When two government advisers threaten to resign, we should perhaps take notice.
Last week a senior government advisor quit, and a second threatened to resign from the advisory committee he chairs, if Public Health England (PHE) does not end its newly announced partnership with the charity Drinkaware. Undoubtedly, both the leadership of PHE and these highly respected professors want to reduce the harms of alcohol, so why their diametrically opposed views?
The new campaign, called Drink Free Days, encourages middle-aged drinkers to have at least two alcohol-free days each week. Nothing wrong with that. The controversy is over PHE’s partnership with Drinkaware itself.
Who is Drinkaware?
The Drinkaware Trust is an alcohol education charity. Whilst it is “independent”, it receives substantial funding from alcohol producers, pubs and other retailers of alcohol (including supermarkets). Its website appears in the bottom corner of most alcohol advertisement in the UK. A quick review of its 11 trustees reveals that, while Drinkaware may be ‘independent’, four of its trustees might be said to have ‘conflicts of interest’ – three have had senior roles in the alcohol industry, and another is a senior figure at a supermarket.
What is PHE’s justification for the new partnership?
PHE are very aware of the issues around working with Drinkaware. On their blog, they argue that they have a strong track record of working with industry partners to encourage healthier lifestyles at a population level.
So, what’s the issue? If the drinks industry is happy to help finance a campaign to encourage healthier lifestyles, why not accept their money?
Let’s consider a different public health issue. It would be very different if we were talking about increasing physical exercise and PHE decided to partner with gyms or manufacturers and retailers of sportswear. In that case, there would be a confluence, rather than a conflict, of interests. Both the ‘exercise industry’ and PHE want people to exercise more – PHE because it is good for people’s health and the industry because they may be able to sell more products and increase their profit. Everybody wins!
Tobacco, alcohol and food
When you consider the three main unhealthy risk factors in society – tobacco, alcohol and excess food – it’s clear that they are very different. In a nutshell, tobacco is the single greatest cause of preventable illness and premature death in the UK and there is no safe level of use. Alcohol is a major cause of premature death, but the harms of low-level drinking are minimal. Obesity is a major public health problem, but everybody needs to eat food – it is only excess consumption that is dangerous.
So, clearly, they need different approaches to public health policy, which need to be sufficiently nuanced to recognise these differences.
Tobacco Industry Funding – a clear code of practice
When it comes to tobacco cigarettes, there is no safe way to smoke. The British Doctors Study showed that on average smokers die 10 years earlier than non-smokers.
Over 170 countries (including the UK) have passed laws excluding the tobacco industry from influencing public health policy.
The two distinguished advisers, who spoke out about PHE’s Drinkaware partnership, Professor Sir Ian Gilmore and Professor John Britton, note that the tobacco industry has a history of using “voluntary agreements and other partnerships with health bodies to undermine, water down or otherwise neutralise polices to reduce consumption.” CRUK goes further – it believes that no form of association with the tobacco industry is acceptable. “The tobacco industry have funded research which is used as part of lobbying strategies to block, amend and delay effective public health policy”. And CRUK’s code of practice states that it will not provide financial support to those supported by tobacco industry funding.
The World Health Organization (WHO) hold a similar position, stating “There is a fundamental and irreconcilable conflict between the tobacco industry’s interests and public health policy interests”.
There is good reason for such a stance. You may not be aware, but Volkswagen was not the first company to cheat emission testing. Long before there were concerns over car emissions, the tobacco industry had devised a way to trick the testing used to measure tar in cigarettes. They were deliberately falsifying results to make their products look less dangerous then they really were. It is no wonder then that the WHO, CRUK and many universities will not collaborate with anyone who accepts money from the tobacco industry.
The risks of alcohol
Alcohol is not nearly as dangerous as tobacco. According to the Office of National Statistics, there were 7,327 deaths from alcohol in the UK in 2016. But that compares to an estimated 100,000 deaths attributable to smoking. And whereas all smokers suffer harms from their habit, most deaths attributable to alcohol occur in heavy drinkers. Recent research suggests that the risk to light drinkers is low. Someone who has one drink a day reduces their life-expectancy by just 1 day (compared to a teetotaller).
But the health problems due to drinking are not all fatal. NHS Digital estimate that in 2016 there were 1.1 million hospital admissions linked to alcohol. This represents 7.0% of all hospital admissions. And not all those hospitalised will have been the drinker – some 9,000 people were killed or injured in a car accident involving alcohol.
The Institute of Alcohol Studies have found that two-thirds of alcohol sales are to heavy drinkers and that if everyone complied with the Chief Medical Officer’s recommendations on alcohol consumption, there would be £13 billion less sales. It is difficult to see how an industry that relies on sales of alcohol to maximize profits for its share-holders can seriously support measures to dramatically reduce the harms to the public of heavy drinking.
Salt and Sugar
When it comes to food, however, the landscape is very different. Two of the most harmful elements of the modern diet are high sugar and salt content.
Consider salt: consuming too much puts you at risk of high blood pressure which in turn increases your risk of stroke, heart attacks and heart failure. But unlike tobacco and alcohol, few companies make much profit specifically from selling salt. If food manufacturers could reformulate their products so that they had less salt but were considered just as tasty, they could contribute to improving public health without reducing sales or losing profits. Thus, Action on Salt’s mission is “to work with the government and the food industry to gradually lower salt intake in the UK to below the recommended maximum level of 6g a day.”
It’s an approach that appears to be working: The Food Standards Agency has introduced voluntary salt targets and there has been a 10% reduction in UK salt intake, saving an estimated 6000 lives each year.
Action on Sugar is now taking a similar approach, working with the food industry and government to reduce the amount of sugar in processed foods. Here too there are signs of early successes, but the problem of sugar and obesity is far from solved. Many experts think that voluntary approaches need to be reinforced with regulation and penalties for those who make no effort to meet the targets. Action on Sugar are supportive of taxes on sugary drinks and have urged for legislation banning the promotion of confectionary.
So what about PHE and Drinkaware?
It is probably because of the success of Action on Salt and to a lesser extent Action on Sugar, that PHE think that a similar approach will be successful for alcohol. But the contexts, confluences and conflicts are altogether very different here. Perhaps that’s why PHE are partnering Drinkaware rather than working with the drinks industry directly.
According to the BBC, dozens of public health experts have told PHE that the tie-up “will significantly damage the credibility of PHE”. But PHE says that it stands by its decision. They point out that “Drinkaware is not the alcohol industry” and are confident that they will influence Drinkaware, not vice versa.
So the question is, when it comes to public health policy should alcohol be treated more like tobacco or is it more like sugar?
Update (20 Sept 2018)
Following Prof John Newtons defense in the Guardian of the partnership between PHE and Drinkaware “We didn’t make a mistake. We are very sorry that colleagues disagree with us on this topic. Public Health England’s independence has not been damaged one iota by this.” The BMJ has published an editorial by professors Gilmore, Bauld and Britton in which they set out their position: “Through Drinkaware, the alcohol industry gains valuable engagement with PHE, establishes working relations with PHE staff, and may even secure a seat at the table when other alcohol harm initiatives are planned and executed. In so doing they tread a path that, at least to those who have worked in tobacco policy, is depressingly familiar. It is right that the alcohol and other harmful commodity industries pay to prevent and treat harm caused by their products, but payment must be made through statutory levies not voluntary agreements.” The BMJ editorial is accompanied by an opinion piece and a feature that discus in more detail why public health professionals are split over the issue.
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The views expressed are those of the author. Posting of the blog does not signify that the Cancer Prevention Group endorse those views or opinions.