The following is an excerpt from Drugs: Without the Hot Air, by David Nutt (2012 UIT Cambridge).

A terrifying new “legal high” has hit our streets. Methyl-carbonol, known by the street name “wiz,” is a clear liquid that causes cancers, liver problems, and brain disease, and is more toxic than ecstasy and cocaine. Addiction can occur after just one drink, and addicts will go to any lengths to get their next fix – even letting their kids go hungry or beating up their partners to obtain money. Casual users can go into blind rages when they’re high, and police have reported a huge increase in crime where the drug is being used. Worst of all, drinks companies are adding “wiz” to fizzy drinks and advertising them to kids like they’re plain Coca-Cola. Two or three teenagers die from it every week overdosing on a binge, and another 10 from having accidents caused by reckless driving. “Wiz” is a public menace – when will the Home Secretary think of the children and make this dangerous substance Class A?

In the days following the publication of our harms paper, several newspapers ran headlines along the lines of “Professor Nutt says Alcohol Worse than Drugs,” as though alcohol weren’t a drug itself. This false distinction is a large part of the communication problem I encounter whenever I try to emphasise how harmful alcohol is. It has a separate language – you get “high” on drugs, but “drunk” on alcohol, drug addicts need a “fix” but alcoholics need a “drink.” As I hope the satirical paragraph above about alcohol shows (methylcarbonol is another chemical name for ethanol, which is the psychoactive part of alcohol), to think rationally about drugs policy we have to see alcohol in the same context as other drugs, not separately. Alcohol also has a lot to teach us about what not to do when a potentially lethal, habit-forming substance is legal.

We are currently facing a public-health crisis of immense proportions. The increase in harms caused by alcohol over the last 50 years in the UK is comparable to the Gin Craze in the early 18th century, when the urban poor of London were consuming a pint of gin a day per head on average. Recent annual statistics show: 40,000 deaths, including 350 just from acute alcohol poisoning and 8,000 from cirrhosis of the liver. More than a million hospital admissions in 2007/8 (including 13,000 under-18s), costing the NHS £2.7 billion.

7,000 road traffic accidents, including 500 deaths.

1.2 million violent incidents and 500,000 crimes, costing the police £7 billion. In addition: 40% of domestic violence cases involve alcohol, as well as 50% of child protection cases.

3.5 million adults in the UK are addicted, and up to 700,000 children live with a parent with a drink problem. 6,000 children a year are born with fetal alcohol syndrome each year.

Globally, the main burden of disease in 15- to 24-year-old males is due to alcohol, outweighing unsafe sex, illicit drug use, and physical accidents combined.

The total economic cost has been calculated as £30 billion a year – though some calculations estimate it may be as high as £55 billion. The drinks industry responds to critiques like mine by saying that alcohol misuse affects only a “minority.” Clearly, alcohol harms don’t affect just a minority, they affect all of us – as victims of car crashes and street violence, as patients, as families of hazardous drinkers, and as taxpayers. Reducing these harms and associated costs is a huge public-health challenge that ought to be a top priority for our policy makers. Unfortunately, while the Labour government was talking “tough on drugs,” trying to score political points by making cannabis Class B, banning mephedrone and exaggerating the harms of ecstasy, they missed the growing epidemic around the most harmful drug of all – or more accurately just looked the other way.

How the drinks industry influences alcohol policy The drinks industry is one of the most powerful industrial groups in the UK today, and spends huge sums of money on maintaining its privileged relationship with our lawmakers. Political lobbying takes place largely in secret. Even so, the Labour government’s 2004 Alcohol Harm Reduction Strategy shows clear evidence of the influence of the drinks industry, because it focused on the measures the industry had recommended (such as information campaigns and education) and ignored the measures recommended by the Chief Medical Officer (such as minimum pricing). In fact, the House of Commons Health Committee itself commented on this in its 2009–2010 report on alcohol: “we are concerned that Government policies are much closer to, and too influenced by those of the drinks industry and the supermarkets than those of expert health professionals such as the Royal College of Physicians or the CMO [Chief Medical Officer].”

Like the tobacco lobby before it, the industry has taken proactive steps to protect the public image of its product even as the evidence about the harm done by alcohol has become incontrovertible. The European Centre for Monitoring Alcohol Marketing recently published a report called the Seven Key Messages of the Alcohol Industry, which summarizes the sorts of messages the industry uses to try and influence alcohol policy: Consuming alcohol is normal, common, healthy and very responsible. The damage done by alcohol is caused by a small group of deviants who cannot handle alcohol. Normal adult non-drinkers do not, in fact, exist. Ignore the fact that alcohol is a harmful and addictive chemical substance (ethanol) for the body. Alcohol problems can only be solved when all parties work together. Alcohol marketing is not harmful. It is simply intended to assist the consumer in selecting a certain product or brand. Education about responsible use is the best method to protect society from alcohol problems. These messages are at best distortions of reality, and at worst outright lies. Their intention is to misdirect policymakers away from measures that will actually reduce harm, and towards policies that will allow the industry to continue to make huge profits at the expense of public health and well-being. Let’s look at each of their claims in turn. 1a. Consuming alcohol is normal It’s certainly true that most societies throughout history have brewed some sort of alcoholic drink, and that this has been part of the human diet for so long that many of us are genetically adapted to consume alcohol.

