL HARMS

Helping youngpeople makebetter choices

THE National Institute for Health and CareExcellence (NICE) is drafting new guidanceto help educate children and young peopleabout their alcohol choices andconsumption.

The new guideline is aimed at givingteachers, local authorities and educationproviders advice about which alcoholeducation programmes can help youngpeople make better decisions about theirdrinking habits. It aligns with therecommendations set by the UK chiefmedical officers which advise that analcohol-free childhood is the healthiest andbest option.

The guidance will be looking at school-based interventions which will helpchildren and young people aged 11 to 18in full-time education, as well as thoseyoung people aged 18 to 25 with specialeducational needs or disabilities who are infull-time education. It comes at a timewhen the education system has changed,in particular with the introduction ofacademy-status and free schools which donot have to follow the national curriculum.

Work on the guideline has begun andwill continue throughout the next year.NICE published other guidance on alcoholconsumption back in 2010, which lookedat a mix of population- and individual-levelinterventions including the pricing andmarketing of alcohol-based products.

For more information about thisguideline, or to be kept updated and/orinvolved in its development, you can signup to become a stakeholder. And to findout about the work of NICE moregenerally, follow it on Twitter@NICEcomms.

Amraze KhanExternal Communications ManagerNational Institute for Health and CareExcellence

THE alcohol industry is dominated by ahandful of multinational corporationswielding enormous economic and politicalpower. With great power should comeresponsibility, and alcohol producers seekto demonstrate this through CorporateSocial Responsibility (CSR) programmeswhich purport to mitigate their economic,social and environmental impacts.

The alcohol industry has a number ofCSR strategies, including public awarenesscampaigns and educational programmes,funding industry-led organisations such asDrinkaware, self-regulation policies,collaboration with charities andsponsorship of research. Whilst someorganisations and their employeesundoubtedly see these initiatives as a forcefor good, there is a growing evidence baseto suggest that in most cases, theseactivities are more likely to be designed toraise brand awareness, ward off regulationand portray a socially responsible image tothe public and policymakers.

While it is now unthinkable that thetobacco industry would have a seat at thepolicy-making table, the alcohol industry hasbeen able to retain this important influenceover policies which could significantlyaffect their profits. When it is enshrined inlaw that businesses’ first responsibility is tothe shareholder, the conflict of interests isclear. Profits come first; as one industry

report stated: “It’s good business for theindustry to promote responsible drinking.”

It has been widely reported that, giventhe opportunity, industry representativesseek to develop industry-friendly policy byframing the issues to shift responsibility tothe individual and casting doubt on theestablished evidence base of measuresdesigned to reduce alcohol-related harm ata population level, including regulation ofthe price, availability and marketing of

alcohol. Instead, the industry has promotedinterventions known to be ineffective, suchas education programmes with limitedvalue for behaviour change, and self-regulation pledges.

Many health and charitable organisationswalked out on the 2011 UK Public HealthResponsibility Deal due to concerns thatindustry arguments were carrying moreweight than those of public health experts.These concerns have been vindicated, withevaluations of the deal showing that many

of the pledges made have not beenadhered to or have had limited effect.

Outside the UK, global industry actorshave also provided ‘assistance’ topolicymakers in developing countries,including the writing of large sections ofgovernment alcohol policies in several sub-Saharan African countries. The offer offinancial support in the wake ofinternational disasters has been suggestedto be more about gaining political influenceand increasing brand recognition inemerging markets than true philanthropy.

The activities of the alcohol industry toimprove their reputation, promote theirbrands and increase profits in the name ofCSR are now being recognised. Leadingpublic health figures are calling for action,including the exclusion of the alcoholindustry from the policy-making arena, thecreation of an independent body to regulatealcohol promotion, and for the prohibitionof all alcohol advertising and sponsorship.Social norms have finally shifted in responseto a strong and consistent approach totackling the tobacco industry, and the effectson population health are clear to see.

Isn’t it time for the same approach withthe alcohol industry?

