Reminder to CDC: Women are more than baby-portals

No one likes to receive unsolicited advice; and government recommendations are no exception to this. But the United States’ Centers for Disease Control and Prevention didn’t heed that warning when on Tuesday it released a new alcohol advisory, aimed at child-carriers (who we in the 21^st century have started to call ‘women’).

The CDC has recommended that women of a childbearing age who are not using birth control completely abstain from alcohol intake to avoid an accidental, alcohol-exposed pregnancy.

From the CDC's Principal Deputy Director Anne Schuchat, M.D.:

Alcohol can permanently harm a developing baby before a woman knows she is pregnant...About half of all pregnancies in the United States are unplanned, and even if planned, most women won’t know they are pregnant for the first month or so, when they might still be drinking. The risk is real. Why take the chance?

Why take the chance? In the off-chance that a woman could get pregnant during 3-4 decades of her life, why wouldn't she abstain from alcohol (and while she’s at it, cut out raw fish, cured meat and soft cheeses, stop skiing, avoid overheating and sign up to antenatal courses too.)

Those outside the- 4-decade span haven't been excluded fully from the press release either. While the CDC mainly addressed the effects of alcohol on pregnant women, their infographic suggests far more ambitious plans to cut down on women's alcohol consumption alltogether. Keep in mind "heavy drinking" is defined by the CDC for woman as "consuming eight drinks or more per week".

Fear-mongering much?

Quite rightfully, the Internet went ballistic over the insinuation women should be prioritizing the biological possibility of pregnancy over their daily activities, which include drinking habits.

These recommendations in the States come just weeks after here in the UK the Department of Health changed its alcohol guidelines, lowering maximum unit intake to 14 a week for both men and women, making the UK’s recommendations some of the most restrictive in Europe.

The CDC's and DoH's recommendations are different, but the recommendations of both government bodies were created with the same, faulty assumption: individuals can’t be trusted to their own lifestyle choices, and if left to make up their own minds, will engage in risky behavior.

There is indeed an appropriate way to advise women about the potential consequences of drinking while pregnant, but terrifying non-pregnant women out of a glass of wine because of ‘what might be’ falls short of providing an education tutorial.

Believe it or not, people actually like smoking and eating fatty food

Public information campaigns and nutritional labelling are good at informing people about what’s healthy and what isn’t, but don’t seem to have much impact on what they actually eat. That’s what a comprehensive review of 121 'healthy eating' policies found, and I think it should make us rethink more heavy-handed policies to do with unhealthy food, tobacco and alcohol. There are benefits as well as costs to every activity that public health groups want to discourage. We know there are benefits because people do them freely. But we know there are costs as well, like living a shorter and less healthy life.

The liberal view is that each person’s cost-benefit calculation is different, because they enjoy and dislike things differently. In this view there’s no case for stopping people from doing things unless they don’t actually have the information they need to make a judgement. We should want to make people’s lives better as they themselves understand ‘better’, not according to a single measure we’ve decided on, like lifespan.

So telling people that sugar makes them fatter may be a good policy, if they didn't already know that. And policies that do that do seem to make people more informed. But what’s interesting is the impact they have on people’s diets – usually not much, and sometimes an unexpected one.

For example, a 2008 study found that people who used nutrition labels had big increases in fiber and iron intake, but no change to their total fat, saturated fat or cholesterol intake. The UK’s ‘five a day’ campaign about fruit and veg was very successful at getting people to think about eating more fruit and veg, but increased people’s intake by an average of 0.3 portions a day (which was not viewed as being a very good improvement). 44 studies of similar campaigns in the US and EU have shown about the same size effect.

To some people that might make it look like we need to do more. To me it looks as if people view the costs of changing their diet to something less enjoyable or convenient as being quite important, and are willing to forgo some level of health to avoid that.

Maybe this tells us something about cigarette regulation too – there is some evidence that smokers actually overestimate the risk of smoking and some that they underestimate it. If they do overestimate the risks, we’re ‘informing’ people so much that it’s become misleading.

It would be fair to respond to this that people have no real way of doing a proper cost-benefit analysis about eating sugary foods or smoking, but because the state can’t measure the benefits – that is, the pleasure – it is just as limited.

The fact that people do change their habits about iron and fibre, but not fats, suggests that they aren’t ignorant, they just don’t want to eat less fat! If that’s the case and we’re working to improve people’s lives on their terms, there is no case at all for more heavy-handed policies like taxes, ingredients restrictions and advertising bans.

