Lay Epidemiology and Alcohol: A Critical Review

Overview of public health issue

Alcohol consumption

Excessive consumption of alcohol is a global public health concern due to the extensive

number of adverse health conditions that it is linked to including cancer, diabetes, heart

disease and strokes (Rosenberg et al., 2017). Alarmingly, the number of alcohol specific

deaths in the UK is following an upwards trend, with an 11% increase from 2006 to 2016

(Office for National Statistics, 2017). This further increased in 2017, from 5507 alcohol-

specific deaths, to 7697 (Office for National Statistics, 2018). However, this public health

concern extends further than the UK, with alcohol being attributable to 5.1% of the global

burden of disease and injury (World Health Organisation, 2018). Alcohol consumption is not

only a major public health issue due to the range of non-communicable diseases associated

with it, but also because of the cost to society through alcohol-related crime, lost productivity

through unemployment and sickness and the increased burden on the NHS (Fenton &

Newton, 2016). For these reasons, governments and public health bodies are continually

working to raise public awareness on the health impacts of excessive alcohol intake – making

consumption guidelines undoubtedly an important policy consideration. Revised alcohol

guidelines were issued in the UK in 2016 – this being the first time they were updated since

1995 (Stautz et al., 2017). The revised guidelines can be seen in Table 1 – they provide

advice for both regular and single occasion drinking and are based on expert understandings

of the health risks of alcohol consumption, both short and long-term (Stautz et al., 2017).

However, inconsistencies in typical serving sizes, differences in drinking cultures and

discrepancies among recommendations between countries all play a role in making current

guidelines somewhat undervalued and insufficient (Makela & Montonen, 2018).

Table 1. Current UK alcohol guidelines (Drink Aware, 2019)

Low-risk guidelines Single-occasion guidelines

To keep health risks from alcohol to a low

level it is safest not to drink more than 14

units per week on a regular basis

Limit the total amount of alcohol you drink

on any single occasion

Spread your drinking evenly over 3 or more

days

Drink more slowly, drink with food and

alternate with water

Plan ahead to avoid problems – make sure

you can get home safely or that you have

people you trust with you

Lay epidemiology

Research to identify other barriers which may be preventing the population from

understanding or adhering to government guidelines is also being carried out, with some

research focusing on how lay epidemiology effects the public’s perception of alcohol

guidelines (Lovatt et al., 2015). Lay epidemiology was demonstrated by Davison et al.,

(1991) in their work on CHD, finding that lay people take a more holistic approach when

considering health risks – utilising their personal experiences and observations to reformulate

public health messages and generate their own ideas of ‘candidates’ for health problems. The

concept of lay epidemiology is somewhat a result of the post-modern world, in which a

decrease in stability and an increase in autonomy have led the truth to be ‘based on a system

agreed by society in terms of current scientific knowledge, cost and the personal preference

of individuals’ (Raithatha, N. 1997). Lay epidemiology is, in itself, a public health concern

due to the barrier that it places in the way of the public when it comes to believing and acting

upon public health messages (Allmark and Tod, 2006). Research has been carried out in

order to explore how lay epidemiology affects the way in which drinkers make sense of

drinking guidelines (Lovatt et al., 2015) – this paper aims to provide a critical analysis of this

work, with further discussion of the epidemiological issues associated with alcohol

consumption and the current situation regarding policy.

Issues regarding data collection

Lovatt and colleagues (2015) provide a clear statement outlining the aims of their research –

to explore how drinkers interpret the current UK drinking guidelines in the context of their

own drinking practices and risk perceptions. Such research is clearly of great relevance and

importance, considering the current situation regarding excessive alcohol consumption in the

UK (Rosenberg et al., 2017). A qualitative approach to data collection was taken for the

study, given its aim to identify personal insights into lay interpretations of drinking

guidelines. The ability to evaluate qualitative research in terms of the conventional criteria

used for quantitative research has previously been questioned (Leung, 2015). Rightly,

researchers contend that qualitative and quantitative research are based on different

paradigms, with quantitative research allowing findings to be grounded on reliability and

validity in order to find ‘truth’ – principles which are inappropriate in qualitative research

(Leung, 2015). However, the purpose of qualitative research is the in-depth exploration of a

specific phenomenon, which further knowledge can be built on, as opposed to the

generalisability of the results (Thomas & Magilvy, 2011). For these reasons, it is now widely

accepted that qualitative research is able to provide complexity and context to a scientific

field, as long as qualitative rigor is upheld (Thomas & Magilvy, 2011). Furthermore, this

research forms part of a larger study – Alcohol Policy Interventions in Scotland and England

(APISE) – which also comprises of quantitative research papers, therefore aiding in providing

a mixed methods approach to the overall findings of the larger study – an approach

considered particularly useful to strengthen understandings of policy support (Li et al., 2017).

