A review of ‘Drink?: The New Science of Alcohol and Your Health’
Note: all statistics are from the book unless otherwise indicated. The book mainly concerned itself with the United Kingdom, but I think the lessons are broadly applicable to other Western countries too.
The overriding impression I got from reading Drink? by David Nutt is that alcohol is Really Bad:
Alcohol use is one of the top five causes of disease and disability in almost all countries in Europe. In the UK, alcohol is now the leading cause of death in men between the ages of 16 and 54 years, accounting for over 20 per cent of the total. More than three quarters of liver cirrhosis deaths, 7 per cent of cancer deaths and 25 per cent of injury deaths in adults under 65 years of age in Europe in 2004 were estimated to be due to alcohol. According to the government, alcohol is the third leading risk factor for death and disability after smoking and obesity.
Alcohol can also exacerbate mental health problems, especially anxiety and depression. One major American study suggested that up to a quarter of young alcoholics have a social anxiety disorder.
This isn’t a big surprise, of course. What I didn’t realise before, though, is how poorly evidenced the beneficial effects of alcohol are. Looking at the available studies, Nutt writes that the positive effect on cardiovascular health has never been definitely proven (i.e. beyond mere association), and even if there is a small positive effect, the optimal level of consumption would be around one unit a day. The benefits don’t outweigh all the other risks.
The impact of alcohol on the UK is pretty significant. 10.8m British people drink at levels posing some risk to their health, and 1.6m ‘may have some level of alcohol dependence’. Different figures, from the NHS, suggest around 9% of men and 3% of women show such signs (which my back-of-the-envelope calculations suggest would be something like 3.3m people in total). In Ireland, 54.5% of men engage in ‘heavy episodic drinking’, along with 23.3% of women.
It’s estimated that alcohol contributes to 30,000 deaths a year in England, Scotland and Wales, and is responsible for 5% of the global disease burden.
There is enough evidence here to make a strong case against alcohol on a number of grounds (which Nutt himself does not quite do).
Alcohol is a drain on economic growth, damaging productivity and forcing us to spend money on healthcare that could be used elsewhere. The CDC estimated the cost of hangovers to the American economy as $249bn in 2010 [Edit: Readers are correct to point out that this estimate is implausibly high. Bizarrely, Nutt cites this figure as $180bn in the iBooks version of Drink?, but as $249bn in the Kindle version, even though the sentence is otherwise identical. The website he cites estimates $249bn as the total costs of alcohol to America, and $179bn as the cost in terms of lost productivity. The site makes no mention of hangovers.] The Institute of Alcohol Studies estimates a cost of £1.4bn a year for British productivity. (The charity Alcohol Change UK puts the productivity damage at £7bn a year instead.) If you think economic growth is important, then alcohol is not worth the hassle.
Treating the results of excessive alcohol consumption is a huge burden for the NHS. In England alone, around 350,000 hospital admissions per year are mainly attributable to alcohol.
It’s strange that this isn’t talked about more. Polls suggest that the NHS is the one institution that almost everyone in Britain cares about. So why not ease the burden on its workers – and the public purse – by reducing our alcohol consumption?
Alcohol also fuels violence: victims thought their offenders were under the influence of alcohol in 40% of all violent crimes in 2016/17 – that’s half a million incidents. (It’s hard to know how accurate this figure is, but even if it was only 20% of the total, that’s a lot of crimes…)
These figures include sexual violence. Alcohol is the most common date rape drug, involved in 46% of cases, while drugs only featured in 33% and sedative drugs in just 2%.
One in three women have been sexually taken advantage of while under the influence of drugs or alcohol, mostly in private homes by someone they know, according to the 2019 Global Drug Survey. Nearly 90 per cent of these cases involved alcohol.
As Nutt makes clear, the blame lies with the assailants here, not the victims. But alcohol’s role in violence and sexual assault is rarely discussed.
This is, then, the case against alcohol: it undermines our health and our economy, it causes violence, including sexual violence, and it’s an addictive drug that ensnares people across society.
Can the culture of alcohol change?
The evidence here is so damning that I wonder how Nutt can still suggest, in good conscience, that we should still drink (within limits). Some of the arguments he makes in favour of alcohol are ridiculous:
A glass to hold gives us something to do with our hands in awkward situations, particularly now smoking has become so vilified.
He adds that food and socialising, which regularly go hand-in-hand with alcohol, are good things. I agree. But there’s no reason that you can’t drink something non-alcoholic while you enjoy dinner and company. If you really need to hold a glass, must it contain alcohol?
Alcohol is important for social rituals, as Nutt points out:
Nearly all of our celebration rituals revolve around alcohol, from the cradle to the grave. We wet the baby’s head, we toast exam results and birthdays, we crack open the fizz at both wedding breakfasts and divorce parties. And we say goodbye to our loved ones with alcohol at a funeral wake (and drown our sorrows too).
Left unaddressed is the presumption that alcohol is necessary to any of those (good and often great) rituals. It’s not. You can get most (perhaps all) of those social benefits without alcohol. Drinks with friends don’t have to be alcoholic.
