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Wednesday, 13 January 2010

Answering the neo prohibitionists, 5 of 10: “Alcohol related hospital admissions - and the cost of alcohol to the NHS – are soaring”

This is the longest, most detailed and technical post of the ten. If you’re not too interested in detailed liver cirrhosis stats, take a quick scan of the sub-heads then go to the summary. But I wanted to put all this out there for the record. Christ, it’s taken me long enough to work out – I don’t want it to go to waste.

Firstly, another caveat: I have no desire to trivialise the burden alcohol abuse places upon the NHS – I know someone who used to work in casualty on a Friday night and she was deeply traumatized by what she had to deal with. I recognise that there’s an issue here. And for the record, I love the NHS – it’s one of the things that makes me proud to be British. I intend no disrespect to the people who have to clear up after drunks and stitch some of them back together.

But there several points that need answering around the whole issue of the size of the burden alcohol supposedly places on the NHS. I can’t say what the true figures are in this – I don’t know. My intention here is merely to cast reasonable doubt on the figures that are quoted, and to suggest that the true cost of alcohol to the NHS is being overplayed. But I can’t say by how much.

(i) The difference between partial cause and total cause

Figures for alcohol-related hospital admissions are bandied about and roughly estimated by the people giving evidence to the report, and then taken as fact by the time the Report is published.

In terms of official figures, what they don’t tell you is that when they are compiled, there's a sharp difference between hospital admission and deaths that are considered wholly attributable to alcohol, and those where alcohol is a secondary or partial factor. And guess what? Only 25% of total ‘alcohol related’ hospital admissions are judged to be entirely due to alcohol.

In the rest, alcohol is one of several factors. In these situations, who is to say whether or not alcohol was the thing that tipped the balance or not? If someone is admitted with high blood pressure or heart attack and they drink heavily, smoke heavily and eat chips every meal, alcohol is part of an overall pattern that’s clearly rooted in a lifestyle. But their condition is still be counted as ‘alcohol related’

To get over this, NHS analysts have come up with a system of ‘attributable factors’, where you try to give each element in admissions and fatalities a percentage of the total cause, to get to an overall statistic. If I had a year to work on this, I might be able to figure out how this works. After spending half a day on it, I only hope someone else with a better statistical background than me can take up the challenge.

(ii) ‘Passive’ alcohol abuse: the difference between correlation and causation

(At this point I’d like to give huge props to Phil Mellows, a longstanding drinks industry journalist and fellow anti-neopro campaigner, who highlighted this point in a recent blog post here.)

This question of partial versus total causes gets more complicated and inflammatory when we look at the secondary effects of alcohol abuse and how alcohol’s contribution to these is weighed.

Here are three quotes from the Report:

“The passive effects of alcohol misuse are catastrophic—rape, sexual assault, domestic and other violence, drunk driving and street disorder—alcohol affects thousands more innocent victims than passive smoking.”

“Heavy drinkers are more than twice as likely to commit suicide as non-drinkers. Between 16 and 45% of suicides are thought to be linked to alcohol and 50% of those ‘presenting with self harm’ are regular excessive drinkers.”

“Alcohol [is] a factor in 40% of domestic violence cases, 40% of child protection cases, and 74% of child mistreatment cases.”

By stating these ‘facts’ without giving them any further analysis, the Report is implying that if you drink, you are more likely to be a rapist, a child abuser, a wifebeater, a suicide, and that the fact that you drink makes you so. As Phil pointed out when he addressed the rape issue, this is not only inaccurate, it is astonishingly offensive to drinkers.

It willfully confuses causation (alcohol made them do it) with correlation (they happened to drink a lot and they also happened to do this). Let’s be careful here: I’m not disputing the fact that suicides, wifebeaters etc are more likely than average to be heavy drinkers. But there are no grounds whatsoever to say that alcohol consumption led directly to their appalling behaviour.

I’m no psychologist, but based on both personal experience and common sense, I would suggest that in many cases, alcohol abuse and domestic violence/attempted suicide etc are both symptoms of a deeper underlying condition or issue.

