How to Deal with the Harm of Alcohol? A Discussion of Nutt (2010).

According to Nutt (2010), alcohol causes more harm than any other drug. Is the answer to ban alcohol? Give reason to support your answer.

Author: Amelia Hart

Alcohol seems to have become almost a “fact of life” (Edwards, 2000), within day to day culture. Streets are overgrown with off-licences, bars and pubs and walls are covered in enticing advertisements. But hidden within these almost in-different drinking routines, is the reality of the harm that alcohol is having on both society and the user, something which is sometimes completely dismissed in every-day life (Edwards, 2000). Scientifically known as ‘Ethanol’, alcohol is a legal psychoactive drug, controlled by taxes, sales and age restrictions on consumption and purchase (Nutt et al, 2010), but within society it is often forgotten that alcohol is in fact a drug. Alcohol acts as a ‘depressant’ on the body, due to the way in which it slows responses, causing inhibitions and feelings of anxiety to be reduced and moods to be exaggerated and like any other drugs, its comes with a variety of side effects and risks, ranging from nausea to long term illnesses and death (Talk to Frank, 2011).  

Whilst the majority of drinkers are able drink in moderation, there are some individuals that struggle to control their consumption and therefore put both themselves and society at risk of harm (Plant, 1997). Problems falling at the hands of alcohol, scoping from family difficulties to early deaths, are slowly becoming a bigger concern from a local to an international level. So the question is, how do we minimise these harms? Do we have to ban alcohol completely? Or is there another way for society to be able to partake in a casual drink, without the potential outcome of great pain? (Edwards, 2000). For many years, alcohol has been a key point of interest to social scientists, but studies have tended to investigate the involvement of alcohol in aggression and violence (Chermack, 1997) and therefore research into the harm that alcohol causes as a whole is sparse.

However, in 2009 Professor David Nutt, who at the time was the chairman of the Advisory Council on the Misuse of Drugs, began to conduct the first stage of his study, “Drugs Harm in the UK: a multicriteria decision analysis”. His study attempted to analyse the harms that a range of different drugs pose to society and to the user, using his own criteria of harm. Nutt believed that drugs harm needed to be put through a much more vigorous assessment, to supply policy makers in areas such as Policing, Health and Social Care with better guidance (Nutt et al, 2010). The results of Nutt’s study found that it is in fact Alcohol that causes the most harm overall, which sparked much debate around both the legality and availability of the drug. This essay will therefore explore the question, “is the answer to ban alcohol? “, using the work of Nutt (2010) and multiple other sources of research. It will explore the advantages and disadvantages of eradicating alcohol completely, whilst looking into different ways of tackling the harm that alcohol consumption is causing by using different methods of minimisation.

Photo by Julia Nastogadka on Unsplash

The work of Professor David Nutt (2010), began to build on Nutt’s existing 2007 study, “Development of a rational scale to assess the harms of drugs of potential misuse” (Rolles & Measham, 2011), in which experts within the field where asked to score the drugs individually in compliance with a nine criteria of harm, triggering a mass of public interest and debate (Nutt, 2007). Much like the 2007 study, Nutt’s 2010 study aimed to asses and analyse drugs harms caused by the misuse of drugs, however this time Nutt wanted to carry out a more thorough assessment of drugs harms, analysing their harm in relation to one another, as he believed that this would facilitate a more impartial and conversant assessment of their harms. This would also aid policy makers in making effective decisions regarding controls (Nutt, 2010). To repair issues from his 2007 study, Nutt aimed to apply the Multi Criteria Decision Analysis (hereafter MCDA) Model to a range of psychoactive drugs harms within UK (Nutt et al, 2010), making it possible to apply a relative weighting to each drug harm, developing a much more in depth analysis of drugs harms. The use of MCDA also lays out a theoretical framework for additional reflection and modification (ACMD, 2010). Knowing that this assessment wasn’t going to be easy due to the extensive range of ways that drugs have the ability to cause harm, Nutt again enlisted the help of experts within the field to identify the harm criteria and score each of the drugs based on the criterion (Nutt et al, 2010).

