Though it is rarely cited explicitly, this simple theory underpins most of the ‘public health’ approach to alcohol today. For example, the National Institute of Clinical Excellence says that ‘the number of people who drink a heavy or excessive amount in a given population is related to how much the whole population drinks on average. Thus, reducing the average drinking level, via population interventions, is likely to reduce the number of people with severe problems due to alcohol.’ Similarly, the state-funded pressure group Alcohol Focus Scotland says that they ‘aim to reduce harm by bringing about a significant reduction in alcohol consumption across the population.’ Both organisations aim to reduce average consumption by targeting the Three A’s – advertising, affordability and availability.
As John Duffy and I explain in a new IEA report – Punishing the Majority – it has long been recognised in the academic literature that the Total Consumption Model theory is built on sand. It is true that there is often a relationship between per capita alcohol consumption and the amount of alcohol-related harm (liver cirrhosis, alcohol poisonings etc.), but there is a simple reason for this: heavy drinking pushes up the average. A relatively small number of drinkers consume a disproportionately large proportion of alcohol. In Britain, more than 40 per cent of alcohol is consumed by ten per cent of the population. Close to 70 per cent is consumed by one fifth of the population. This distribution is not unusual in markets – it is the Pareto principle – but it indicates the extent to which per capita consumption depends on the drinking patterns of a minority. If you have more heavy drinkers you are almost bound to have a higher rate of per capita alcohol consumption. You are also likely to have more alcohol-related harm, but that is because of the heavy drinking, not because of the average.
The public health lobby take the wrong lesson from a statistical correlation. When they see average consumption rising and falling roughly in line with alcohol-related harm they assume that the answer is to reduce overall consumption. If they attempted to do this by tackling the minority of heavy drinkers, it might be effective, but they do not. Instead, they favour policies around price, availability and advertising which are aimed at the general population. Price rises can have an effect in reducing consumption, but they have more effect on moderate drinkers than on heavy drinkers. Restrictions on availability and advertising have very little effect on anybody. All three policies create problems, including the deadweight costs of taxation, the welfare cost of being unable to drink at chosen times and search costs incurred by limitations on advertising.
If you can reduce the number of heavy drinkers and alcoholics in a given population – or if you can get the heavy drinkers to reduce their consumption – you are likely to see a fall in average alcohol consumption, but there is no reason to think that getting moderate drinkers to reduce their alcohol intake is going to magically reduce levels of heavy drinking.
There are numerous real world examples of alcohol-related harm failing to move in line with overall alcohol consumption when the ‘wrong’ drinkers reduce their alcohol intake. In the UK, per capita consumption has dropped by 18 per cent in the last ten years without any commensurate decline in alcohol-related mortality. If you look at drinking patterns within the UK, it is the poorest socio-economic groups that have the lowest average consumption, but it is these groups that have the highest rates of alcohol-related mortality. By contrast, the richest groups drink the most and suffer the least harm. Average consumption is no guide to the amount of alcohol-related harm between countries or within countries. It’s who’s drinking, how they’re drinking and how much they’re drinking that makes the difference.
Despite the obvious shortcomings of the Total Consumption Model, it continues to influence work not only in the field of alcohol but in other areas of ‘public health’. For example, it was recently reported that ‘the UK population is still eating far too much sugar, fat and salt’. A nutritionist at Public Health England claimed that ‘we all need to make changes to our diet to improve our health’. As evidence for this, we were told that the average man gets 12.6 per cent of his calories from saturated fat, which is more than the recommended limit of 11 per cent. But whilst the national average tells us that some people must be eating too much fat, it is plainly wrong to assume that everybody is. Some people eat less than the recommended limit and some people eat much, much more. It is the latter who ‘need to make changes’, not the whole population.
If enough people cut saturated fat out of their diet completely, the national average would slip below 11 per cent, but this would be a Pyrrhic victory if the obese continued to eating way over their limits. Similarly, a surge of Islam and Methodism would reduce per capita alcohol consumption by creating more abstainers, but it is difficult to see how this would impact alcoholic street drinkers.
H.L. Mencken said that for every complex problem there is an answer that is clear, simple, and wrong. The belief that targetting the majority of drinkers somehow helps the at-risk minority does not stand up against the facts. Though wrong, it persists because it is clear and simple. The real reasons why some people drink to dangerous excess are complex and varied. It is not always easy to reach problem drinkers and even those who seek help may find it difficult to tackle their alcohol problems. Targetted interventions, rehabilitation, proper enforcement of the law, and harm reduction policies are expensive, time-consuming and are not always guaranteed to work. By contrast, lobbying for political interventions in the areas of price, availability and advertising offers campaigners achievable goals, a high profile and an identifiable enemy in the drinks industry. Unfortunately, these policies don’t work and they bear significant costs on the majority of responsible drinkers, but like the Total Consumption Model, at least they are clear and simple.
Download the new IEA report as a PDF here.