Emma KainSpecialty Registrar in Public Health Devon County Council

SPECIAL FEATURE: ALCOHOL HARMS

WINTER 2017 1312 PUBLIC HEALTH TODAY

SPECIAL FEATURE: ALCOHOL HARMS

These activities aremore likely to bedesigned to raisebrand awareness andward off regulation‘

‘SO HOW much is too much? Read thepatient safety leaflet and you’ll find that, iftaking prescribed drugs for depression,anxiety or psychosis, the message is clear:don’t mix alcohol with these medications.

Sounds straightforward, except thatpeople who are depressed often rely onalcohol to keep the black dog down.Substance-use disorders often co-occurwith mental illness such as depression,anxiety and psychosis. In a number ofhigh-profile celebrity deaths – WhitneyHouston, Amy Winehouse and HeathLedger, for example – there was muchspeculation that a cocktail of alcohol andprescription drugs played a role.

Mental health professionals have longfaced the difficulty of trying to work outwhich came first – the alcohol dependencyor the depression. Alcohol may help torelieve the numbness caused by psychiatricmedications. Conversely people who drinkalcohol may develop depression because itis itself a depressant.

Many medications can interact withalcohol, leading to increased risk of illness,injury or death. Mixing drugs and alcoholcan result in a life-threatening overdose orthe development of alcohol dependence.For example, alcohol increases the sedativeeffect of tricyclic antidepressants such asamitriptyline, impairing mental skillsrequired for driving. Consuming alcoholwith antipsychotics – used to reducedelusions and hallucinations – can alsoresult in increased sedation, impairedcoordination and potentially fatal breathingdifficulties. The combination of chronicalcohol consumption and antipsychoticdrugs may result in liver damage.

Low-level reliance on alcohol maypotentiate the impact of prescribed

medications by competing with the sameset of metabolizing enzymes. This increasesthe risk of harmful side effects.

In contrast, long-term or chronic alcoholconsumption may activate drug-metabolizing enzymes which reduce theeffects of medication. So a patient mayrequire higher doses to achieve atherapeutic level. Elderly people may be atincreased risk of these harmful interactionspartly because older bodies take longer tometabolise toxins and partly because elderlypeople may be on a cocktail of drugs totreat a number of co-existing conditions.

Prozac is one of a group of medicationspopular for depression, anxiety and panicdisorders. These drugs increase the levelsof the neurotransmitter serotonin in thebrain. Alcohol too can increase the level ofserotonin, a combination which can lead to‘serotonin syndrome’ – manic anddangerous behaviour. Mixing alcohol withProzac can also heighten feelings ofdepression and anxiety – the verysymptoms that Prozac is designed totreat – and may increase suicidal ideation.

People often overlook warning labels butthey are there to reduce harm to patients.Drug and alcohol interactions are notcompletely predictable, and everyone’sbiochemical make-up is different, sopeople have different sensitivities toalcohol-medication interactions.

Alcohol and psychiatric medicationsdon’t mix, but just saying ‘no’ rarely works.With prescribing of antidepressants morethan doubling in the past decade, this is aproblem that is not going to go away.

Frances MacGuireFreelance consultant in environmentaland health risk management

Why drugs make apoor mixer with drink

Responsible parties?Why is the alcohol industry still invited to the policy-making table while tobaccocompanies have long been excluded from discussions, asks Emma Kain

Responsible parties?Why is the alcohol industry still invited to the policy-making table while tobaccocompanies have long been excluded from discussions, asks Emma Kain

TORN AND FRAYED: An old poster of Amy Winehouse

BOOKS & PUBLICATIONS

WINTER 2017 15

Less judgementand morenudgement‘CHOICE architecture’ is sure to be thephrase on everyone’s lips following RichardThaler’s Nobel prize in economics for hiswork on behavioural economics and nudgetheory. This has prompted a new edition ofhis 2008 book Nudge, written incollaboration with Cass Sunstein. Notbeing well versed in either economics orfinance, I was initially sceptical that I wouldfind a book that includes chapter titlessuch as ‘Privatizing Social Security:Smorgasbord Style’ or ‘Credit Markets’interesting, but I was wrong. It is a treasuretrove of amusing, outrageous and amazingobservations about human behaviour andhow to change it.