Sure, the alcohol doesn’t help. But when someone does something appalling and then says, “The drink made me do it,” they are denying personal responsibility for their actions and we tend to dismiss this as a lame excuse. The Report seems to buy it 100%.

Added to this personal speculation, when you look at studies into the social effects of alcohol on a global, scientifically sound level, such as those carried out by Dwight Heath at Brown University, there is no direct causal link between violent and dysfunctional behaviour and alcohol consumption. If there were, the Czech Republic would have much worse rates of anti-social behaviour, drunk driving, domestic violence etc than the UK, because that population drinks significantly more than we do. But they don’t. Alcohol abuse is a symptom of something else – not a cause.

We can demonstrate that this is true by looking at the body of the Select Committee Report itself, and the evidence given to it by the BMA.

Here’s what the BMA says about the relationship between alcohol consumption and class:

“Individuals in managerial and professional occupations are more likely to have drunk alcohol in the previous week, and to drink more frequently than those in routine and manual occupations.”

And here’s what the Report says about the relationship between alcohol abuse and class:

“People from lower socio-economic groups were more harmed by a given level of alcohol consumption. In the most deprived areas of the UK, men are 5 times more likely and women 3 times more likely to die an alcohol related death than those in the least deprived areas.”

If alcohol is a cause of these problems, how can both statements possibly be true?

If alcohol consumption was the cause of dysfunctional and anti-social behaviour, most people fighting on a Friday night, beating their wives or children or committing suicide would be managerial or professional people. They’re not.

And if people from a lower social class are more likely to be harmed by a given level of alcohol consumption, then it is patently obvious that alcohol is not the issue – it’s something else that goes with being a member of that class. That’s logic that even a child could understand – but the Committee chooses not to.

(iii) The issue of liver disease, particularly liver cirrhosis

To be clear: it would be foolish to argue against the simple fact that alcohol misuse is one of the main causes of liver disease, and that figures for liver disease and liver cirrhosis in particular are increasing. Even in countries that don't share the alleged link in the UK between heavy alcohol consumption and crime, violence, anti-social behaviour etc, those that are heavy consumers of alcohol tend to have higher rates of liver disease.

But claims such as "The WHO has put alcohol as the third most frequent cause of death after hypertension and tobacco" cannot go unchallenged. It completely mixes up factors contributing to death with cause of death. Otherwise, what is 'death by alcohol' exactly? And are we honestly expected to believe that it causes more deaths than heart disease? Than cancer? Globally, are we expected to believe it causes more deaths than malnutrition or Malaria? Really?

The truth is that 1.3% of deaths in England and Wales are due to alcohol consumption.

But the Report argues that these are only deaths where alcohol is stated as a cause of death on the death certificate – and it's fair to say it does play a contributory role in other deaths too. But the report then goes on to claim that alcohol consumption is "probably a significant factor in 30 to 40,000 deaths per year.” That ‘probably’ betrays the fact that there is no scientific calculation behind this figure. But naturally, the ‘probably’ and the ‘significant factor’ disappear by the time we get to press coverage, where alcohol is simply ‘responsible for 30-40,000 deaths per year’.

But the biggest health-related story in the report is the shocking rise in deaths by liver disease in the UK over recent decades. Now that is undeniable, and obviously worrying. And given that cirrhosis is caused by long term alcohol abuse, I’m not disputing alcohol’s role in this, given that consumption was increasing over the 1970s, 80s and 90s. But we must acknowledge the link between current cirrhosis deaths and past alcohol consumption.

But there are other factors contributing to liver disease that are being ignored. Firstly, there are various causes of liver cirrhosis. Here’s an estimated breakdown from a health consultancy in the US (I've been unable to find UK figures so far):

Liver cirrhosis can also be caused by fatty liver syndrome, which is the result of a bad diet. When the health lobby or the media choose to attack the obesity epidemic, they are very quick to point out that obesity can lead to liver disease, even cirrhosis. But they neglect to mention this when attacking alcohol.

Why does this matter? Because in the UK, every single death by liver cirrhosis is counted as being caused by alcohol abuse – even if the person was a non-drinker!