The first step in creating this harm criteria was taken during a meeting in 2009 conducted by the UK Advisory Council on the Misuse of Drugs (hereby ACMD). During this meeting ‘scientific-experts’ made decisions on the harm’s they were going to include and developed a sixteen criteria of harm, nine of which were harm to self and seven were harm to society (Rolles & Measham, 2011). These harms where then gathered into five subgroups signifying Physical, Psychological and Social harm and then further ordered into, ‘To User, which would be harm to the individual using the drug and ‘To Others’ which would be harm as a result of the use of a drug to other, both directly and indirectly (ACMD, 2010). This is shown below in Figure 1 and 2.

Figure 1: (Nutt et al, 2010).
Figure 2: (Nutt et al, 2010).

The second stage then commenced in June 2010, whereby a meeting was arranged, supported by the Independent Scientific Committee on Drugs – a newly developed organisation of drug experts free of any government involvement- , to begin to construct the MCDA model. Within this meeting, scores for 20 indicative drugs all of which are pertinent to the UK and cover the range of possible harms, were also assessed (Nutt et al, 2010). During an open discussion the group scored each individual drug from 0-100 (0 showing no suggestion of harm), in accordance with each of the harm criterion and then went on to evaluate the significance of the criteria within each cluster (Nutt et al, 2010). These scores were then weighted, meaning that those drugs that scored 100 were compared across the full criteria, subsequently showing how certain drugs scoring 100, are more harmful than the others (ACMD, 2010). This process occasioned a ‘common unit of harm’ across each of the criterion, completing the new analysis of relative drugs harms (Nutt et al, 2010).

The findings of Nutt’s 2010 study found Heroin, Crack Cocaine and Metamphetamine to be the most harmful drugs to user (individual scores being 34, 37 and 32, correspondingly) and Alcohol, Heroin and Crack Cocaine to be the most harmful drugs to others (individual scores being 46, 21 and 17, correspondingly). The study found the most harmful drug overall to be Alcohol (overall harm score being 72), followed by Heroin (55) and Crack Cocaine (54) (Nutt, 2010). The figure below shows the overall weighted scores for each drug analysed.

Figure 3: (Nutt et al, 2010).

So what do Nutt’s findings show? Well firstly, these findings correspond greatly with the findings of the small amount of prior research there is into the area. For example Nutt’s 2007 study showed Alcohol to be a big factor in the causation of social harm (Nutt et al, 2007). The findings of the 2010 study also show how the current UK legal classification of drugs, bear little correspondence to the results and therefore display little resemblance to their harms (Nutt, 2010), which again follows on from what Nutt discovered in his 2007 study. However, there are a number of problems with this piece of research, the first being that legal status of the drugs isn’t taken into account. For example, Alcohol is a legal substance which is readily available to the general public and therefore much easier to access and consume than the majority of other drugs. This will clearly have an impact on its level of harm. Equally, the controlled status of a number of other drugs, such as Heroin, has the potential to make the drugs more harmful due to dangerous production on the drug, presenting risks like contamination and unsafe administration. This could then put the user at risk of contracting diseases such as HIV and blood born viruses (Nutt, 2010). Could making changes to the legal status and controls of drugs potentially minimise drugs harms? Could this therefore reduce the amount of alcohol related harm without having to ban the substance completely?

Another major issue with this study is that fact that it is based solely on the opinions of the professionals, rather than external evidence. This means the study is highly vulnerable to subjectivity and the findings maybe a result of bias, reducing their credibility (Rolles and Measham, 2011). Each of the professionals work with Professor David Nutt and it could therefore be said that they may be persuaded by his personal opinion, again leaving the findings open to bias. Although Nutt. Et al argued that the use of the “group process, known as ‘decision conference’” (2010:1564) was put in place to reduce bias, the method is lacking in recognised ways of measuring the reliability of the findings, such as inter-rater reliability between the professionals (Rolles and Measham, 2011). It has been said that repeating the study, but on a different group of individuals, may change the findings due to the subjective opinion of each expert (Cohen, 2010).