The book makes the case for policy-makers or employers to deploy nudges.According to Thaler and Sunstein, a nudgeis “any aspect of the choice architecturethat alters people’s behaviour in apredictable way without forbidding anyoptions or significantly changing theireconomic incentives… Nudges are notmandates. Putting the fruit at eye levelcounts as a nudge. Banning junk food

does not.” This is an interestingdichotomy – nudging versus banning – forpolicy-makers to consider when assessinglevers for change.

Nudge is very wide-ranging and includesinteresting anecdote such as how toencourage men to have better aim at aurinal (paint a black housefly on the centreof the urinal) to how to increase your ownself-control around temptations. I foundthe chapter on organ donation the mostinteresting having worked on the issue in apolicy role. It’s also especially relevant giventhe Prime Minister’s October announcementthat England will consult on followingWales in switching to a system ofpresumed consent for organ donation.Thaler and Sunstein describe the model ofpresumed consent (as opposed to routineremoval or explicit consent) as passing the‘nudge’ test. Essentially, a system ofpresumed consent assumes that all citizensconsent to donation and provides themwith the chance to ‘opt out’ if they don’tagree. This is a very successful and simpleway to nudge people towards donation.Studies in the US have shown that whenpeople have to opt in, only around 40%become donors, but when they have toopt out, the figure more than doubles.

Other chapters discuss marriage, how tosave money and lose weight (sometimes atthe same time), and how to save the planet.

I don’t know if I’m a complete convert tothe Church of Choice Architecture,especially considering the magnitude of thepublic health challenges we face, but I’vedefinitely been nudged in that direction.

Lisa Plotkin

Why stigma is a major healthdeterminantIN 1930s CENTRAL Europe, an electedgovernment began requiring Jews to wearyellow badges to distinguish ‘them’ from‘us’. They were drawing on a long traditionof stigmatisation. A caliph in the 8thcentury, a pope in the 13th, and many otherrulers in France, Spain and England had allforced visible stigma on Jews, Muslims andChristians variously. It was an importantway of normalising their ill-treatment,deportation and premature deaths.

In 2017, a UK council passed legislationto criminalise rough sleepers who beg –potentially increasing their suicide risk.Recently, a powerful president hasmanipulated public opinion, putting themark of stigma on Muslims, the poor,African countries, migrants and transsexuals,legitimising them as acceptable targets fordiscrimination. Another offered Africanspayments to emigrate.

This books shows how our professionmust confront, quantify and tacklestigmatisation and discrimination as majorhealth determinants affecting huge

populations. Discrimination activelylegitimises war, rape, murder and torture. Itmust be tackled directly and at source ifwe are to prevent and mitigate its impact.Witness the astonishing life expectancygaps between the ‘us and them' in the USand the UK. The authors show how just sixstigmatised characteristics (mental illness,sexual orientation, obesity, HIV/AIDS,disability and ethnicity) affected more thanhalf the US population. These stigmasdirectly impacted on critically important lifedomains such as housing, employment,social relationships, education and health.There are now clear causal pathways, andthe numerous chapters are crammed withmodels for effective action. Here areblueprints for tackling enduring pervasivedeterminants of misery, illness, prematuremortality and inequalities.

The contributors’ distillations of research-based material detail the many waysthrough which discrimination about skincolour, body size, deformity, deafness andmany other characteristics damages health.At the same time it shows how we cantake effective action against it. It coverssocial and psychological mechanisms andpathways, but also examinations of howstigma and discrimination influence, notjust economic disparities, but also thehealthcare quality and provision given to

different groups. We must incorporate thisbook’s recommendations and guidance intoour profession’s vision for better health,and into our curriculum, training and work.

Andy Beckingham

Oxford Handbook of Stigma,Discrimination, and HealthEdited by Brenda Major, John FDovidio and Bruce G Link

Published by Oxford University PressISBN 9780190243470RRP: £115

Nudge: Improving decisionsabout health, wealth andhappinessRichard Thaler and Cass Sunstein

Published by PenguinISBN 9780141040011RRP: £7.99

Reducing harmby having a sayin licensing

A MAJOR study is aiming to find out ifpublic health teams can make a differenceto unhealthy drinking by getting involvedin alcohol licensing.

