Betty Ford has every right to be proud of these programs. It’s worth noting that in the past decade, many children’s programs have disappeared. Says Moe: “So often in our field, these programs are the first to be cut. If I had a dream? All treatment centers would have to have a children’s program to become accredited.”
What does it feel like to be a mother in recovery, helping young children make sense of what they remember of your drinking past, and to adjust to your sober present? A woman I will call Lesley agrees to meet me for coffee, and to discuss why she is determined that her children will be exposed to “others in similar circumstances, to help them to talk about alcohol openly and realize it isn’t a big secret. To draw it out is not an easy process—the feelings and emotions.”
Poised and beautiful, with a mellifluous voice, Lesley is a picture of self-control. Her story is otherwise. The forty-two-year-old mother of two says: “I loved drinking from the very beginning: the sense of ease and comfort it brought. It made me feel confident. It was easy to socialize. But at sixteen, I blacked out with my first drink. My family drank heavily, and no one criticized me when I would come home from a date and pass out on the kitchen floor. And by the time I was eighteen, I was starting to feel the shame. I knew it was causing me heartache: all my relationships were falling apart. And for that reason, I could not wait to leave home.”
At twenty, Lesley moved to Toronto—but the geographic cure did not work. On her first night in the city, she went to a downtown pub, and ended up falling in a ditch. “That was the story of my life,” she says. “People having to get me home.”
Eventually, Lesley fell in love, married, and had two children, now twelve and eight. Married life came with a family cottage—a lifestyle that was suited, as she says, “to an alcoholic. Caesars at breakfast, beer in the afternoon, wine at dinner, then shooters of tequila. I loved it—and I hated it.” Eventually she decided she should cut back her drinking—and she spent several years trying to find a solution: “I did a program of controlled drinking. That didn’t work. I couldn’t stop. I did hypnosis with a doctor. That didn’t work. I tried drinking something I didn’t like—beer. That didn’t work. I asked my husband to tell me when I had had enough. That didn’t work because I would say, ‘Don’t tell me what to do.’”
Her drinking caught up with her. One afternoon, she left her two young children and three others she was babysitting to buy vodka. That night at dinner, her young daughter described what had happened. “No, I was just moving the car,” said Lesley. Her daughter challenged her story. Lesley had to tell the truth.
Within weeks, her siblings intervened on her at a family reunion. By that point, says Lesley, “I was destroyed, emotionally, spiritually, physically destroyed.” She joined Alcoholics Anonymous, and she stayed. She found a new job, working with people she likes. However, her marriage ended and there has been a lot of “emotional turmoil” for her children.
Most recently, Lesley has had her daughter and son take part in the Children’s Program at Renascent treatment center in Toronto. “There was a lot of turmoil,” she says. “I was very worried about my children’s emotional well-being.”
Heather Amisson, a family counselor at Renascent who leads the adult portion of the Children’s Program, is herself a mother in recovery—a wife of an alcoholic, a daughter of two alcoholics, a mother of two, a niece, and an aunt. “It’s really difficult for us to forgive ourselves,” says Amisson, who has been sober for many years. “Even now, it’s a struggle for me.” In the Children’s Program, each child writes a letter to the addiction of their parent. They also make a family shield, one that articulates the family traditions that would make a difference in their life: meals together, shared outings. The shield is then framed and presented to the parent. “It’s very powerful,” says Amisson. “We really believe addiction is a family disease, and often the addicted person didn’t do the simple care things. This weekend brings a recognition that traditions matter. Meanwhile, it’s really important that we present things in a way that doesn’t cause the mother to shut down. The shame can cause a woman to do this—feelings of remorse, guilt, living in the past. We’re trying to keep the shame and blame off, and help them take care of their family.”
For Lesley, this has meant establishing new traditions with her children. Friday night is pizza and movie night; Sunday means going to church and then to a local bookstore. They play charades on Sunday night. Says Lesley, “It’s not an easy process. But I want them to feel loved.” Today she is not ashamed of her drinking. “It’s a victory,” says Lesley. “I fought a battle that not many win. There is hope.”