Although Nutt’s 2010 study began to develop a further understanding of drugs harms, replication of this study within other countries and with other significant individuals, such as those in the police, doctors, teachers and even users themselves, would form a bigger picture of drugs harms overall (Nutt, 2010). In 2015 a study named ‘European Rating of Drugs Harms’ was conducted by 4 EU drugs experts, one being David Nutt, which did just that (Van Amsterdam et al, 2015).  The study aimed to explore whether a European-wide agreement could be made regarding the respective overall harm of 20 of the most pertinent drugs. Then to consequently rank them from a European perception, thus creating a guide for future drug policy much like Nutt’s 2010 study. Using the same method as, ‘Drug Harms in the UK’, Alcohol, Heroin and Crack Cocaine again transpired to be the most harmful drugs overall (scoring 72, 55 and 50, respectively), showing how the previous results of Nutt’s 2010 study are supported throughout the EU.

So how does Nutt’s scale of harm transpire in real life? And how much harm is Alcohol truly causing its users and to the society it is used within?  It is important to apply the work of Nutt (2010) to reality and attempt to distinguish links between Alcohol and the harm criteria, to fully understand the capacity of alcohol related harm and to begin to think of the best way to tackle it. Furthermore, in order to accept Nutt’s findings that alcohol causes more harm than specified illicit drugs, comparing alcohol related harm with that of illicit drugs is necessary. When looking at Alcohols part scores, shown in Figure 3, there are three criterion that stand out due to their weighting being much bigger than the rest. These are Injury, Family Adversities and Economic Cost, all of which are categorised under ‘harm to others’.

 Injury is defined within the work as “Extent to which the use of the drug increases the chance of injuries to others both directly and indirectly-e.g. violence, (including domestic violence), traffic accidents, foetal harm…” (2010:1560). There is a strong link between Alcohol and Violence, mainly due to the fact that Alcohol reduces self-control, leading an individual to act in a way they potentially wouldn’t if they weren’t under the influence (CIVITAS, 2012). Alcohol is said to be involved in approximately 60% of all violent offences within England and Wales (Brennan, 2015) and research into Domestic Violence typically shows that between 25% and 50% of offenders that commit acts of domestic abuse, are under the influence of Alcohol when the assault is perpetrated, studies such as that of Bennett & Bland (IAS, 2014). That is potentially half of all domestically violent assaults. This percentage was found to be even higher in certain studies, such as “Domestic Violence Offenders: characteristics and offending related needs” by Gilchrist et al, which shows a much higher result of 73% (Gilchrist et al, 2003). It was also reported in the 2010/11 British Crime Survey that the victim believed the offender was under the influence of alcohol in 47% of violent cases, which equates to 917,000 offences and also 39% of domestic violence incidents (Home Office, 2011). However, it has been alleged that alcohol misuse doesn’t seem to be the root cause in domestic abuse, but more an intensifying factor, posing the idea that working with the perpetrator on both their alcohol consumption and their personal anger management could stop the violence (IAS, 2014). This suggests that banning alcohol consumption completely would not stop domestic violence, however intervention schemes focussing on personal aggression and alcohol use may do. Research has also found that alcohol plays a large part in the abuse of elderly people. For example, a study conducted by Homer & Gilleard (1990) found alcohol consumption in carers, to be major risk factor in the abuse of the elderly receiving respite care in England, with 45% of caregivers admitting to a form of abuse (WHO, 2005). Whilst alcohol should never be seen as a justification for why offenders commit acts of violence, its influence within the act should not be ignored, as this could be the gateway into minimising the harm that is being caused (IAS, 2014). So how does this compare with that of illicit drugs? The British Crime Survey 2008/09 found that a much lower number of victims, 19%, believed their offender was under that influence of an illicit drug at the time of the incident (WHO, 2009). That is 28% lower than that of alcohol, portraying that alcohol does potentially play a bigger role in violence than illicit drugs and is, as Nutt (2010) states, a more harmful drug.