Since 2011 in England and 2009 inScotland local public health teams arenotified of premises applications for alicence to sell alcohol and have the right toformally comment. Many work intensivelyto try to influence the alcohol premiseslicensing system. Although there have beensome encouraging studies, it is not knownif, or how, these activities have aninfluence on licensing processes, healthoutcomes or crime rates. Better evidence isneeded to guide practice.

There were 339,000 alcohol-relatedhospital admissions in 2015/16 and 6,813alcohol-related deaths in 2015 in Englandalone; both figures have risen since 2005by 10% and 22% respectively. Systematicreviews have identified control of theavailability of alcohol as a key approach toreducing alcohol-related harms. However,the relationships between public healthactivities, specific local licensing controls,indicators and types of availability, andalcohol-related harms, are not clear orconsistently examined in the literature.

In the UK, local licensing authorities mayinfluence the types of premises licensed,hours of operation or density of outlets.Public health teams may collate local datato assist with policy formulation, makeformal representations against licenceapplications, develop licensing conditionsfor individual premises and trial innovativeactivities.

The ExILEnS (Exploring the Impact ofalcohol Licensing in England and Scotland)study aims to find out what public healthteams have been doing in this area, andwhether their actions have had any impacton health and crime outcomes over theperiod 2012 to 2018. The study consists offour work packages:n examining current public health team

engagement in licensingn analysing changes in health and crimeoutcomes over time in areas of high publichealth activity compared with areas of low activityn examining whether this activity mightimpact on health inequalities or longer-term outcomesn developing a theory of how such activitymay work and making recommendationsabout future practice, policy and researchin this area.

The project is led by Dr Niamh Fitzgeraldat the University of Stirling and funded bythe National Institute for Health ResearchPublic Health Research Programme (project15/129/11). The study involves co-investigators from the universities ofBristol, Edinburgh and Sheffield, theLondon School of Hygiene and TropicalMedicine and Alcohol Research UK and

is overseen by an advisory group thatincludes public health professionals,academics, charities and members of the public.

The project began in April 2017 and willrun until March 2020; recruitment of localpublic health teams is underway. Theintention is that the study findings willenable public health teams and localauthorities to make best use of theirresources and powers to influence the localalcohol retail environment and reducealcohol-related harms.

More information is available fromwww.ukctas.net/exilens or by emailingexilens@stir.ac.uk.

Colin SumpterSpecialty Registrar in Public HealthNHS Forth ValleyCurrently working on the ExILEnS studywhile on academic placement at theUniversity of StirlingNiamh FitzgeraldExILEnS Principal InvestigatorSenior Lecturer in Alcohol StudiesInstitute of Social MarketingUniversity of Stirling

14 PUBLIC HEALTH TODAY

SPECIAL FEATURE: ALCOHOL HARMS

Alcohol labelsfail to informconsumers

WHEN it comes to alcohol, we’re not doingenough to help people make informedchoices. There are no high-profile massmedia campaigns to offset the glamorousadvertising of the big alcohol brands. Andthere’s a real lack of information aboutalcohol on packaging and at point-of-sale.

There’s far more consumer informationprinted on a pint of milk than on a bottleof vodka; the first is an everyday essential,the second an addictive and carcinogenicsubstance. The need for better informationis clear: only one in 10 of us is aware ofthe link between alcohol and cancer.

Manufacturers have got away withproviding minimal information – usually thenumber of units in the container and a no-alcohol-in-pregnancy symbol. They shouldbe compelled to display prominent healthwarnings, along with information aboutunits, ingredients, nutrition and calories.

We took part in research, as part of theAlcohol Health Alliance, which showed thatletting alcohol producers decide what to puton labels meant that consumers were beingleft in the dark. A review of 315 productlabels found only one which showed thelow-risk drinking guideline of 14 units aweek. There was no mention of any healthrisks nor advice on spreading drinkingthroughout the week and alcohol-free days.

