Richard Smith: What to do about binge drinking?

Richard SmithEarlier this week I attended a lunch in an expensive London restaurant where a motley collection of people discussed what to do about binge drinking. Alcohol was served, but I felt duty bound to decline (and I was cycling). The lunch was sponsored by an alcohol company, and they must have been well pleased with the confused result. (Chatham House rules applied.)

The British population—and certainly the people at the lunch—are much bothered about binge drinkers and much less concerned about their own drinking. People don’t like drunken youths vomiting on their lawns on Saturday nights while they sit in their houses pickled to the eyeballs on Chateau Demimonde and more likely to fall asleep than pick a fight.

But what is binge drinking? One medical definition is drinking more than twice your daily allowance in one go (about four pints of beer for a man and three for woman). Another definition is drinking to intoxication, and by either definition those stewed in Chateau Demimonde may be binge drinkers as well as their teenagers now copulating on the lawn. Indeed, they may well have put away more than the teenagers. Another “difficulty” with this definition is that alcohol consumption is falling, particularly among the young, when many people egged on by the Daily Mail perceive binge drinking as a growing problem.

The think tank Demos, which has produced a report on binge drinking (also sponsored by a drink company), prefers to define binge drinkers as “young adults that drink to extreme excess, often in an intentionally reckless and very public way, putting themselves and others at risk of harm.” So those outside are binge drinkers, those inside might be called “responsible drinkers.”

The lunch was prompted by the Demos report, and the speaker who started the discussion saw three broad strategies for controlling binge drinking: pricing, policing, and parenting. Pricing he thought to be the least effective, which it might well be. Increasing the price is the single most effective intervention for reducing all alcohol harm (including the incipient cirrhosis of the Chateau Demimonde drinkers), but I concede that we may not have convincing evidence of its effect on binge drinking.

Policing he thought to be more effective, but he worried that the police have “tacitly accepted” binge drinking and that it has become “normalised.” He liked the idea of the police talking firmly to drunken youngsters and possibly scooping them up in a “booze bus” and delivering them to an alcohol recovery centre. At least then they wouldn’t clog up A and E.

Parenting was the favoured response. “Tough love” is the preferred mode, which I always think of as “leaving your child at the bottom of the stairs when she falls down them drunk.” Let them sleep in their own vomit. Certainly you shouldn’t get sloshed in front of your little ones, and perhaps you shouldn’t have alcohol in the house. I asked my 20 year old daughter who is studying sociology what she thought of tough love, and—surprise, surprise—she was against it. A much older sociologist at the lunch said that it was fashionable to blame parents for everything and that there wasn’t good evidence of the influence of parenting.

After the clear but disputable talk the lunch descended into babble. I like to think of myself as post-modern—recognising that there is not one truth but many and that there are many ways to think about the world, none of them intrinsically superior—but in this group I came across as a hard boiled rationalist and reductionist.

Many people didn’t see overall alcohol consumption as a problem. Most were against “nannying.” Some were “nudgers,” and one man complained that “the Guardian readers who went on about alcohol problems were the same people who were attacking Rupert Murdoch.” He must have imagined that he was among Murdoch supporters, and perhaps he was.

My brief tirade was not welcomed. I suggested that the organisers of the lunch had been captured by their sponsors and that it was not helpful to focus on binge drinkers, alcoholics or whatever rather than everybody, including as one of the sponsors put it, “the 99% of people who are responsible drinkers” (all of us sat round the table). Alcohol is a delightful but also lethal substance, probably killing more people in Britain prematurely than smoking. But most of the problems associated with alcohol are social rather than medical: domestic violence, absenteeism, family breakdown, accidents, suicide, homicide, financial problems, and so on. There is no doubt, I lectured, that an increase in alcohol consumption in a society or community leads to an increase in those problems, and probably an increase of x in consumption causes an increase of x2 in problems. Increasing the price brings down consumption and the problems. My final flourish was to say that I was sceptical of the received wisdom that a little alcohol is good for you.

Two women from the drink trade got in the last words, pointing out that Britain has the “fourth highest tax on alcohol in Europe” and that they have built a website to encourage responsible parenting. I’d better go and learn from it.

Competing interest: RS is generally believes that the private sector has an important role in preventing and controlling non-communicable disease, but he’s sceptical that the drink trade can help. His lunch—mozarella and tomato, chicken with fried potatoes, and three bites of desert—was paid for by a drink company. He doubts that they will think it money well spent. He was a member of a Royal College of Physicians working party on alcohol in the 80s, has written a book on alcohol problems, drinks more in a week than the recommended limits, and occasionally binges. As a medical student he binged regularly, sometimes while on call.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.