Thursday 12 December 2013

Alcohol Healthwatch

From the full version of the Rankine report for AHW on women and alcohol:
The BERL analysis was critiqued for its methodology by Crampton and Burgess (2009), who called the final BERL figure ‘grossly exaggerated’ (Crampton, 2009). Crampton and Burgess estimated external alcohol costs at $662 million, which they said was almost matched by the $516 million received in alcohol taxes. Crampton and Burgess cited literature indicating that drinkers earned at least 10% more than equivalent non-drinkers, that moderate drinking increased benefits from experience and education, that moderate drinkers lived longer, and that alcohol saved more lives than it cost. They also questioned BERL’s estimate that 50% of costs were avoidable. Crampton and Burgess’s conclusions were unsupported by other research reviewed above, including studies cited in section 9.1: New Zealand health benefit estimates, and section 10: Alcohol-related health problems. 
Later, related research by Crampton, Burgess and Taylor critiquing alcohol cost studies was commissioned by the Australian National Alcohol Beverage Industries Council (NABIC). Crampton presented it to the national conference of the Australian Liquor Stores Association, and at NABIC’s request spent a day in Canberra discussing the research with media and ministry officials (Crampton, 2012).
I wish that they'd cited our 2011 working paper or the 2012 NZMJ summary version. The 2009 version, referenced by AHW as a link to the blog, contained an error that we only caught on going through the Collins & Lapsley report on which the BERL report was based. The corrected figure had social costs closer to $975 million. We also there noted that we'd missed excise revenues collected at the border, for a total excise take of $713 million. We only caught the error understating alcohol's social costs when we took this on as a paid project by NABIC. So the net effect of industry funding was to substantially increase the measure of alcohol's social cost in New Zealand; I think that AHW is trying to insinuate otherwise in the last paragraph. They didn't mention that some of my current work is industry-funded, but I expect that will change quickly enough. I'd be curious to know how much money Alcohol Healthwatch sucks out of MoH every year.

One of the biggest problems in the BERL report was double-counting. We argue that you can't simultaneously count the productivity losses associated with premature mortality and the intangible costs of lives lost where the MoT survey-based measure of the value of a statistical life is inclusive of the lost productivity. BERL added both of those together, along with a strange assumption about that the economy's at full capacity so a deceased worker can never be replaced with either another worker or more intensive use of capital. They also specifically zeroed out all of the alcohol aetiological fractions where alcohol use reduces the burden on the health system, despite that their source, Collins & Lapsley, allowed alcohol to both increase and decrease burdens on the health system, depending on the disorder.

Further, whether the excise take matches the social cost doesn't necessarily imply anything about the direction of optimal regulation. If excise does more to deter drinking's harms than to curtail moderate consumption, it's possible for it to make sense to increase excise even if the total tax take is well in excess of alcohol's social costs. Conversely, if excise does more to deter moderate drinkers' consumption and to reduce heavy drinkers' consumption mostly on non-binge days, then it's harder to justify tax increases even if the total tax take is below social costs. The latter seems to be the case. We really need cost-effectiveness measures that weigh up both the value of harm avoided and the costs imposed on non-harmful consumption for any regulatory measure, whether excise or otherwise.

If we look back to Section 9 of the AHW report, they rightly note that some early studies on the J-curve combined never-drinkers with former drinkers, but take this as debunking the J-curve entirely, citing Fillmore (of course). They ignore di Catelnuovo and Donati. They note Rimm and Moats, but in the most superficial way. They write:
Rimm and Moats (2007) restricted analysis in a large prospective study to non-smoking men who exercised and ate a good diet. They found that among these men, those who drank moderately had a lower rate of coronary heart disease (CHD) than non-drinkers. They concluded that moderate drinking reduced the risk of CHD. However, the same possible confounders may apply and there are also harmful effects from moderate drinking. For women any such benefit may be outweighed by an increased risk of breast cancer.
Rimm and Moats picked a sample of very healthy men with good health behaviours. Within that group there remained strong protective effects of moderate alcohol consumption. The possibility for residual confounding among a group pre-selected for very healthy behaviours is much lower than among a pooled group with larger unobserved heterogeneity in health behaviours. And the effect was very large. I'd summarised the overall literature a while back.

And if AHW were right that "for women they [the benefits of moderate drinking] are outweighed by health dangers from moderate drinking, such as an increased risk of breast cancer", then we would hardly expect to find that the J-curve is stronger for women than for men, albeit with peak protection at a lower level of consumption than for men. Again, here's di Castelnuovo and Donati:
A J-shaped relationship between alcohol and total mortality was confirmed in adjusted studies, in both men and women. Consumption of alcohol, up to 4 drinks per day in men and 2 drinks per day in women, was inversely associated with total mortality, maximum protection being 18% in women (99% confidence interval, 13%-22%) and 17% in men (99% confidence interval, 15%-19%). Higher doses of alcohol were associated with increased mortality. The inverse association in women disappeared at doses lower than in men. When adjusted and unadjusted data were compared, the maximum protection was only reduced from 19% to 16%. The degree of association in men was lower in the United States than in Europe.
They also cite bad effects subsequent to the dropping of the alcohol purchase age and ignore Stillman's findings.


  1. Alcohol Healthwatch took $678,717 in government grants and contracts in the year to 2013, according to their annual report. That's 96% of their gross income. (

  2. $678,717 from government grants and contracts in the year to 2013, which is 95% of their gross income:

  3. Oh yes, council pool inspectors. At our last house (a rental on Auckland's North Shore) the inspector insisted that an extra set of door handles be fitted at a height only an adult could reach. The result was that any kid who did manage to find their way out to the pool area was guaranteed no possible way to get back into the house. A champion bit of safety.