Consumers have the right to be informedabout products that may pose a risk tohealth, and they expect this information tocome from an independent, trustworthysource. Unfortunately, the Department ofHealth recommends that alcohol labelsdirect people towards the alcohol-industry-funded Drinkaware website, despite theWorld Health Organization stating that thealcohol industry should not be involved inhealth promotion. NHS Choices (or NHSInform in Scotland) would be a far bettersource of information on alcohol.

More information and health warnings onlabels alone won’t lead to people drinkingless. For that we need policies to reduce theaffordability, availability and marketing ofalcohol. But better labelling would be apositive step forward in repositioning alcoholand letting people know the significantrisks associated with its consumption.

Alison DouglasChief ExecutiveAlcohol Focus Scotlandwww.alcohol-focus-scotland.org.uk@AlcoholFocus

Reviews haveidentified control ofthe availability ofalcohol as a keyapproach to reducingalcohol-related harms‘

‘

16 PUBLIC HEALTH TODAY

ENDNOTES ENDNOTES

WINTER 2017 17

From the CEOFPH President John Middleton and Iattended the European Public HealthAssociation (EUPHA) 10th conference inStockholm in November, along with2,000 other delegates.

We took this opportunity to raise ourprofile and influence debates through amixture of oral presentations, posters,chairing and contributing to sessions,but also of course through networkingand side-meetings.

As well as representing FPH at the

meeting of the Governing Board ofEUPHA, we also discussed opportunitieswith many other key partnerorganisations, including the Associationof Schools of Public Health in theEuropean Region and the Agency forPublic Health Education Accreditation.The FPH Europe Special Interest Groupbegan to structure a forward plan,including engagement with the WorldHealth Organization ‘Coalition ofPartners’ capacity-building work, anddeveloping collaborations betweenschools of public health.

FPH was strongly represented at theroundtable session on ‘The MoralMandate of Public Health’, with Johnchairing and Farhang Tahzib, Chair ofthe FPH Ethics Committee, presentingon active engagement in the science ofsocial justice. Martin McKee presentedon the abuses of power in old and newmedia to influence social perceptionsand inequalities.

The opening ceremony gave us anentertaining presentation from OlaRosling, in memory of the late, great,Hans Rosling. Ola challenged hisaudience to be more positive about the

progress we have made on health in thelast 200 years and pointed out therather dismal basic understanding ofsignificant health facts among groupswho should know better! Isubsequently took the ‘gapminder test’(www.gapminder.org/), partly to see if Icould score better than a chimpanzee,but also to take advantage of anexcellent set of resources. I encourageyou to try it.

My third take-away came from aplenary looking at how public healthsystems adapt to a world moving frompublic to private ownership. AaronReeves of the London School ofEconomics gave a summary of theevidence, highlighting the trend awayfrom a collective organising society. Heflagged the adverse impacts of economicpolicy on pension values and howchanges in collective bargaining andminimum wage policies are adverselyaffecting health. Aaron gave a similarcall to arms: it’s not enough for publichealth to monitor and research thesechanges – we need to challenge them!

David Allen

How to getinvolved andhelp a SIG grow

I WAS involved in the first meeting of theSexual and Reproductive Health SpecialInterest Group (SH SIG) and from that wasinstantly involved in its work. The firstmeeting had support from FPH for theadministrative work, but this changedshortly afterwards as FPH was unable tocontinue to provide support as the numberof SIGs grew. It became apparent thatwithout some help, the SH SIG would

flounder, as all the members wereextremely busy and under pressure in theirday jobs. So I stepped in and began towork under the exciting title of‘coordinator’.

Although I had done some work onsexual health topics both before andduring my work as a speciality registrar, Ihad no clinical background or any expertisein sexual health. However, I have learnt agreat deal in a short period. As well asissues relating to sexual health, it hasincluded navigating the structures andpolicies of FPH and trying to build the SHSIG membership and increase its presenceamong members and professionalsworking in the field. I have also been ableto work with SIG members to developarticles for the newsletters and briefings,and listen in to discussions on a range oftopics from PrEP to commissioning services.