Another major way in which alcohol is causing injury and harm to others is through traffic accidents. Since 1995, incidents involving drink-driving have made up 5% of all road-traffic accidents and 15% of all road deaths (CIVITAS, 2012).  From the figure below it is possible to see the mass of fatalities that drink-driving causes and begins to comprehend the harm that alcohol is producing.

Figure 4: (CIVITAS, 2012).

For comparison purposes, in England and Wales 2009/10 there were 618 homicides, meaning drink-driving incidents killed over half this amount of people (CIVITAS, 2012).  In 2015, there were 4,718 road traffic accidents due to alcohol impairment, 126 of these were fatal, 1,120 were classed as ‘serious’ and 3,522 were classed as ‘slight’ (Department of Transport, 2016), again showing the scale of harm that alcohol consumption is implementing on society. Is the only way to prevent this risk to eradicate alcohol consumption completely? When comparing these statistics to traffic accidents were the driver was impaired through illicit drug use, it is evident that alcohol is a much higher risk factor. In 2015 there were 881 road traffic accidents due to drug impairment, 62 were fatal, 259 were classed as ‘serious’ and 560 were classed as ‘slight’ (Department of Transport, 2016). Overall that means traffic accidents caused by drink driving were almost 6x more prevalent than that of drug-driving. This once again reiterates Nutt’s findings and poses the question, is the only solution to ban alcohol?

Another aspect of the ‘Injury’ criterion is foetal harm such as, Foetal Alcohol Syndrome (FAS). FAS is a form of Foetal Alcohol Spectrum Disorder (FASD), caused through the consumption of alcohol during pregnancy, subsequently resulting in mental and physical problems in the baby (NHS, 2017). Exact incidence of FASD within the UK is unknown due to a number of different factors, including differing definitions of the disorders and the lack of self-reported alcohol consumption, however international studies say that prevalence is 1 in every 100 babies minimum. This would therefore equate to between 6,000 and 7,000 babies born with FASD each year within the UK (NOFAS, 2011). Babies can also be born with disorders such as Neonatal Abstinence Syndrome if the mother has used opiate based drugs whilst pregnant, consequently the baby is born suffering the effects of opiate drug withdrawal. NHS statistics show that in 2014/15, 1,048 babies were born in England affected by maternal use of opiate based drugs, a much smaller number of babies than the estimates of babies born with FASD. This again shows how alcohol is causing more harm to others than that illicit drugs, following the findings of Nutt (2010) and begins to question why it is that alcohol is more accepted both socially and within the eyes of the law.

This then follows through into the criterion ‘Family Adversities’, defined within Nutt’s work as, “Extent to which the use of a drug causes family adversities” and looks into factors of harm such as child neglect (1560:2010) . In a report prepared by 2 members of the NSPCC and a Professor of Applied Psychology, it is stated that in England around 79,000 babies under the age of 1 are living with a parent who is categorised as a ‘hazardous or harmful’ drinker (Rayns et al, n.d.). These statistics are the result of analysis of the National Psychiatry Morbidity Survey 2007. Research shows that excessive drinking in parents has links to poor parenting practice, for instance not being affectionate towards the child and showing high criticism and when the parents focus becomes the alcohol, this then results in a compromised capacity to parent, thus they become less caring and unpredictable (Cleaver et al, 2011). The misuse of alcohol is also thought to be a significant risk factor is child neglect cases of injury and death due to co-sleeping (Blair et al, 2009). On comparison with illicit drugs it can again be said that alcohol is the more harmful substance, as statistics from the same report show around 43,000 babies under the age of 1 to be living with a parent who uses illicit drugs (Rayns et al, n.d.)