When calculating deaths from liver disease, the ONS states, “Very few of the deaths coded to these causes include a mention of alcohol on the death certificate. However they are included in the current ONS definition on the assumption that in England and Wales many of them were caused by alcohol, even if this was not explicitly stated,” and goes on to say “All liver disease deaths where alcohol is not mentioned (other than biliary cirrhosis) should contribute to the count of alcohol-related mortality.”

So the ONS makes a calculation it knows to be wrong, in order to make up for the fact that across the board, alcohol-related deaths are under-reported. But then, the Royal College of Physicians inflates the resulting figure massively, also to account for under-reporting. The alcohol-related deaths that are not on death certificates are being - at least - double counted.

The surge in liver cirrhosis correlates with increased alcohol consumption. But it also correlates with the obesity problem in the UK. I’m not arguing obesity is more of a cause than alcohol consumption. I’m arguing that it is a cause alongside alcohol consumption, as are "autoimmune inflammation of the liver, disorders of the drainage system of the liver (the biliary system), metabolic disorders of iron and copper (hemochromatosis and Wilson's disease), and drugs such as pain-relievers such as acetaminophen and non-steroidal antiinflammatory drugs (NSAIDs), certain antibiotics, antidepressants, anti-cancer agents, and drugs used in controlling high blood pressure, high cholesterol , diabetes, and irregular heart rhythms".

Somewhere in these statistics, the Beer Widow’s Uncle George is being counted as having drunk himself to death, despite the fact that he died of liver cirrhosis after being a lifelong teetotaller.

(This sounds like a bit like one of those arguments that smokers make to deny the link between smoking and lung cancer. I'm not trying to deny the link between drink and liver cirrhosis. But while we're comparing the two, as far as I'm aware no one is trying to argue that 100% of lung cancer deaths are smoking related.)

A final point on liver cirrhosis: one of the most disturbing charts from the Report, which has been extensively reproduced, shows cirrhosis rates soaring in the UK while they decline in several European countries. Two points on this:

  • The countries shown were chosen selectively: if you look at the data objectively, death from liver cirrhosis in the UK (6.5 per 100,000) is still considerably lower than in the USA (9.3 per 100,000) or the average for the whole of Continental Europe (10 per 100,000) (Source: the International centre for Alcohol Policies)
  • One of the countries that shows a steep fall in cirrhosis that's almost a mirror image to the UK’s rise is Spain. Per capita alcohol consumption in Spain and the UK is roughly the same. Clearly then, the relationship between cirrhosis and alcohol consumption is not as linear and direct as is being claimed

(v) “The cost of alcohol to the NHS has doubled in recent years”

Radio 4’s More or Less programme demolished this one on January 8th. The claim from the NHS Confederation is that the cost of alcohol abuse to the NHS (however it is calculated, given all we’ve said) doubled between 2001 and 2006.

As Radio 4 calculated: this is based on a report in 2001 that said the cost was £1.4-1.7 billion, and a second report in 2006 that claimed it was £2.7bn (so for a start, even from the very lowest base it's not quite a doubling).

If you adjust these figures for inflation – and take into account cost inflation inside the NHS, which is higher because of the amount of money pumped into the NHS in the early noughties, a figure of £1.4bn equals £2bn in 2006 prices – which would mean an increase in real terms from £2bn to £2.7bn.

However, the people who compiled the 2006 numbers had better information, and claim that the 2001 figure was probably an underestimate. So if you take the upper limit of the 2001 estimate - £1.7bn – and adjust for inflation, you get £2.4bn, meaning a net increase of £0.3bn to get to that £2.7bn figure. Not a doubling at all then, but an increase of 12-13%.

In addition, between the two periods the total percentage of the NHS’ budget spent on treating alcohol remained constant at 3%. Hardly ‘soaring’ then. Hardly a problem ‘raging out of control’.