We have achieved a lot in a short spaceof time. In around 18 months we havedoubled our membership, had a poster atthe FPH annual conference in Telford, putout two newsletters and one professionalbriefing on sex and relationship education.The work we have undertaken is allavailable on FPHs website at:http://bit.ly/2FM9XOz

As well as enjoying the work and

interactions with members and theprofessional development in sexual andreproductive health issues, I have also beenable to add a great deal to my ePortfolioand competency development. This workbalances leadership, writing forpublications, policy development andprofessional development. We have alsoreceived a great deal of positive feedbackfrom the members of the SIG and thewider FPH members on the publications wehave undertaken.

The SH SIG continues to grow and twonew professional briefings are planned thisyear on Modern Slavery and Sexual Health,and Adolescent Sexual Health. We at theSH SIG continue to discuss new ideas toimprove our outreach to the widermembership to support your work.

If you want to get involved with the SIG,or have any ideas for possible topics forour professional briefing, or just want tobe added to our email list for newsletter,please do not hesitate to contact me.

Megan HarrisSpeciality Registrar in Public Healthmeganharris@nhs.net

For further information on FPH SIGs, go towww.fph.org.uk/special_interest_groups

ENDNOTES

In memoriam

Gary Black HonMFPH1949 – 2017

Gary Black lived in Clover, North Carolina,USA and was a Public Information Officerfor Mecklenburg County, retiring in early2016. Gary and I, representing theAmerican Public Health Association(APHA), worked many hours and formed aproductive partnership with the then FPHPresident, John Ashton, and FPH memberUy Hoang as we forged on to establish thepopular film festival component at the FPHannual conference. Gary attended FPHconferences, led sessions and lent advicerelated to capturing compelling stories onfilm for the purpose of promoting publichealth. He was the co-founder of theAPHA Global Public Health Film Festivalwhich served as a model for three filmfestivals established in the UK: FPH’s, thePublic Health Film Society’s in Oxford andthe Royal Society of Medicine’s GlobalHealth Film Festival.

FPH President John Middleton says:“Gary was a great public health advocate,an enthusiast for film, a great colleagueand a friend to the United Kingdom.”

FPH CEO David Allen adds: “Every nowand again we are lucky enough to meetsomeone special – someone who has the capacity for wonderful things, to cheer us, support us and who asks fornothing in return. Gary was one suchperson.”

While Professor Ashton recalls: “Garywas a very special man. Evocative of allthat was best about the 1960’s: ‘Peace and Love’.“

I knew Gary to be a grassroots, roll-upyour sleeves advocate, who propped-upthe reluctant and cheered the needy. Heencouraged them to tell their stories inhopes of creating change and improvingtheir lives and others. This is a continuingstory for all of us in this profession. Thestory continues; the show must go on.

Pamela Luna

Basil Hetzel FFPH1922 – 2017

Basil Hetzel was born in London toAustralian parents. After an education inAustralia and then abroad, he became amedical pioneer, with impacts so influentialthat he was awarded Companion of theOrder of Australia.

He studied medicine in Adelaide, goingon to become a Fulbright Research Scholarin the 1950s, which included anappointment at New York Hospital and aResearch Fellowship at St Thomas’ Hospitalin London. His first job was as a houseofficer in a mental health hospital (laterbecoming a founding member of the SouthAustralian Mental Health Association).

He was the University of Adelaide’sProfessor of Medicine and then FoundationProfessor of Social and Preventive Medicineat Monash University in Melbourne, beforejoining the Commonwealth Scientific &Industrial Research Organisation as the firstChief of Human Nutrition. At timesstationed in remote areas of Papua NewGuinea, he and his team established theeffect of iodine deficiency as a commoncause of brain damage, stillbirths andfoetal growth retardation. As Director ofthe International Council for Control ofIodine Deficiency Disorders he worked totranslate the scientific and clinical findingsinto effective preventive public healthpolicy on dietary iodine supplementation.