It would be very tough to change those cultural norms – although, as Nutt notes, an increasing number of young people are eschewing alcohol altogether. This trend seems to be linked to a greater focus on health and ‘wellness’, although it may also be because people are taking other drugs instead.
Notably, that there are enormous differences in the levels of alcohol consumption around the world. Some of this is because of religious prohibitions on alcohol in Muslim-majority countries, or because many people carry genes that mean they feel flushed and nauseous after consuming alcohol (commonly known as Asian flush). But even among countries with no religious or biological hindrances to alcohol, consumption varies a lot, and Britain and Ireland do unusually poorly on this front.
One might assume that the British (and Irish) have always been habitual drunks. In fact, there has been significant variation in the amount of alcohol British people have consumed over the past few centuries. We’re at (or just after) the peak of a decades-long trend of more alcohol being consumed in Britain. Figures for Ireland are less easy to come by, but you also see the ebb and flow of alcohol consumption over time, including the impact of taxes and the 2008 recession.
Alcohol consumption varies across place and across time, often as a result of policies or moral campaigning. Cultural change is both possible and desirable.
The drinks lobby
Alcohol is regulated with a light touch, in large part due to the cosy relationship the drinks industry has developed with politicians. Nutt relates a sad tale of a cabinet office committee under Tony Blair that proposed new policies to tackle alcohol addiction, but was scuppered by a drinks industry lobbying effort. This is not a surprise:
Despite repeating their message of ‘sensible drinking’ at every opportunity, the drinks industry wants you to keep drinking. That is its reason for existing. One estimate is that, if everyone drank within recommended limits, the industry would lose £13 billion. That’s a lot of lost profit. Its aim is often aided by the government, which wants the tax income.
The government is pretty much in the pocket of this industry, with gifts to MPs in the ‘All-Party Parliamentary Beer Group’ every year and the perceived importance of the tax revenue from alcohol. There is something repulsive about MPs receiving these gifts while alcohol causes so much harm in society. And they are being shortsighted, fiscally:
…it’s been estimated that when you add in the costs of alcohol to society, there is a net loss to the Exchequer. This is undeniably a difficult argument to disentangle economically, and a complicated sum. But the costs of alcohol to society are relatively well established. These are: £3.5bn on health, especially hospital admissions and accident and emergency attendances; £6.5bn for policing drunkenness; £20bn for lost productivity through hangovers. The total is £30 billion.
[Edit: Readers may notice that this estimate for lost productivity due to hangovers is much larger than the previous estimates for total lost productivity in Britain due to alcohol. The editor suspects that David Nutt is carelessly using the phrase “lost productivity through hangovers” as a synonym for lost productivity. Nutt’s source is the website for a research programme, but he doesn’t mention a specific paper, and they have a large number of publications about alcohol.]
Even public health messaging that encourages responsible drinking is funded by the drinks industry. While this is a far cry from the propaganda that was once spread by Big Tobacco, often governments don’t have the money to run awareness campaigns without hefty “donations” from the drinks lobby:
Public Health England wanted to do an advertising campaign promoting (at least) two drink-free days a week. This is sensible, safe and appropriate advice. But PHE doesn’t have much money for public advertising so they agreed to partner with Drinkaware, a charity that’s funded by the alcohol industry . . . It wasn’t the content of the campaign that was contentious, it was where the money was coming from.
Nutt suggests his own set of policy solutions: taxing drinks by the amount of alcohol in them and increase that tax back to 1950s levels (i.e. triple it); stop selling strong alcohol in supermarkets; make it a law that all alcohol outlets must sell non-alcoholic drinks; install breathalysers in pubs and stop drunk people from buying more alcohol; banning all alcohol advertising; and many more.
He focuses most on minimum unit pricing (MUP), i.e. a floor on the price at which a unit of alcohol can be sold. As the government has not raised its duty on alcohol, it now costs a third of what it did in 1970 in real terms. The duty paid in England varies wildly by the type of drink, rather than directly relating to the amount of alcohol in it, so it’s possible to purchase a lot of alcohol for little money.
Scotland introduced MUP in 2018 – with initially positive results:
…the amount of alcohol bought in shops and supermarkets per person per week fell by 1.2 units (just over half a pint of beer or a measure of spirits) compared with what would have been drunk without MUP. In England over the same time, consumption increased. The biggest drop – two units a week – was in the heaviest fifth of drinkers.
Targeting the heaviest drinkers is important because they are the worst affected; they account for the vast majority of the health costs.
The Republic of Ireland introduced MUP in 2022, but it’s too soon to understand the effects.
It’s often believed that people, particularly alcoholics, will consume just as much alcohol if it’s more expensive. But the closest thing that economics has to an iron law is that demand curves slope downwards: If you make something more expensive, people will typically consume it less, at least to some small extent. For example, if you make beer 1% more expensive, people will drink it 0.98% less. (Of course, we should also be concerned with the possibility that higher alcohol prices will result in substitution for more dangerous drugs.)