In summary

Britain does have a health problem in which alcohol plays a part. But the Select Committee Report:

  • Confuses where alcohol is a partial or contributory factor with it being the primary cause
  • Confuses correlation (the presence of heavy drinking) with causation (heavy drinking being the main driver of the problem)
  • Quotes data selectively and partially
  • Wrongly implies that every single case of liver disease in the UK is alcohol related
And the true cost to the NHS is deliberately being deliberately exaggerated.


Crown Brewer Stu said...

keep up the good work Pete!

mentaldental said...

Have you though of going over to There must be someone there who could help with the heavy duty stats stuff.

Anonymous said...

Hi Pete, interesting stuff. Might be worth having a chat with Ben Goldacre
sounds like the clear manipulation of data that went on in this report would be right up his street.

Anonymous said...

Apologies that was the link to my new phone, this is Ben's blog,
I think he's the chap behind the Bad Science net site

Barm said...

This is great stuff Pete. The only teeny criticism I have is that your own graphs and statistics need to be totally watertight so that you can credibly attack spin-laden graphs and statistics. One thing I'm not sure about is the use of US statistics on the causes of liver disease. I can think of at least two factors – the vastly different structure of US healthcare (including the methodology of compiling the numbers) and the vastly different patterns of alcohol consumption – that might very well cause the result to be different if British figures were used. Your point is probably valid, but would be more convincing if data from this country were available.

Pete Brown said...

Barm - you're quite right. My frustration with all this is that all I can do is apply my ability to analyse and read data correctly from my old adman days together with what I can find on Google. I've spent almost a week working on this and I need to get back to earning some money asap! But don't worry - I will be trying to encourage others who are more capable than me to take it on a step further.

Alan said...

Does not the good beer cause have a similar admissions to make? Is there not a concurrent theme needing addressing in the nature of social problems related to alcohol not being admitted by craft brewers.

I trotted out Beer Bloggers Against Drunk Driving last year and was told in emails by a few beer writers that I was not going to be supported as that sort of thing is not positive. But shouldn't CAMRA have an anti-drunk driving message, for example? Maybe it does and I am not seeing it from over here.

Pete Brown said...

Fair point Alan - which is why I'm always very careful to caveat my posts and be very clear what I am and am not objecting to.

As far as I'm aware CAMRA don't really put out any kind of responsible message. I'm sure they'd tell you this is because real ale drinkers are not irresponsible drinkers.

I agree we need to be seen as responsible and find it difficult to argue against responsible drinking messages in drinks advertising (though how effective they are is a moot point). But there are plenty of people out there already putting that message across ands very few challenging the myths, lies and distortions of the neo-pros.

lizvater said...

I hope the All-Parliamentary Beer Group are aware of this work you've been doing. Would be interesting to see what crosses their desks about beer and comparing notes. They might know someone who could help verify some of your analysis too.

Alan said...

I see what you mean, Pete, but without contextualizing your message in healthy and responsible drinking, you can be taken as being merely "anti-anti" as opposed to presenting a vision of what the role of good beer actually is or should be.

John Q. Publican said...

On the general subject of responsibility; while I am slightly surprised that CAMRA haven't published something basic on drink-driving, it's publicans who are the front-line on that one. Apart from having a legal responsibility to promote sensible and safe drinking, we're the ones who can make a difference to the drinker's pocket. Designated driver schemes which make a night out cheap if you stay sober and similar immediate gratification systems need to follow up the huge (and aiui broadly successful) information campaign against drink driving over the last 20 years.

More specifically: Pete, this is a fantastic series. I did want to pick up this, though:

(This sounds like a bit like one of those arguments that smokers make to deny the link between smoking and lung cancer. I'm not trying to deny the link between drink and liver cirrhosis. But while we're comparing the two, as far as I'm aware no one is trying to argue that 100% of lung cancer deaths are smoking related.)

In fact, they are. Usually only the most hysterical end of the passive-smoking lobby, but yes, people do argue that passive smoking is responsible for 100% of lung cancers, whether the victim (and doctors) know it or not. On the other hand, I've had someone turn a hose on me in the street because I was smoking, so...

Anonymous said...

Tremendous information! Will you follow-up on this specific topic?