Basil’s work led to the research facility atthe Queen Elizabeth Hospital, Adelaide,being named the Basil Hetzel Institute forTranslational Health Research. In May 1992,he was appointed Lieutenant Governor ofSouth Australia and elected Chancellor ofthe University of South Australia. He wasgiven the Prince Mahidol Public HealthAward and awarded FPH’s Alwyn SmithPublic Health Medicine Prize in 1993.

Timothy Stamps FFPHM 1936 – 2017

TIMOTHY Stamps’ remarkable career tookhim from his early life in Wales to becomeMinister of Health for Zimbabwe from1986 to 2002. Despite being the onlywhite minister in Robert Mugabe’s cabinetfor much of that time, he was able toachieve a great deal to improve healthcarefor the people of Zimbabwe. However, hisrefusal to distance himself from theregime’s worst excesses brought him muchopprobrium internationally and he wasbarred from visiting the EU.

Timothy qualified from Cardiff medicalschool, having been active in left-wingstudent politics, and emigrated to whatwas then Southern Rhodesia in 1962,working in the public health service. In

1970 was appointed chief medical officerfor Salisbury, today’s Harare, only to besacked four years later for trying too hardto improve healthcare provision for blacks.

He worked on a number of communityprojects, becoming a fervent advocate forcitizen’s rights. This soon led him intopolitics as a city councillor and in 1980 hestood as an independent parliamentarycandidate for the Kopje seat in centralHarare against Ian Smith’s Rhodesian Frontparty. He lost but gained important friendsin Mugabe’s ZANU party.

In 1982 he won a $2 million grant to setup a cooperative dairy farm giving work andhomes to 2,000 blacks, an initiative thatwon him international recognition. Threeyears later Mugabe made him an MP andminister of health and child welfare. Among

his many achievements was theestablishment of health centres in everydistrict in Zimbabwe and the setting up of anational agency for AIDS which had infecteda quarter of the sexually active population.

Timothy’s international reputation wastarnished when he actively defendedMugabe’s seizure of white-owned farms in2000. He stepped down as minister in2002 after a stroke.

In 2016 he wrote to this magazine tocomplain that a piece by Baroness Kinnockabout water and sanitation in Harare hadgot the facts wrong. Interestingly, forsomeone who had built his career onpolitical activism, he also criticised FPH forallowing itself to be used as a vehicle forpolitical comment.

DeceasedmembersThe following members havealso passed away:

Allison Thorpe MFPH Charles Camm FFPHDouglas Paton FFPH John Charlton HonMFPHMichael Ashley-Miller CBE FFPH

18 PUBLIC HEALTH TODAY

ENDNOTES NOTICEBOARD

FPH Annual General Meeting

The 46th Annual General Meeting (AGM)of the Faculty of Public Health will be heldon the morning of 7 June 2018 at CityUniversity, Tait Building, NorthamptonSquare, London, EC1V 0HB.

The AGM will note the admittance ofnew members and fellows to distinctionand honorary grades of membership, prizeand award winners, election results andthe composition of the Board for 2018-2019. It will also receive the FPH annualreport and accounts for 2017 and reportsfrom the officers on the first half of 2018.

Elections

n Dr Stephen Watkins has been elected asVice President for Policy for a term of threeyears from the AGM on 7 June 2018.n Professor Neil Squires has been re-electedas International Registrar for a second termof two years, again from the AGM.

A number of vacancies will arise from theAGM for faculty advisers, deputy facultyadvisers and CPD advisers across the Englishregions. Details of the vacancies, includingpost descriptions, are available on the FPHOnline Members’ Area or from CarolineWren (carolinewren@fph.org.uk, 020 36961464). Nominations close on 3 April 2018.

