The team which last year declared in The Lancet that the UK could save as many as 250,000 lives in England and Wales over the next 20 years by drinking less has returned to the fray.

Their new estimate, again in The Lancet and widely reported  is slightly more modest – 210,000  deaths over 20 years. The team (this year enlarged to Nick Sheron, Ian Gilmore, Camille Parsons, Chris Hawkey and Jon Rhodes) have taken into account the virtually flat trend in deaths from liver disease to which I drew attention last year in my commentary on their first projection.

That’s good. The new projection has alcohol-related liver deaths rising from 6,317 in 2010 to around 8,000 by 2030. That’s a rise of 26.6 per cent, in a period when the population is expected to rise by 15.4 per cent. The confidence intervals are wide because the projection is based on a short run of data, 2003-2010, and the lower 95 per cent confidence interval actually projects deaths rising more slowly than population.

So where do the huge figures for potential lives saved come from? The assumption, as before, is that liver deaths – and, by extrapolation, other alcohol-related deaths – can fall as rapidly as they did in France and Italy between 1986 and 2006. As I argued last time, this is unlikely because both these countries started at a much higher level and have now reached much the same rate of alcohol-related liver deaths as England and Wales.

However, back in 1986 alcohol-related liver deaths recorded in England and Wales were much lower – around 2,500 a year. So maybe the ambition of getting back to that level isn’t unrealistic?

The problem is that that figure was probably a serious underestimate (1). Until 1984 deaths related to alcohol were treated as if they were poisonings, and required a Coroner’s inquest. To avoid stigma and distress to relatives, the true cause of death was often concealed, with causes of death such as myocardial ischaemia and bronchopneumonia substituted instead. Coroners were left uninformed; hospital post-mortems were performed and the findings recorded as “nutritional cirrhosis” or simply “cirrhosis”.

So the chances are there was never a golden age of low alcohol-related liver deaths in Britain, with the five-fold fall in such deaths between 1900 and 1920 being influenced by the introduction of the Coroner’s legislation, and the doubling after 1984 with its removal.

The rise of alcoholic liver disease in the 1990s puzzled many doctors. In the West Midlands, one study found (2), the rate of alcoholic liver disease tripled between 1993 and 2000, even though alcohol consumption rose much more modestly. (Customs and Excise data show litres of pure alcohol per adult per year rising by 12 per cent in this period.) The authors of this study were at a loss, suggesting demographic change might have contributed, since Asians were found to be at higher risk, or that there was another dietary factor, or that it was a change in certification practice.

International comparisons of the kind made by The Lancet team are also tricky. For example, WHO figures show Ireland consuming 13.69 litres of pure alcohol per adult per year, higher than the UK (11.75) but the European Health for All Database suggests Ireland’s alcohol-related liver disease rate is half that of the UK. The Netherlands has an even lower rate of liver disease, about a quarter of the UK’s – and while they do drink less, the difference is not huge. In the mid 1990s UK consumption was at the same level as the Netherlands is today, but its recorded liver mortality rate then was twice that of the Netherlands today.

As an interesting report from the Institute of Alcohol Studies in 2008 found, there’s no very clear relation between reported consumption and reported harm. “Some countries have high levels of per capita consumption but low levels of harm, while others have relatively low levels of consumption but high levels of harm” its author, Russell Bennetts, concludes.

However, there’s no dispute that lower rates of liver disease are highly desirable, and there is good evidence that relatively small changes in drinking habits can have significant effects. The issue is how to achieve such changes. Among other things The Lancet team favours increasing prices, but the UK already has some of the most expensive drink in Europe.

Mr Bennetts used the price of a Big Mac – a product the same wherever it is sold – as a kind of international currency. On this basis, alcohol was more expensive in the UK than anywhere but Ireland and, surprisingly, Sweden. Big Macs are evidently so expensive in Sweden that drink is, relatively, cheap. Nor did he find any relation between affordability and consumption.

The other remedies suggested are reducing availability and preventing marketing of alcohol to children and young people. These ideas, and others, are likely to appear in a new alcohol strategy for England, due for publication this year.

But let’s hope the Government doesn’t take up the suggestion made in The Lancet of copying Mikhail Gorbachev’s anti-drinking crusade in the then Soviet Union in 1985. That led to widescale production of illicit hooch and a boost to organised crime before it collapsed in disarray three years later.

References

1. Accuracy of death certification for alcoholic liver disease, J.D.Maxwell, British Journal of Addiction, (1986) 81, 168-169
2. Mortality from Liver Disease in the West Midlands 1992-2000, N.C Fisher et al, BMJ, 2002;325:312.1