15.
Something in the Water
SHAPING A STRONG PUBLIC HEALTH STRATEGY
Here’s a question. Let’s say there’s a frog pond where a growing number of frogs are developing odd-looking growths, and others are becoming sterile. Do you send in surgeons to remove the growths, and fertility experts to deal with the sterility? Or do you say to yourself: maybe there’s something in the water?
—DAN REIST, ASSISTANT DIRECTOR, KNOWLEDGE EXCHANGE, CENTRE FOR ADDICTIONS RESEARCH OF BRITISH COLUMBIA
Is there something in the water? Of course there is. We live in an alcogenic culture, one where risky drinking has been normalized. We swim in an ocean of advertising, and that advertising says one thing: drink, and great things will happen. We absorb this in our pores. In fact, it’s so prevalent, we barely notice it.
Robert Brewer knows there’s something in the water. “This is a huge public health problem,” says the leader of the alcohol program at the National Center for Chronic Disease Prevention in Atlanta, a division of the Centers for Disease Control. “We have to broaden our understanding of what we consider an alcohol problem to be—well over eighty percent of frequent binge drinkers are not alcohol dependent.”
Robert Strang agrees. The chief public health officer of the province of Nova Scotia, Strang knows that the culture of normalized heavy drinking is growing. “This is not an addiction issue,” says Strang. “Addiction is the far end of the spectrum. This is about the impact of alcohol right across society. Lots of harms are coming from those who are not addicted. Periodic, episodic binge drinking leads to acute and chronic problems in society. The problem with alcohol? We don’t acknowledge it as a drug—and as such, we haven’t paid enough attention to it.
“It’s about changing social norms,” says Strang, “getting those communities already aware of the damage to work together—the medical community, the FASD community, the violence against women community, the road safety community, the breast cancer people. We need to have a robust discussion about this issue: How does alcohol play out in your community? In terms of suicides? Kids being abused? Violence? Teens in emergency rooms? Are we having an adult discussion? I don’t think so.”
Is there something in the water? Mike Daube knows there is. Well seasoned from the tobacco wars—he was the first full-time director of Action on Smoking and Health in the U.K.—Daube is cochair of Australia’s National Alliance on Alcohol. Says Daube: “Alcohol is where tobacco was forty years ago. And it’s the same: a massive and powerful industry, cynically promoting its product. There is a ruthless recognition by industry that young people have more access, freedom, and money than ever before—products are designed and marketed, targeting young women to get drunk as quickly as possible.”
There is no doubt: the U.S. Congress, state legislatures, local city councils, and provincial governments around the world are in the pocket of big alcohol. The alcohol industry employs one lobbyist for every two members of Congress. It gives generously and across political party lines. And it succeeds, over and over again, at blocking evidence-based public health steps to control alcohol problems.
Is alcohol the new tobacco? Strang believes the answer is yes. A veteran of the tobacco fight, he is determined that the harm from drinking be recognized faster than it was with smoking. “We had to work for thirty or forty years on tobacco,” he
says. “If we apply what we learned on tobacco control concerning price, advertising, and access, we could make significant progress on alcohol in a much shorter period of time.”
What Brewer and Strang and Daube are envisioning is a comprehensive public health response to the harm caused by alcohol. They are far from alone in their fight to move alcohol to the top of the public agenda. But what government wants to tamper with our favorite drug? Says alcohol policy guru Robin Room, who has experience in the United States, Canada, Sweden, and Australia: “As market-friendly governments get more desperate as to what they’re going to do about alcohol, you see a move back into a more individualized control system: deal with the bad-apple killer drunk and leave the market alone.”