Participants were purposively sampled 19-65-year-old male and female drinkers of both

lower and higher socio-economic backgrounds. Purposive sampling allows researchers to

deliberately select the type of people that they wish to obtain information from for the

purpose of their study, in order to establish a theoretical awareness of the cultural variables of

the population (Etikan et al., 2016; Taherdoost, 2016). However, it is recognised that

selecting a sample in this way may provide opportunity for selection bias, therefore imposing

limitations on the findings (Etikan et al., 2016). Although in this case the researcher failed to

specify the type of purposive sampling used, it would appear to be maximum variation

sampling, as the researcher produced a sample of high individual variation. Although this

type of sampling limits the generalisability of results, as afore mentioned, it allows for depth

as opposed to breadth – providing the researcher with the ability to achieve a greater insight

by covering all available angles (Etikan et al., 2016). Furthermore, maximum variation

sampling aids the researcher in identifying common themes which may occur across the

sample. From an epidemiological perspective, this is of particular importance in order to

identify if a particular demographic is of higher concern, or whether lay epidemiology is

affecting the utilisation of public health messages throughout the entire population.

However, in the case of this study, the author fails to identify differing opinions between

demographic groups. Instead, a general consensus between groups is noted in the cases of:

“participants of all ages felt that having a guideline for daily use was unhelpful” (Lovatt

1915) and “attitudes towards drinking in relation to long-term health conditions did not

generally appear to be linked strongly to age or gender” (Lovatt 1915). It is highlighted that

one participant from the 19-24 group considered himself not to be at risk, as he would drink

less as he got older and only associated risk with prolonged heavy drinking (Lovatt et al.,

2015). This suggests that the young population may specifically be at risk of using alternative

reasoning derived from their own risk perceptions in order to monitor their drinking – this

specifically demonstrates how lay epidemiology informs alcohol related risk within 19-24-

year olds. However, due to the small sample size it is uncertain whether this can be applied to

the whole population. Aside from this, demographic variances seem to be largely ignored.

Previous findings have demonstrated that those living in more deprived areas are more likely

to die or suffer from alcohol-related disease (Burton et al., 2017), hence, Lovatt and

colleagues had an opportunity to add to such findings and indicate whether or not lay

epidemiology could be a contributing factor to this. Nonetheless, the findings focus on

common beliefs and opinions of an inclusive sample with regards to the alcohol guidelines,

therefore still provide valuable insight for policymakers.

Focus groups were the chosen method of data collection for this study, allowing a large

amount of information to be obtained from a small number of participants (Thomas &

Magilvy, 2011) – 66 in total. Focus groups are an effective way of not only gaining an

understanding of participants attitudes, beliefs and opinions, but also how these can change

and develop through interaction with other people (Carey & Asbury, 2016). However, a small

number of participants may preside over the discussion, setting a perceived group norm and

leading to a ‘false consensus’ (Carey & Asbury, 2016). In order to overcome such areas for

error in data collection, one to one interview’s are often used in qualitative research to extract

behavioural information and personal insight – such a form of data collection may also have

been appropriate for this study (Carey & Asbury, 2016). However, in order to reduce the

likelihood of such a bias occurring, Lovatt and colleagues encouraged moderators to promote

the group to discuss any differences of opinion.

Discussion of the impact of policies

In response to excessive alcohol consumption, at least 37 countries have published low-risk

consumption guidelines aimed at informing the public on how to manage their intake

(Kalinowski & Humphreys, 2016). However, the findings of Lovatt et al. (2015) demonstrate

that in the UK, these guidelines are generally disregarded due to three main interrelated

factors; a divide between the guidelines being based on regular consumption and participants’

tendency to drink irregularly, a divide between the guideline amounts and participants’

typical consumption levels and finally, difficulties measuring and monitoring units. In the

UK, the recommendation is to not exceed fourteen units per week, which should be evenly

spread over at least three days (Drink Aware, 2019). However, this differs between countries,

as demonstrated in Table 2.