When ethanol breaks down in the body it produces acetaldehyde, a substance even more toxic than alcohol, which needs to be oxidised to avoid unpleasant and dangerous effects. People from ethnic groups who don’t have a history of alcohol use – such as Native Americans, Inuit and many Chinese – often have a form of the ALDH2 enzyme (the enzyme that breaks down acetaldehyde) which is less effective at this oxidation process, leading to high levels of acetaldehyde in their system when they drink. The resulting facial flushing, nausea, headaches and general discomfort largely outweigh the pleasant effects of intoxication, and by and large these groups drink less alcohol than groups who have a more active form of the enzyme (as most Europeans, Africans and South Americans do), and suffer less alcohol addiction and liver disease. So, drinking alcohol is “normal,” in a sense – people who possess the high-activity variant of the ALDH2 enzyme, come from a long line of people whose bodies adapted to consuming and breaking down alcohol. Indeed, until the 1850s weak beer was often “healthy”: it was the safest thing to drink, because most water was contaminated with viruses or bacteria. However, in the past most of what was drunk was mostly relatively low strength beer and wine, and its consumption was surrounded by custom and ritual to mitigate its social harms. The other, more recent, history of alcohol is one of disruption and damage, where societies that are unfamiliar with its effects suffer hugely when new types of alcohol appear, particularly if they are aggressively marketed. From the Gin Craze in Britain in the 18th century, to the enormous rates of alcoholism on Native American reserves in the USA, there are dozens of examples of societies unable to cope socially and medically with the drug. We’re at a similar point now in the UK: the access people have to cheap, high-strength alcohol is almost unprecedented, and binge drinking of the sort we see today is something our ancestors would rarely have been able to indulge in even if they’d wanted to. Teenagers being encouraged to drink themselves to death every day is not what any society should consider “normal.”

1b. Consuming alcohol is healthy What about the health benefits of alcohol? The drug does have some positive psychological effects, and it can be calming for some people with anxiety disorders (see Case Study 1 below) although with heavy use the effects of withdrawal will start to make them even more anxious when they’re sober. Physiologically, alcohol’s benefits have never been proven, but the idea that low levels of drinking are protective is a pervasive myth – and a very useful one for the industry. We know that, for a particular group of people (middle-aged men), those who drink small amounts, particularly of red wine, have slightly lower levels of heart disease than those who don’t drink at all. However, this may be because this group has more healthy lifestyles, or because of the “sick teetotaller effect” – where many people give up alcohol because they are ill (perhaps from some other disease); their worse health outcomes may have nothing to do with whether or not they drink, but do make the health statistics of non-drinkers appear worse. To know for sure if alcohol is actually preventing heart disease, we would need to do a randomized trial where some of this group drink no alcohol, others drink it in small amounts and others drink more heavily. Until this experiment has been done we don’t have proof that alcohol has health benefits.

There is no such thing as a safe level of alcohol consumption. Alcohol is a toxin that kill cells and organisms, which is why we use it to preserve food and sterilize needles. Acetaldehyde, produced when the body breaks down alcohol, is even more toxic, and any food or drink contaminated with the amount of acetaldehyde that a unit of alcohol produces would immediately be banned as having an unacceptable health risk. Although rare, alcohol addiction after a single drink does happen in a small proportion of cases, as you can read in Case Study 2; since we can’t predict who those people will be, any exposure to alcohol runs the risk of producing addiction in some users. And apart from the possible cardiovascular benefits of low intake for some middle-aged men, for all other diseases associated with alcohol the risks rise inexorably with intake. This isn’t to say that I think nobody should ever drink at all – I drink, and I enjoy it. But I understand that there are always risks involved, and I certainly don’t drink for the good of my health.