France had an extremely high rate of liver cirrhosis in the 1980s as a result of alcohol consumption. They tackled this by focusing on advertising (banning the drinks industry from it, basically), health warnings on bottles (‘alcohol abuse is dangerous for health’), price (restrictions on ‘happy hours’), and driving (reducing the blood alcohol content limit). The French wine industry has turned out to be more profitable following these changes – but the UK hasn’t followed suit:
The UK drinks industry know this data. They know that if we went down the route of raising the price of alcohol, they would be more profitable over time. In my opinion, the reason they don’t is that making money in the short term is so easy. And they think that if they make any concessions in this direction, people will begin to question all our other beliefs around alcohol and health.
Is this a case of companies prioritising short-term economic performance over the long run? It’s doubtful. Higher prices would shrink the market for alcohol. If policies aimed at dissuading drinking actually grow the profits of drinks companies, something has gone wrong. But if Nutt is still somehow correct, then presumably the drinks businesses must fear the consequences of temporary disruption; perhaps each is worried that they wouldn’t survive a shakeup.
This system has led to the Swedes drinking roughly three-quarters of what we drink per year in the UK. And to a rate of deaths from liver cirrhosis approximately half of ours. This shows, yet again, how small changes in consumption lead to bigger health gains.
He fails to demonstrate that these government-run shops cause this effect, but still, it seems like a sound policy.
So: Alcohol is bad, too much alcohol is really bad, and we could go a significant distance toward solving this problem if we could work out the political economy a bit better. But we can’t work out the political economy, at least for now. Unless there is a sudden national temperance movement, a combination of inertia and the drinks industry’s lobbying efforts means that change is unlikely.
Alcohol’s damaging impact on society seems doomed to remain. You could lobby your MP, and if enough people did so effectively, then maybe the drinks industry would eventually be cowed. But this is unsatisfactory. This book shows that so much of alcohol consumption is cultural; it’s just ‘the done thing’ to go out for an alcoholic drink or ten with your mates. Unacceptably high levels of drinking are a big part of the culture of Britain and Ireland.
The winners in this equilibrium are people who aren’t genetically predisposed to alcohol addiction, don’t feel the need for Dutch courage, or, perhaps, are successful or content in different spheres of their lives. Some successful people are vulnerable too, in a different way – being wined and dined if you’re an executive, or trying to climb a corporate ladder by getting drinks after work. Nonetheless, it’s wrong that the privileged class of people who can manage this drug effectively do not try harder to make sure that the underprivileged, vulnerable members of society don’t end up addicted to alcohol.
I don’t enjoy drinking alcohol, frankly. I drink a little bit on some social occasions, but, following my arguments here, I’m not sure that I should. Abstention from alcohol is more or less costly for different individuals, and I am one of those fortunate enough to manage it with ease.
It’s possible to consume alcohol in a safe manner, with risks to your long-term health that you might consider acceptable, if you enjoy drinking it. But, if you do so, then, at the margin, you are contributing to the idea that it’s normal to drink it. And that norm should be broken down. Drinking alcohol should always be a choice, not a default.
This social benefit of teetotalism is especially important to remember if you have negative associations with the groups, such as conservative Christians, who have campaigned against alcohol.
Modern liberalism has no real argument against people harming themselves with alcohol, if that’s what they want to do. In the absence of a Christian or other religious framework, it’s quite difficult to argue that you should do anything about people destroying their lives with alcohol. Who can tell you what makes your life worthwhile?
For example, in the 1980s, America introduced the National Minimum Drinking Age Act, raising the drinking age to 21, and Nutt writes that “this law … may have saved hundreds of thousands of lives”.But Nutt doesn’t want to raise the minimum drinking age, despite this data:
If someone can vote, if they can join the army, fight and die, get married, then they should be allowed to buy alcohol.
Granted, there is a certain logic here. Yet the same argument could be made about cocaine or heroin – you’re an adult, you can decide (Nutt has been willing to follow his logic to its conclusion for ecstasy). Those drugs are damaging to society, and I don’t think anyone has a ‘right’ to take them. But if we simply believe that each person is autonomous from age 18, entirely in charge of themselves, then we have limited moral arguments against drugs of any kind. If a moral framework of individual responsibility is not available to British and Irish society anymore, then perhaps individual teetotalism is the only way to go. That way the norm of alcohol consumption can be undermined, one person at a time.
Alcohol occupies a sinister position in British and Irish society and culture. But there is a better way, with stricter rules and different norms. You don’t have to fully agree with my prescriptions here to wonder what a society with no alcohol problems would look like. Formerly wasted talent would be used in the economy, countless lives would be saved, and families and relationships would be healthier and less violent. If we want to get there, we need to talk about the problem of alcohol.
Fergus McCullough works at an energy startup and holds an Emergent Ventures grant. An earlier version of this essay appeared on his blog.
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I have no idea where he got this outrageous figure from. I cannot find any figures nearly that large in the paper he cites, and even the proponents of the law estimate the benefit at a few hundred or possibly thousands of lives saved per year. If the law literally averted all traffic accidents caused by people under 21, it’s unclear whether this would have saved “hundreds of thousands of lives”.