New publichealthspecialists

Congratulations to the following onachieving public health specialtyregistration:

UK PUBLIC HEALTH REGISTER

Training and examination routeEmily Parry-HarriesGerald TompkinsIan DileyJudith StonebridgeKathryn CobainKathryn IngoldKaty ScammellKeith AllanMartin SeymourMartine UsdinSarah TunnicliffShannon KatiyoStuart KeebleConall WatsonJohn Mair-Jenkins

Defined specialist portfolio routePaula Hawley-EvansLaurence GibsonMuhammed KhanPhilippa PearmainLiz PetchTom FrostDianne DraperDenice Burton

GENERAL MEDICAL COUNCIL REGISTER

Katharine WarrenDaniel TodkillRachel MearkleKate MandevilleCatherine MbemaTazeem BhatiaLilianganee TelisingheRobert AldridgeShamil HaroonJames ElstonEsther Curnock

Have you started thinking aboutyour annual CPD return yet?

THE end of the continuing professionaldevelopment (CPD) year approaches and sonow is the time to submit your annual CPDreturn for 2017/18. This is the return thatstates how many CPD credits you will beclaiming for the period 1 April 2017 to 31March 2018. Your return is due to reachFPH no later than 30 April 2018.

FellowsCristina RenziJoanna LeungRoberto DeBono

MembersAnkush MittalCaroline TaitDavid SmithHarriet EdmondsonHendramoorthy

MaheswaranJohn Mair-JenkinsLaurence GibsonLiann Brookes-Smith

Diplomate MemberShuk Mui Lai

Specialty RegistrarMembersAhimza ThirunavukarasuAlice KadriBeverley GriggsBronagh ClarkeDanielle SolomonEmily RobinsonFiona MaxwellGrace GroveHannah BarnsleyHannah JaryJennifer ClynesJessica JarvisJulia DarkoKathryn ClareKirsty BellLaura StollLouis Hall

Louise SweeneyMalcolm MoffatMegan Emma GingellMichael AllumNatalie DaleyRobert GreenRooah OmerSally O’BrienSamuel HaywardSarah Hanae ReevesSmita Nagmoti

PractitionersBriege LaganEdwin Larry Panford-

QuainooJonathan HerbertPeter HudsonRachel McIlvennaRussell Sinclair

InternationalPractitionersArif AzadGeoffrey ClarkGeorge Duke MukoroJabulani NyenwaMohamed AbdallaTerna NomhwangeWingTung HoYvonne Powell Campbell

Student MembersAdam JonesAli BlatcherArmida GunzonBernadette GallagherCalum Barnetson

Charlotte NorthinDorothy Jane Maria TerhuneEimer McGuckianElsie Ososese UgegeJun Tian WuMey AlfadilOlujimi Olusola AinaRachel Louise HepburnRamia JameelRebecca CudworthRhea Danielle SnounouVictoria Rice

AssociatesAngela Turner-WilsonAnna GouldingCatherine HuntleyCatherine PrattChidi ChimaChris RamsdenChristopher ExeterDeborah HarringtonImo-Obong EmahJessica OrmerodKaren NicolsonKaren ThomasLorna Isabela HallLynne WalkerMichelle Graham-SteeleMolly AgarwalOliver Jackson-AgerPhilippa ParrettRajeev RajaRoger NascimentoSimone ReillySindisile DubeSultan CetinerVickie Braithwaite

Welcome to new FPH membersWe would like to congratulate and welcome the following new members who wereadmitted to FPH between September 2017 and January 2018

WINTER 2017 19

NOTICEBOARD

Letter

THE article on vaccination (Debate: Shouldchildhood vaccinations be mandatory?Public Health Today Autumn 2017)mentioned that Wakefield’s article had

been discredited and its findings refutedbut omitted to mention that they wereactually fraudulent, not just wrong1 andthat he profited personally from theallegations about MMR2. The many issueshave been summarised3.

1. Deer B. How the case against the MMRvaccine was fixed. BMJ. 2011; 342:c5347https://doi.org/10.1136/bmj.c5347 2. Deer B. How the vaccine crisis wasmeant to make money. BMJ. 2011;342:c5258https://doi.org/10.1136/bmj.c52583. Rao TSS, Andrade C. The MMR vaccineand autism: Sensation, refutation,retraction, and fraud. Indian J Psychiatry.2011; 53(2):95-96. Doi: 10.4103/0019-5545.82529

Jenny Mindell FFPH

© Alan Maryon-Davis