1c. Consuming alcohol is responsible “Responsible drinking” is another industry favorite. It’s a very curious phrase, considering the drug’s actual effects. Alcohol is a depressant (similar to GHB, and benzodiazepines like Valium) which, if taken at high enough doses, will produce amnesia, sedation and eventually death. It stimulates the GABA receptors in the brain, reducing anxiety and motor coordination, and blocks specific glutamate receptors, switching off the parts of your brain that keep you alert and awake, and switching on the parts that make you drowsy and tired. Alcohol also indirectly stimulates the noradrenaline circuit, producing some stimulating effects. This is what creates the noisy energy we associate with drunkenness, even though the drug is a depressant. Some interesting recent research showed that alcohol interferes with our ability to recognize emotions in facial expressions, which may be part of the reason drunk people are so quick to take offense and start fights. The overall effects of increasing GABA and noradrenaline in the brain are disinhibition, decreased concern for social codes and standards of behavior, an increase in risk taking and disregard for long-term consequences. I’m sure the majority of the 40 million drinkers in this country are people who take their responsibilities seriously in everyday life, but almost all of them – with the possible exception of addicts in withdrawal – will be more responsible when they’re sober! 2. The damage done by alcohol is caused by a small group of deviants who cannot handle alcohol Millions of people, not a tiny minority, suffer harm from their own alcohol consumption, or cause harm to others. Alcohol dependence is on the rise, with the attendant social damage and ruined lives, and binge drinking is killing hundreds of people a year as well as causing cirrhosis in patients as young as their early 20s. But it’s very important to understand that much of the surge in harms is actually among people who don’t engage in these extreme behaviours. It is the everyday drinking of people who have come to see alcohol as an essential part of life rather than the luxury it used to be, that has created a spike in cancers and stomach problems, and will see liver disease match heart disease as the leading cause of death in the UK by 2020. This new habitual daily consumption has been made possible because alcohol is now only a third the cost relative to income than it was in the 1950s, and particularly because of the availability of cheap liquor in supermarkets.

3. Normal adult non-drinkers do not, in fact, exist The drinks industry wants to portray itself as serving an important social function, and remind governments of how unpopular any measures to restrict access to alcohol will be. The existence of non-drinkers obviously threatens this portrayal of society, so the industry tends to dismiss them as having something wrong with them. While some teetotallers are recovering alcoholics, many others have made a positive choice not to drink. Some don’t drink because there is alcoholism in the family and they know they are at increased risk of becoming dependent if they start. Others, particularly athletes, know that alcohol impairs performance, so they never touch it – David Beckham, for example. And, of course, many people avoid the drug for religious or cultural reasons. These are all perfectly valid choices, yet non-drinkers are often heavily pressured to consume alcohol in order to fit in with others. This message is constantly reinforced in the press, on TV, and in alcohol advertising. 4a. Ignore the fact that alcohol is a harmful substance for the body Far from being safe, there is no other drug which is so damaging to so many different organ systems in the body. Figure 6.2 illustrates how alcohol can harm almost every part of the body through its toxicity alone. (The figure doesn’t show the other physical damage caused by falls, road traffic accidents and violence.) Most other drugs cause damage primarily in one or two areas – heart problems from cocaine, or urinary tract problems from ketamine. Alcohol is harmful almost everywhere.

Alcohol is not the most addictive drug, but its widespread availability and social acceptability make becoming dependent more likely. This social context also makes relapse after treatment highly likely, as Case Study 3 shows. It can be hard for anyone, let alone an addict, to refuse a drink when it’s offered socially. About a quarter of the adult population of the UK drink more than the recommended weekly limit; 6% of men and 2% of women are “harmful drinkers,” where damage to health is likely, and levels are higher still in Scotland. As with many other drugs, dependent users suffer withdrawal symptoms when they stop. 5. Alcohol problems can only be solved when all parties work together

The drinks industry wants to portray itself as having the same aims and interests as people who want alcohol policy to be guided by a concern for public health. But there is a fundamental conflict of interest: however much the industry wants to pretend otherwise, you can’t reduce harm without reducing the amount people drink, whereas companies looking to maximize profits need to sell as much alcohol as possible. There is a lot of evidence that the drinks industry relies upon hazardous drinking as a major source of income. In fact, it has been calculated that if everyone who drinks more than the recommended daily limit started drinking moderately there would be a drop in total alcohol consumption of 40% – equivalent to over £13 billion in sales. However much the industry talks about taking the harms seriously, nothing can change the fact that its success is indirectly related to the amount of damage it inflicts on society at large. This is not to say that the industry brings no benefit to society at all – brewers contribute billions every year in tax revenue, and the industry does provide a lot of jobs. Pubs in particular are important social spaces and local employers, but they’ve seen their profits plummet in recent years as a result of the cut-price alcohol available from supermarkets and off-licences. “Working together” implies that everyone can win, when in fact politicians need to weigh up the different interests involved, and bring in policies that will produce the best outcomes for society as a whole, even if that means that some parties have to lose out.