The final criterion that makes up the 3 highest part scores for alcohol is Economic Cost, which is defined as, “Extent to which the use of a drug causes direct costs to the country, e.g. health care, police…” by Nutt et al (1560:2010). In a review conducted by Public Health England it is stated that alcohol-related harms in 2016 held a total economic cost of between £27bn and £52bn (Campbell D, 2016), something that has been commonly underestimated. A report by Drink Aware states that this cost is annually around £21bn and is inclusive of £11bn crime costs, £3.5bn to the NHS due to ill-health and £7.3bn in loss of productivity (Drink Aware, 2016), but admits that this has been challenged. Alcohol-related hospital admissions, narrow measure, in 2014/15 made up 2.1% (339,000) of all hospital admissions. Broad measure made up 7% (1.1million) of all hospital admission and nearly half of these were for Cardiovascular Disease and constitute a lot of the alcohol-related costings to the NHS (ONS, 2017).  In 2016, 188,000 prescriptions for alcohol dependency were distributed and the total Net Ingredient Cost for these prescriptions was £4.87 million (ONS, 2017). In comparison to the £730 million cost to fund methadone prescriptions (The Telegraph, 2011), the cost of alcohol prescriptions seems quite inferior and therefore poses the question, why is it that so much money is being put into treating drug addiction, when alcohol seems to be posing the biggest threat to both the consumer and society’s safety? Could a more developed alcohol treatment service, minimise the harms being caused, without having to forbid the use of it entirely?

Although the above has discussed the three highest scoring criteria, Injury, Family Adversity and Economic Cost do not constitute the full scale of alcohol-related harm. Drug Related Mortality is “The extent to which life is shortened by the use of the drug” (Nutt 2010:1560). In 2015 there were 6,813 deaths relating to alcohol consumption, making up 1.4% of all deaths, 65% of which fell at the hands of liver disease. Drug-related deaths made up a smaller 0.5% of all deaths, 2,479 registered deaths, proving that alcohol isn’t just causing more harm to the society its used within, but also to the user themselves (ONS, 2017). Finally Crime, which is defined as “Extent to which the use of a drug involves or leads to an increase in volume of acquisitive crime (beyond the drugs act) directly or indirectly)” by Nutt et al, (2010:1560), is also closely related to alcohol consumption. This essay has already discussed alcohol in violence, (in particular domestic violence), drink-driving and child-neglect, all of which are of criminal nature creating a strong association between alcohol and crime. However a major piece of evidence that solidifies this relationship is within the analysis of the NEW-ADAM report. 57% of arrestees were found to be problematic or dependent drinkers and 56% stated they had used it in the past 3 days (Bennett T, 2007), portraying a link between alcohol consumption and criminal behaviour. Does this mean that by banning alcohol, crime rates may subside?

The main question is how do we tackle the harm that alcohol is causing? Is the only solution to ban alcohol or is it possible to minimise the harms through different methods? This essay has briefly touched on the idea that changing alcohols legal status, may result in a reduction of harm. The Misuse of Drugs Act 1971 provides, “…the basis of control for certain drugs (controlled) whose misuse gives rise to social problems”, (Department of Health, 1989:1), however despite the fact that there is a multitude of evidence suggesting that alcohol causes more harm than any other drug, it is not controlled under the act, yet Magic Mushrooms that scored the lowest on Nutt’s scale of harm are classified as a class A drug (Nutt et al, 2010). Nevertheless, making the substance illegal, prohibiting both sale and consumption of alcohol, may result in more harm to user due to unsafe production (Nutt, 2010), so it is impossible to say conclusively that illegalising alcohol would reduce harm. An example of this would be the trial of Prohibition in 1920’s America, the idea being to eradicate the negative effects of alcohol on society and to restore peace within it (Edwards, 2003). Prohibition was subsequently abandoned nearly 14 years later, having failed to meet its aims and additionally giving rise to an increase of organised crime (Edwards, 2003). Furthermore, a study by Dills et al, found that prohibition has some short-term impact, but very little long-term impact, depicting that prohibition would not work as a long-term solution to alcohol-related harm (Dills et al, 2005). There is also studies that suggest that alcohol in moderation lowers the risk of heart conditions, due to the positive effects that alcohol has on cholesterol levels (Siddique, 2017) and therefore prohibiting alcohol consumption completely would remove some of the positive effects that alcohol can provide.