Why we should cut alcohol and tobacco taxes and why we can’t

The socioeconomic profile of drinkers and smokers across countries are similar. Smoking and drinking is more prevalent amongst the less fortunate, the disadvantaged and the uneducated. In the UK, it is no different. Hiscock, Bauld, Amos & Platt (2012) found that smoking rates were four times higher amongst the disadvantaged versus the more affluent (60.7% versus 15.3% - the factors that determined disadvantage included unemployment, income, housing tenure, car availability, lone parenting and an index of multiple deprivation). Fone, Farewell, White, Lyons & Dunstan (2013) found that “respondents in the most deprived neighbourhoods were more likely to binge drink than in the least deprived (adjusted estimates: 17.5% versus 10.6%...)”. Clearly, the incidence of these taxes falls disproportionately on the disadvantaged.

People often smoke and drink for pleasure; this means that these taxes stifle those with fewer resources from attaining pleasure. Conversely, affluent people generally have less trouble substituting consumption goods or in quitting substance use altogether. This prevention of stress alleviation and pleasure attainment will be reflected in sub-potential labour productivity.

The Biopsychosocial model of health suggests that any biological health benefits could be offset by the emotional and financial strain that these taxes induce. The situation is worse for those who are both addicted and poor since they substitute consumption even less than their poor, non-addicted counterparts (thereby reducing their consumption of other important goods). This simultaneously deprives their dependents (quite often children).

A primary concern is that the increase in smoking and drinking will cause several negative externalities (especially in the form of increased healthcare costs). One should consider that, if a drinker or a smoker is aware of the threat of liver failure or lung cancer and yet they choose to ignore it, it is ultimately their choice, their body and their health. A certain degree of respect must be afforded to choice especially since we cannot fully empathise with others.

However, one’s disregard for one’s own health often incurs costs for taxpayers whilst, personally, there are negligible financial costs. In this sense, many may feel disinclined to take care of their health as they might have if treatments weren’t free. So whilst the NHS is still around in its current form, it makes (some, albeit limited) sense to heavily tax alcohol and tobacco. Alternatively, a healthcare system that is at least partially privatised (e.g healthcare vouchers) would enable lower taxation of the disadvantaged and impoverished.

The latest attempt from the booze wowsers

We do love this latest attempt at justifying minimum alcohol prices:

Minimum alcohol pricing of 45 pence per unit would be 50 times more effective in targetting harmful drinking than current policies which only ban the selling of alcohol as a loss leader, research suggests.

Really?

Researchers at the University of Sheffield compared the effects of the two policies on public health using a mathematical model alongside General Lifestyle Survey data to estimate changes in alcohol consumption, spending, and related health harms among adults.

What did that model look at?

In their findings, published by bmj.com, they estimated that below cost selling would increase the price of just 0.7 per cent of alcohol units sold in England, whereas a minimum unit pricing of 45p would increase the price of 23.2 per cent of units sold.

They estimated that below cost selling would reduce harmful drinkers' mean annual consumption by just 0.08 per cent - or around three units per year. By contrast, a 45 pence minimum unit price would reduce consumption by 3.7 per cent or 137 units a year - a 45 times greater effect.

So they plugged the price change into their estimate of the elasticity of demand and found that....wait for it, wait for it....higher prices reduce demand and or consumption?

Gosh, do we really need a team of highly trained and expensive alcohol researchers to tell us that?

Unfortunately this latest paper fails to tell us the three things we'd actually like to know about minimum alcohol pricing.

This first being should we be attempting to reduce consumption in the first place? Current levels of booze taxation more than cover the public costs of boozing. There are, indeed, substantial private costs remaining: but those are being carried by the people doing the boozing which is just where they should be. Is there actually a reason or justification left for public policy action in this case?

The second is whether that rise in prices actually reduces harmful drinking, or just deters the occasional tippler from a small pleasure. There is, after all, fairly convincing evidence that the addict will always feed their addiction while the diletante is more amenable to price signals.

And thirdly, even if the above can be answered in a manner that leads to our wanting to increase the price, why on earth would anyone want to have minimum pricing? Not only is it illegal under EU law but it puts the extra cash into the hands of the retailers and manufacturers. Rather than into the Treasury as would be the case if prices were raised through higher taxation.  Minimum alcohol pricing just doesn't make sense.