Table 2. Inconsistencies between guidelines in differing countries (Lovatt et al., 2015)

Country Regular guideline Single occasion guideline

Australia No more than 3 units per

day for both men and

women.

No more than 5 units on a

single occasion.

Canada Women should drink no

more than 17 units per week,

with no more than 3 units

per day.

Men should drink no more

than 25 units per week, with

no more than 5 units per

day.

No more than 5 units for

women and 7 units for men

on a single occasion.

Stay within the weekly

limits.

These substantial variances in guidelines makes the publics difficulty measuring and

monitoring units and general ambivalence towards alcohol related risk limits somewhat

unsurprising. This confusion around measuring intake is further demonstrated in a more

recent study evaluating reactions to the updated 2016 guidelines on social media platform

Twitter, with one member of the public sharing: ‘They won’t engage the public by referring

to “units” rather than commonly understood measures’ (Stautz et al., 2017, 5). After

identifying all posts on twitter with the hashtag ‘alcohol guidelines’ posted one week after the

revisions were made public, the study found 103 other posts with a general theme of

confusion (Stautz et al., 2017). These findings support those of Lovatt et al. (2015) and

highlight a primary concern with regards to the current government guidelines – although

aimed at the general public, they fail to be published in layperson terms and therefore fail to

be understood and engaged with by the target audience.

Since the affordability of alcohol is a key determinant of both related consumption and harm,

price regulation represents a vital element of policy (Burton et al., 2017). In May 2018, the

Scottish government introduced minimum unit pricing (MUP) of 50p per unit, after

considering modelled evidence from both the UK and Australia demonstrating its ability to

be a highly effective strategy for reducing alcohol consumption (Angus et al., 2016; Sharma

et al., 2016). Such a pricing policy is expected to impact consumption levels the most among

those that are at greatest risk of alcohol related harm (Angus et al., 2016; Sharma et al.,

2016). This is due to the MUP having the greatest effect on the alcohol causing the most

damage – the cheapest and strongest – which is consumed disproportionately in the most

deprived groups (Angus et al., 2016; Sharma et al., 2016). Furthermore, some areas of

Canada implemented MUP ahead of Scotland, the evaluation of which confirms the findings

of the modelled studies, demonstrating that a 10% increase in the minimum price of alcohol

led to a reduction in total consumption of 8.4% in just two years (Stockwell et al., 2012).

Despite this, such policies are often considered paternalistic and can acquire opposition from

the public, who feel their freedom of choice is being interfered with (Marteau, 2016). Recent

research into public attitudes towards alcohol control policies supported this notion, with

restricting access to alcohol through increasing the price being the least popular policy option

(Li et al., 2017). This is not only evident with this type of policy but with government advice

in general – in one week, 149 posts on Twitter were identified as being ‘libertarianism’

regarding their response to updated alcohol guidelines, with a general theme that public

bodies should not interfere in private behaviours (Stautz et al., 2017). Despite strong

evidence demonstrating the effectiveness of MUP, a lack of public support can be an

important influence on political decision making – as is partly the case for the withdrawal of

government support for MUP in England (Li et al., 2017).

Drink-driving limits are another example of a policy aimed at reducing alcohol related harm,

as well as being another policy which differs between countries. Globally, road traffic

accidents (RTA’s) cause high levels of morbidity and mortality – with drink driving being a

major risk factor (Haghpanahan et al., 2019). Limiting the permitted blood alcohol

concentration (BAC) for drivers is a widespread public health intervention strategy to

decrease the risk of RTA’s, alongside reducing alcohol consumption (Haghpanahan et al.,

2019). In 2014, Scotland took another step towards reducing alcohol related harm by

reducing the BAC limit for drivers from 80mg/100ml to 50mg/100ml (Haghpanahan et al.,

2019). This followed a comprehensive review conducted in 2010, which considered whether

or not the BAC limit of 80mg/100ml is still appropriate, given that it was set over 50 years

ago in 1967 (Department for Transport, 2010). However, despite evidence leading to the

lowering of the BAC for Scotland, a recent study assessed the impact that the lowered limit

had – finding no reduction in RTA’s (Haghpanahan et al., 2019). At the same time as