Instead of controlling alcohols legal status, it may be more beneficial to further control aspects of consumption, purchase, the media and marketing that surrounds the alcohol trade and also educating society in the dangers that misuse poses. It has been found that increasing the age restrictions on drinking has had a positive effect on the minimisation of alcohol-related harm, for example when the US raised the minimum legal age to drink they saw a fall In traffic-accidents involving young people, thus suggesting that age and harm of this nature have a fairly clear relationship (Raistrick et al, 1999). It has also been found that creating a safer drinking environment by use of server-intervention and responsible beverage server programmes, can dramatically reduce intoxication and alcohol impairment, subsequently reducing alcohol related injuries and deaths (Plant et al, 1997). Controlling both the number and the size of alcohol outlets and their hours of sale could also assist in minimising the harms alcohol poses (WHO, 2012), as this would begin to restrict its availability and convenience. Minimum pricing laws are another efficient way of minimising alcohol-misuse, due to the fact that one of the main determinates surrounding alcohol consumption is affordability (WHO, 2012), and therefore upping the prices per unit should lead to reduced alcohol consumption. A current example of this would be the 50p minimum pricing (per unit) that will be introduced in Scotland in the near future. The aim of this new law is to tackle binge drinking and sets out to reduce hospital admissions by 8,254 in the first five years, consequently minimising alcohol-related harm (Carrell, 2017). A further way to tackle harm would be within the mass media, for example promoting moderate drinking behaviours and exposing the harms that misuse carries (Raistrick et al, 1999), much like the Talk to Frank adverts do with illicit drug use. With regards to marketing, introducing both standardised packaging, like that of cigarettes, and unit labelling on both consumer and health care goods would educate the user on the amount of alcohol they are consuming as studies, such as Stockwell et al 1990, show that both wine and beer drinkers considerably underestimated the amount of units within their drink and therefore could not control consumption (Raistrick et al, 1999). A final way of attempting to minimise the risks that alcohol misuses poses is treatment for alcoholism, such as Alcoholics Anonymous. Alcoholics Anonymous is a ‘fellowship’ aiming to help alcoholics that wish to be sober, in discovering and sustaining abstinence (Alcoholics Anonymous, 2017). The fellowship uses the saying, “once an alcoholic, always an alcoholic”, believing that sobriety is the only way forward and that acceptance of this puts the user on the path to recovery (Edwards, 2003). Although, it has been suggested that no single treatment fits all and that minimising alcohol misuse and subsequently alcohol-related harm through Alcoholics Anonymous may be ineffective (Beck et al, 1993).

To conclude, this essay has attempted to answer the question, ‘is the answer to ban alcohol?’ in relation to the work of Nutt 2010 and multiple other researchers. As alcohol is slowly becoming almost this ‘fact of life’ (Edwards 2003), alcohol-related harm is becoming more of a wide-spread issue on both an individual and social level. The work of Nutt et al 2010, accomplished its aims and developed an extremely in-depth assessment of relative drugs harms, not only providing policy-makers with guidelines but bringing to light the reality of what alcohol is capable of. Although many would say that the only way to control the risk that alcohol poses is by banning the use of alcohol, history has proven that attempting to eradicate consumption completely, worked more as a catalyst for crime than as a deterrent of harm. Prohibiting consumption would also remove the positive aspects that alcohol brings to a moderate users health and social life, as previously discussed. Therefore, a more realistic and effective approach to minimising alcohol-related harm would be to control and regulate the substance in terms of consumption, pricing, availability, mass media and marketing. Implementing a higher age restriction on consumption, as previously explored, had been proven to reduce harm, as has controlling the drinking environment. Estimates made in relation to Scotland’s introduction of a minimum price, provides support for the potential minimisation of harm caused by alcohol consumption and studies regarding unit labelling suggest that if the consumer was more aware of the strength of the substance, they would have the ability to regulate and control their own consumption. Overall, it seems strengthening the regulations surrounding alcohol would act as a more realistic and effective solution and provide a better answer to minimising alcohol-related harm within society.


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