In England last year, the total volume of duty paid alcohol (or “booze” to you and me) was 1.2% less than the year before the COVID pandemic, which is good news. Some of us, at least, are drinking less.
The volume of duty paid wine and spirits rose by 8.9% and 7.3%, respectively, whilst beer and cider fell by 16.7% and 14.7%. Facetiously; good news for the whiskey distillers and vineyards, but bad news for breweries. Behind the statistics, however, there is a more troubling picture. Beer and cider tend to be sold in “on trade” settings, meaning, pubs, bars, and hotels; and these were all shut during the pandemic. “Off-trade” sales rose by 25%, so what everyone suspected, turned out to be true. We all stayed at home during the lockdown and consoled ourselves with alcohol. (1)
This, however, is not the whole picture. Public Health England analysed the figures for the previous two years, dividing drinkers into five separate groupings based on the volume of alcohol purchased. The group with the heaviest consumption of alcohol increased their purchasing by 5.3 million litres of alcohol, which is a 14.3% increase, and accounted for 42% of the extra volume of alcohol consumed. When combined with the next highest quintile, this rose to 62%. So, the 40% of the population that were already big drinkers, accounted for the majority of the increased consumption, which they did at home, instead of in the more social context of licensed premises.
I think we must be careful not to be judgmental, or over extrapolate. What the figures tell us is that the UK population was hugely stressed by COVID, that the social impact was profound, and that for a significant group of people this resulted in increased drinking. As we return to more normal conditions and more social drinking patterns, hopefully, those figures may start to correct. Such are the numbers involved, however, that if a small number of people do not go back to pre-COVID levels of drinking, then the impact on alcohol-related deaths will still be significant.
The overall picture of liver-related deaths in the UK is not good. Liver disease accounts for 10% of deaths in adults between the ages of 35 and 49 years and is now the biggest cause of ill health in that cohort. This is particularly significant because the years between 30 and 50 are when we have our children, raise our families, and are potentially at the most productive period of our careers. The trends are perhaps even more significant, with a 30% increase in liver deaths since 1970, at a time when deaths from most other causes, have been falling. (2) It is surprising then that liver disease is still not a priority for the Westminster Government. Health policy determined at Westminster only affects England because health is a fully devolved issue for Scotland, Wales, and Northern Ireland. The UK Government, however, still controls fiscal policy, including excise taxes and VAT. Unlike Scotland and Wales, England still has no minimum net pricing policy and it is currently unlikely to be introduced in the near future. As a result, it is still possible to purchase a 2.5-litre bottle of cider containing 19 units of alcohol for just £3.59, around 19 pence per unit, meaning that in theory, a full week’s 14 units would cost £2.66, about the cost of a cup of coffee. (3)
The issues around minimum pricing are similar to those deployed 30 years ago around smoking, and even reflect some of the controversies surrounding COVID, civil liberties, and lockdown. There is always a tension between personal liberty, the right to smoke, drink, eat or COVID oneself to death, against the need for public health and safety. Smoking affects other people through passive smoking and damage to the fetus. Alcohol also damages the fetus and affects others through accidents, drink driving, and the use of NHS facilities. As health professionals, we tend to rank public health over personal liberties, but governments do not always see it that way. To make progress, we must justify our viewpoint and arguments, based on facts, and we must also increasingly counter deliberate falsehoods that are spread through social media.
Talking down to the public and adopting a “holier than thou” attitude will not win the battle. About 5% of doctors are estimated to fulfil the criteria for alcohol dependence. 44% of us binge drink and 8% of us probably have a binge eating disorder. (4) We need arguments tempered by empathy and understanding for our patients, as well as a fresh acknowledgement that we as a profession also have problems.
Last month, the BSG Executive and Council considered the issue of alcohol at BSG events. The BSG overwhelmingly wants to encourage responsible drinking, but we also have to set a good example. It has therefore been unanimously agreed that the BSG will not serve alcohol at its dinners and events. Members can buy alcohol if they wish and we will provide non-alcoholic alternatives for our guests, but we will not buy alcohol for them. The decision was unanimous which surprised me. It is a small measure, no pun intended, but it states an important point.
A retired colleague of mine would often say, “Facts are chiels that winna ding, an downa be disputed.” With the greatest respect to my former colleague Ashley Mowat, I have only recently discovered that he was quoting Burns. Roughly translated it means, “facts are things that will not be overturned and cannot be disputed”. To argue the case for liver disease, we need data, which is why the BSG wholeheartedly supports the new British Liver Alliance and its Chair, Pam Healy of the British Liver Trust, and our own Professor Phil Newsome, who recently stepped down as VP for Hepatology.
Politicians are not always influenced by facts and are accomplished masters and mistresses of the body swerve. In the long term, as much as people may try to avoid the issues, solid data and evidence-based facts, remain the unmovable rocks that cannot be overturned.
When I talked to Pam Healy recently, I was interested in how optimistic she feels that this is the right time to make an impact on liver disease, and public attitudes. By making sure, for example, that Trusts and Boards have proper pathways to let people get to specialist care quickly. The figures on alcohol and lockdown are a bit grim, so would it be better to wait until life returns to normal before we make our case?
The full quote from Shakespeare’s Julius Caesar is: “There is a tide in the affairs of men (and women – my parentheses) which taken at the flood leads on to fortune.”
When it comes to liver disease, we are at the flood. Let us seize the day!
(1) Public Health England. Alcohol consumption and harm during the COVID-19 pandemic. 2021; Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1002627/Alcohol_and_COVID_report.pdf. Accessed 07/30, 2021.
(2) British Liver Trust. Key Statistics: The rise in deaths from Liver Disease compared to other major diseases. 2021; Available at: https://britishlivertrust.org.uk/about-us/media-centre/statistics/. Accessed 07/30, 2021.
(3) Alcohol Health Alliance. Small change: alcohol at pocket money
prices AHA pricing survey 2020. 2021; Available at: https://ahauk.org/resource/small-change-alcohol-at-pocket-money-prices-aha-pricing-survey-2020/. Accessed 07/30, 2021.
(4) Medisauskaite A, Kamau C. Does occupational distress raise the risk of alcohol use, binge-eating, ill health and sleep problems among medical doctors? A UK cross-sectional study. BMJ Open 2019 British Medical Journal Publishing Group;9(5):e027362.