In practice, what the industry means by “working together” is bringing in voluntary codes rather than statutory regulation – solving problems through rules that the industry chooses to comply with, rather than laws which they must comply with. These are supposed to be easier to implement and more flexible than going down the legal route. However, evidence from across the world shows that the voluntary codes adopted by drinks industries are essentially ineffective at reducing alcohol harms – they tend to focus on the wrong sort of interventions, and are routinely ignored by signatory companies anyway. This was recognized with smoking and the tobacco industry, and is equally true of those who profit from alcohol. 6. Alcohol marketing is not harmful. It is simply intended to assist the consumer in selecting a certain product or brand The drinks industry spends around £800 million a year on advertising, marketing, sponsorship, contests and special promotions. While the most important factors determining consumption are price and availability, marketing does have a demonstrable impact on levels of drinking, not just the brands people choose to drink. This is particularly true with young people and a number of studies have concluded that marketing communications do have a marked effect on consumption. A recent British Medical Association (BMA) publication, Under the Influence, revealed many of the techniques the drinks industry employs to target a younger audience, including email campaigns with embedded film clips advertising alcohol, Facebook links and texts going direct to people’s phones. The industry claims its advertising is aimed at providing information and choice, but there is a powerful symbolism to the sheer volume of advertising that people are exposed to on a daily basis. To quote the BMA: “the fact that promotion is allowed, ubiquitous and heavily linked to mainstream cultural phenomena, communicates a legitimacy and status to alcohol that belies the harms associated with its use. It also severely limits the effectiveness of any public health message.” There’s a lot of evidence that the more common and acceptable consuming alcohol is seen to be, the more people will drink, and this cultural context is especially influential on young people. All this further entrenches the false division between alcohol and illegal drugs, persuades people that consuming alcohol is safe, and makes realistic discussions of the harm alcohol causes very difficult.

7. Education about responsible use is the best method to protect society from alcohol problems It is useful for the drinks industry to emphasise the value of education, because it takes the focus off regulation: if how much a person drinks is just their individual choice, then there’s no need to control how much alcohol they have access to. As well as being implausible with a drug like alcohol that dissolves one’s self-control, there is also extensive evidence gathered by the WHO from around the world, showing that merely providing information and education without bringing in other policy measures doesn’t change people’s drinking behavior. At best, they are a waste of money – though in the UK the sums involved (a few million pounds a year) are pitifully small anyway. At worst, especially when these education programs are funded by the industry, they can reinforce heavy drinking by improving people’s opinions of the industry. This is especially worrying in the UK, as from 1989 to 2006 the drinks industry-run Portman Group was funding and delivering many of the alcohol-awareness campaigns in this country. Of course I believe that informing people about the harms done by drugs has an important role to play in reducing those harms – that’s why I’ve written this book – but it’s not enough on its own. When it comes to an addictive substance that impairs our judgement, we can’t rely on people cutting down the amount they use, just because they have a rational understanding of its harms. If the product is freely available, being aggressively marketed all around them, and changes their brain to make self-control nearly impossible, they need other sorts of interventions too. Case Study 1 I was called out on a home visit to see a man in his late 40s with severe agoraphobia (the fear of going out). He had been drinking heavily all his life, and was now dying from cirrhosis and the damage alcohol had done to his nerves. He had been diagnosed as an alcoholic, but the reason he drank was to control his extreme anxiety: he told me he had to drink four cans of lager to be able to get to his Alcoholics Anonymous meetings, and one can of lager just to be able to brave going outside to cut the grass. His anxiety disorder pre-dated the drinking, and, having been given no other help, he felt forced to self-medicate with alcohol. But as soon as he started drinking regularly, all the health practitioners he saw identified his primary problem as alcoholism, and no one would treat the underlying anxiety while he kept drinking. I treated him with SSRI antidepressants which help with anxiety disorders. Case Study 2 I was taken to see a man in his late 30s who had been admitted to hospital to dry out. He’d been through problematic withdrawal several times, and had had seizures in the past when trying to dry out. I asked him when his drinking began. He said he was given his first can of beer at age seven when he was out fishing with his dad, and he immediately felt that the person he became when under the influence of alcohol was his real self: “For the first time in my life, I felt normal.” He probably belongs to a minority of people who are biologically programmed to have very strong liking for alcohol, and are highly likely to become alcoholics. Hopefully in the future we will be able to identify these people before they start drinking, so they know to avoid the drug, and we may develop medications to help them feel normal without alcohol. Case Study 3 A 28-year-old man had been in for treatment which had gone well – he had dried out and seemed in good shape when he left us. A few months later he was readmitted. I asked him why he had relapsed and he said that he’d been walking past an off-licence (liquor store) and had had such an uncontrollable urge to drink he’d walked in and drunk a whole bottle of vodka right there in the shop. Helping people stop drinking is relatively easy; avoiding relapse, especially when cheap high-strength alcohol is available on every street corner, is much more difficult.

This excerpt published with permission from Drugs: Without the Hot Air, by David Nutt, (C) 2012 UIT Cambridge, all rights reserved. Published in paperback, Kindle, epbub and PDF editions.