The politics of drinking
           February 05, 2013

Alcohol stats and the comorbidity conundrum

Evidence is a nice thing to have. But what happens when the evidence base you’ve stood on all these years starts crumble beneath you?

The progress made by the public health lobby, by the ideology of medical temperance, over the decade between the Labour government’s Alcohol Harm Reduction Strategy and the current coalition’s Government Alcohol Strategy has been in large part the result of leveraging the alcohol harm statistics to grab the headlines and the attention of politicians.

So what do you do when the numbers start improving, apparently of their own accord since the major plank of public health policy, minimum unit pricing, is still only a twinkle in the legislator’s eye?

The Office for National Statistics’ latest figures for the UK show alcohol-related deaths were down in 2011. Only by 42, or half-a-percent, to be sure, but the trend has been downwards for several years. The figure is now the lowest it’s been since 2002.

Combined with the continuing fall in alcohol consumption it just isn’t adding up for the health lobby.

Even so, I’m perfectly willing to believe that 8,748 deaths in 2011 is too many and whatever the number is we should try to reduce it. In the interests of evidence-based policy, though, we ought be clear about the exact scale of the problem, and I’m not sure we are.

The definition used by the ONS for “alcohol-related deaths”, for instance, “includes all deaths from chronic liver disease and cirrhosis (excluding biliary cirrhosis), even when alcohol is not specifically mentioned on the death certificate”.

It may not be surprising that alcohol isn’t always mentioned. Chronic liver disease (CLD) covers not only alcoholic liver disease and cirrhosis but obesity and viruses such as hepatitis C, which is on the rise thanks to improved detection.

I’ve often mentioned here the strong correlation between alcohol harm and deprivation, and Alcohol Research UK is, I’m pleased to say, currently working on a study of that. But I was shocked to see that for CLD a man living in the most deprived areas of Scotland  is 12 times more likely to die of liver disease than someone from the least deprived areas.

Poverty kills people, and part of the reason could lie in what’s known as comorbity. You are, for instance, at much greater risk of dying from CLD if you are both and heavy drinker and obese. And obesity itself is tangled up in other social determinants of health.

Among other things this makes it hard to attribute such harms to alcohol alone. Specialists in other fields have noticed the problem. Douglas M Walker has declared that attempts to attach a social cost to gambling are “almost useless”.

“To what extent does a person’s gambling problem contribute to their socially costly behaviour(s) when they have other medical or psychological problems aside from the gambling problem?… I suspect the comorbidity problem also affects the credibility of many cost-of-alcohol studies.”

Whatever the stats say, trying to isolate drinking as a cause of harm is futile. We have to search much further upstream.

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