Who is really driving the public health debate?
A century ago, America was in the grip of Prohibition. When it ended in failure in 1933, the campaign to demonise drink appeared to be dead and buried. But it’s back in a coalition of NGOs, public health officials and temperance crusaders under the banner of the WHO. In the first of a new series, Tom Bruce-Gardyne explores how we got here.
With just three words, the European office of the World Health Organisation effectively declared war on the drinks industry on January 4th 2023. There was now “no safe level” to consumption. A press release quoted Dr Carina Ferreira-Borges, the report’s lead author and its regional advisor for alcohol and illicit drugs, saying: “It doesn’t matter how much you drink – the risk to the drinker’s health starts from the first drop.”
It marked a radical shift in position. “The most revealing thing about the “no safe level” campaign is not the science, it’s the language,” says Mike Coppen-Gardner, founder and CEO of SPQR. “For nearly 20 years, the WHO’s agreed term was “harmful use of alcohol”. Thirty-six civil society organisations formally lobbied to have those words removed, because “harmful” implies non-harmful use also exists. That is not a scientific argument. That is a prohibitionist argument. The WHO eventually moved in their direction. The science followed the objective.”
Drink and wood dust
The justification was alcohol’s links to cancer. In the measured words of Ferreira-Borges this “toxic, psychoactive, and dependence-producing substance” is in the same group of carcinogens as “asbestos, radiation and tobacco.” Other products in the group are salted fish, wood dust and processed meat.
But this was no great revelation. As Dr Creina Stockley, co-director of the International Scientific Forum on Alcohol Research explains: “It has always been written in guidelines on alcohol, the acknowledgement that it’s a group 1 carcinogen. It’s nothing new.” The WHO itself acknowledges it was classified by the International Agency for Research on Cancer “decades ago”.
Countering this has been the weight of scientific evidence on the way light drinking can protect the heart. The understanding that “alcohol might actually reduce cardiovascular disease really took effect in the mid-1990’s,” says Stockley. “It was accepted in most literature in guidelines that there was a beneficial effect for low to moderate consumption.”
Discrediting the J-curve
This is the famous J-shaped curve whereby those who drink within the guidelines – currently 14 units of alcohol a week in the UK, are likely to outlive those who abstain. Drink more than that, and the odds go steeply into reverse. In recent years there has been a concerted effort to discredit the J curve by those who back WHO (Europe)’s hardline position, notably Professor Tim Stockwell of the Canadian Institute for Substance Use Research.
The Institute was behind the CCSA study, released to coincide with the WHO’s announcement in January 2023, that sought to cut Canada’s ‘low-risk’ drinking guideline to just two drinks a week. Stockwell admitted the risks at that level were in fact “tiny” and the attempt failed. “I think inside Government there has been a lot of recognition that this is little extreme for Canadians,” says Professor Dan Malleck of the Department of Health Science at Brock University in Ontario.
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Malleck has been following the change in rhetoric over the years and the constant references to tobacco with interest. “The tobacco analogy is very clear, as is the fixation on cancer,” he says. “The language is very calibrated to pick up this fear, and the cancer one is especially powerful for obvious reasons, even if the risks of dying of cancer are lower than heart disease for which alcohol is protective in moderate amounts.”
Follow the money
Another crucial point, in his view, is that “all the research funding is funding designed to identify harm. As a researcher you’re going to adjust your research to the funding agency’s question. It’s not so much dishonest, it’s going where the money is. Whereas it’s very rare to find funding to support a counter-narrative unless it comes from the alcohol industry, in which case it’s seen as corrupt or distorted.”
For Stockley, a key milestone on the road to ‘no safe level’ was the UK’s 2016 drinking guidelines which stated “there is no level of regular drinking that can be considered completely safe,” regarding some cancers. But she praises the wording as a rare example of nuance in respect of science which is contested and very complex.
The importance of that word “completely” is hard to exaggerate. Without it, it becomes far easier to try and justify cancer warnings on drinks. It also begs the question – just how risky is drinking at moderate levels? As Stockley says: “A world devoid of risk is aspirational at best. No human activity is risk-free.”
Blanket statements
While most politicians should be able to grasp that, she says: “The biggest thing governments struggle with is how do you have one message that gets across everyone? So, they go to the lowest common denominator which is a very blanket statement which is not nuanced at all.”
The media has the same issue. “Not completely safe” is never going to make a headline, and in her view: “The media has had a large part to play in why politicians are quite nervous about taking this head on.”
Ignacio Sanchez Recarte, head of the European wine lobby – the Comité Européen des Entreprises Vins, traces the involvement of WHO (Europe) to the collapse of the EU’s Alcohol and Health Forum in 2015 during a decade when alcohol mortality rates fell 20%. The WHO was “the Trojan horse” in his view. “They simplified the science, and said we don’t care about mortality or the J-curve. We’re looking at a single, unique issue which is cancer. From the data we have there is always a risk.”
A political slogan dressed up as epidemiology
He has some sympathy for policy-makers. “You’re a politician confronted with 70 topics a day. If you read a memo, or you go to a conference at the WHO, you take it as a Holy word, as gospel,” he says. But in this case, there seems an obvious agenda at play. “‘No safe level’ is a three-word political slogan that has been dressed up as epidemiology,” says Mike Coppen-Gardner. “The drinks industry should challenge it.”
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