Scotland, the limit was also lowered to 50mg/100ml in New Zealand (Hamnett & Poulsen,

2018). A retrospective study evaluated the effects of the reduced limit on driver fatalities,

finding increased numbers of deceased drivers positive for alcohol (Hamnett & Poulsen,

2018). These findings suggest that reducing drink driving limits is not a successful public

health strategy to reduce alcohol-related RTA’s. However, it could be that the change in

legislation was not appropriately enforced, for instance, by carrying out increased random

breath tests to drivers (Haghpanahan et al., 2019).

Suggestions for policy response

Research into the general public’s response to current guidelines demonstrates somewhat of

an opposition, with some members of the public deeming the governments advice

untrustworthy and interfering (Lovatt et al., 2015; Stautz et al., 2017). It is possible that this

is due to psychological reactance, in which opposition is provoked within a person when a

threat to their personal choice is perceived (Steindl et al., 2015). At present, guidelines come

from a largely epidemiological perspective – focussing mainly on long-term detrimental

health effects. The guidelines fail to take into account the pleasure that alcohol consumption

offers – something which has been shown to cause annoyance among the public (Stautz et al.,

2017). Guidance acknowledging the good times associated with alcohol consumption, whilst

providing advice on remaining safe, alongside health risks may lead to less reactance and

therefore opposition from the public. Furthermore, as proposed by Davison et al., (1991),

some people may only be willing to change their behaviour if a personal benefit is

anticipated. Rather than focussing on the negative aspects of alcohol consumption, guidelines

could incorporate the benefits realised when abstaining from drinking – encouraging the

public to cut down for their own immediate benefit, rather than to prevent long-term

consequences.

Evidence regarding MUP has demonstrated potential beneficial effects regarding both

alcohol consumption and the health inequalities associated with it that Scotland introduced

the policy a year ago (Angus et al., 2016; Scottish Government, 2019). Although the effects

of the policy are yet to undergo evaluation, models of the policy predict 38,900 fewer alcohol

related hospital admissions within the first 20 years (Angus et al., 2016). Furthermore, the

largest price increases will disproportionately affect alcohol purchased by the heaviest

consumers – those who are at the greatest health risk (Angus et al., 2016). Although

considered paternalistic by some, public health issues and the social determinants associated

with them are too complex for the general public to understand and take control of on a

personal level. From a public health perspective, MUP is able to reduce inequality and

improve the health of the population and therefore should be considered for the UK.

In terms of informing the public of current and updated guidelines regarding alcohol

consumption, Stautz et al., (2017) demonstrated a lack of use of health-related social media

accounts in responding directly to concerns stated by the public, despite being highly

involved in initially sharing the information. Social media accounts such as Twitter have a

potential utility of communicating particular health policies directly to those that are

expressing concern or confusion towards it (Stautz et al., 2017). Research in this area has

demonstrated promise in using social media to change attitudes and knowledge around public

health messages in an inexpensive way (Gough et al., 2017). However, although this work

indicated that information-based messages regarding public health are likely to be most

highly shared on social media, the extent to which this actually results in behaviour change

remains unexplored (Gough et al., 2017). Furthermore, such methods of sharing public health

messages would fail to reach those who do not engage with social media. Despite this, it

would appear to be an inexpensive tool to use alongside current methods of public health

messaging.

Conclusion

Lovatt and colleagues (2015) identified a number of concerns regarding the effect of lay

epidemiology on public health perceptions of current alcohol guidelines – an important piece

of research due to the growing disease burden of alcohol consumption (World Health

Organisation, 2018). The qualitative approach to the research allowed for in depth

perspectives and reasonings to be collected regarding current alcohol guidelines, however,

issues with data collection such as a small sample size and purposive sampling technique

result in the data being somewhat ungeneralizable (Etikan et al., 2016). Nonetheless,

important considerations for policy were raised, such as the need to provide guidelines in

clearer and more consistent terms in order to minimise confusion. Furthermore, although it

remains important to inform the public of the health risks associated with alcohol

consumption, outlining the more immediate benefits of reducing alcohol consumption

alongside these messages may prove to be a more effective strategy.

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