Market-friendly governments may want to ignore the broader picture, but the evidence is building: alcohol-related harm is widespread. It’s costly. It’s disturbing. This is a public health issue, and it’s begging for leadership. Says Jürgen Rehm, director of social and epidemiological research at the Centre for Addiction and Mental Health, author of more than five hundred journal articles and ten books: “When you consider the science, alcohol is doing the most harm in our society. Unless we start seeing leadership on alcohol policy, our life expectancy will decrease. We should move on taxes, on pricing, on advertising, on the general availability of alcohol.”
What is public policy? At its very essence, it’s a simple equation: evidence plus values plus politics equals policy. We have solid evidence that widespread risky drinking is costly. We also have solid evidence that key policy levers will influence this picture: upping price, restricting the accessibility of alcohol, and limiting marketing are the three strongest. Press on those levers and you can shift consumption. You can also tackle some other big problems along the way: alcohol taxes are easy to administer, and would cover many shortfalls in cash-strapped times.
But society has to want to make those shifts—and to do so, we have to be clear about our values. Let’s face it: when it comes to alcohol, our values are a little fuzzy. We tend to other the problem: it’s the rare alcoholic, the drunk driver, the guy on the street corner swigging from the brown paper bag. And if it’s our own problem? Well, we’re just trying to drink like the French or the Italians.
Actually, only a small proportion of the population are alcoholic. If you eliminated all risky drinking, you would decimate alcohol sales. Says Rehm: “Our drinking patterns are not benign. Alcohol consumption creates more harm to others than secondhand smoke. It’s about time we took a hard look at the problems that drinkers cause in their immediate environment and in society at large. This starts with family problems and ends with drunk drivers.” In 2010, in the first major study of its kind, Australian researchers estimated that the costs of harm to others matched the traditional costs of the drinker to society.
Solid evidence plus fuzzy values adds up to political inaction—inaction for which women may pay a bigger price than men. Policy isn’t gendered. No, says Sally Casswell, director of the Centre for Social and Health Outcomes Research and Evaluation at Massey University in New Zealand. “But what we’re looking to do is to prevent the early uptake and heavy drinking of young women—and we can only do this through state policy versus educating them.”
Tim Naimi, a physician and alcohol research scientist at Boston Medical Center, takes it one step further. “Parity in alcohol consumption is one area in which the otherwise wonderful overall trend towards greater gender ‘equality’ is shaping up to be an unmitigated disaster for women. Women arguably have the most to gain from a strong policy environment: they are disproportionately likely to suffer the health and social effects of alcohol abuse, to suffer from interpersonal violence including sexual assaults, and sexually transmitted infections. They are definitely prone to the secondhand effects of excessive consumption.”
Policy shifts can cause seismic cultural and environmental shifts. This is well documented. Look at drunk driving. Look at tobacco control. But as the feisty, seasoned California activist James Mosher says: “With tobacco, it was easier. We eradicated the product. With alcohol, you want to manage it. But as you know, politics are so driven by special interests—and money. We don’t have the power base to counter the strategic lobbying of the alcohol industry.”
Which raises the question: what would a comprehensive public health response look like? Since alcohol-related harm is an under-the-radar issue, each country should begin by creating a comprehensive national alcohol strategy. Strategies need teeth: strong federal endorsement, with the understanding that all levels of government will engage in the solutions, including regional and municipal, state and local. Each has a role to play.
Strong strategy should make a priority of the three most effective policy tools: taxing and pricing, restrictions on accessibility, and limitations on marketing.
When it comes to taxing and pricing, the implementation of minimum pricing and the indexing of price to inflation are key. The following formula is time-tested and true: price goes up, consumption goes down. Minimum pricing is the most targeted approach because it has the strongest effect. It targets the youngest drinkers, who prefer cheap alcohol, and the heaviest drinkers. It’s the most feasible and publicly acceptable because it’s not hitting everyone’s hip pocket. And the health benefits are significant: many fewer people die.
On pricing, British-born Tim Stockwell is the international go-to guy: this is the man the Scottish parliament turned to when they wanted advice in 2011. Currently head of the Centre for Addictions Research of B.C., Stockwell gives Canada full marks for its minimum pricing: “This country is almost alone in setting the floor, or minimum prices for alcohol.” In a recent paper in the American Journal of Public Health, he reports that a 10 percent rise in the price of alcohol is associated with a 9 percent drop in hospital admissions for acute alcohol-related issues—“those people getting drunk and injuring themselves”—and a similar drop over two to three years in admissions for chronic alcohol-related problems.
Scotland has indeed declared its intention to set a minimum price for a standard unit of alcohol at fifty pence—a decision backed by the medical profession. There was an immediate backlash. The policy was challenged by the European Union: backed by such wine-producing countries as France, Spain, and Italy, the EU said the minimum pricing breaches free trade. Moreover, the Scotch Whisky Association and Spirits Europe were granted judicial review of the legislation: they have many arguments, including one saying that minimum pricing would damage a valuable export industry. Whiskey is Scotland’s number one export after oil and gas. The Scottish government won the first round in what looks to be a lengthy court battle when a judge ruled that its decision to set a minimum price for alcohol was legal and justified. The brouhaha pleases Stockwell, whose research has been at the center of much of the press: “There hasn’t been such a sustained debate about alcohol policy in many, many years—something good will come of this.”
Meanwhile, Prime Minister David Cameron seems to have reneged on his promise to stop the flow of cheap alcohol being sold in British supermarkets. He has been quoted as saying that he wished to eradicate the reality of twenty-pence cans of lager. A base price of forty-five pence per unit had been proposed for England and Wales, but Cameron seems to have abandoned his commitment to minimum pricing. The medical community and others are pushing him to be courageous: “don’t wimp out” is the general message. In the U.K., there are more than a million alcohol-related hospital admissions each year.
Very few expect the United States to tackle minimum pricing. In most states, alcohol is just plain cheap. You can visit a corner store in many American cities and find that beer is the cheapest liquid available—cheaper than water, orange juice, or milk. Federal alcohol taxes have not been raised since 1991. Historically, there was a time when alcohol taxes accounted for 30 percent or more of federal government revenues; now they account for less than half a percent.
Few states have addressed the tax issue. The most r
ecent hike was in Maryland in 2011: significant politically, but minimal in price—three cents on the dollar. Bear in mind that in the United States, alcohol-related costs amount to an estimated $220 billion annually. Ideally, Congress would maximize excise taxes, and link them to inflation. This could have a major impact and raise revenue—but there is no sign of anything happening in the foreseeable future. “The landscape is pretty bleak at the moment,” says Naimi. “Ultimately, cheap booze is not healthy for society. And industry is framing the issue—not public health.”
Says the influential Thomas Greenfield, director of the California-based Alcohol Research Group: “Public health won the battle against tobacco. But in the alcohol area, the producers are shrewd. And gender convergence is propping up sales. The cocktail culture is alive and well.”
Which brings the discussion to accessibility. This one’s simple. “The fewer miles between you and the nearest alcohol outlet, the more likely you are to drink,” says Stockwell. “If you let the market control alcohol access, public health and safety are out the window.” In much of the United States, it’s possible to buy beer and wine 24/7 in grocery and drugstores. In Britain, alcohol is often used as a loss leader in its four major supermarket chains: Tesco, Sainsbury’s, Asda, and Morrisons. There alcohol is 44 percent more affordable, in real terms, than it was in 1980. Accessible, and cheap.
When it comes to marketing, I turn to David Jernigan, director of the Center on Alcohol Marketing and Youth at Johns Hopkins University. He points out that after decades of using women to sell alcohol to men, alcohol companies have discovered they need women to drink—and they are marketing accordingly. And countries like the United States, with its protections for “commercial speech,” offer a clear runway for that marketing to take off. “The solution is going to be different in each setting,” he says. He cites South Africa, where there is a proposal to ban all alcohol advertising. “In South Africa, drinkers tend to drink heavily, but most of the population abstains. Advertising will recruit new drinkers into that heavy-drinking pattern. With the heavy problematic drinking that exists, allowing advertising a free hand is a mistake.”
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