Proposals for a national alcohol policy in Ireland

Perhaps the simplest way to introduce the concept of a national alcohol policy, as it has been developed under the auspices of the WHO since the 1970s (Moser, Reference Moser and Glass1991), is to contrast it with the disease concept of alcoholism which had preceded it as a major influence on public policy on alcohol, both in Ireland and internationally, for 30 years prior to this. Historically, the disease concept had its origins in post-Prohibition America, where it purported to offer a scientifically valid and politically consensual basis for public policy in an arena previously characterised by intense moralism and social conflict (Beauchamp, Reference Beauchamp1980). The essence of this perspective was that for the vast bulk of its consumers alcohol was a harmless drug, and that it was only a minority of biologically vulnerable drinkers which succumbed to what was now being presented as a unitary disease referred to as alcoholism. The major policy implication of this concept was that state regulation, much less prohibition, of alcohol was neither justified nor necessary since the prevalence of alcoholism was unaffected by changes in population drinking habits. A lesser, but important, implication was that the state had a duty to provide adequate alcoholism treatment facilities within the wider healthcare system, while simultaneously persuading the public that alcoholism was a disease and challenging any residual, benighted attitudes on this subject. Throughout the 1950s and 1960s, the WHO was an enthusiastic promoter of the disease concept of alcoholism, but from the early 1970s it moved decisively away from this model, effectively repudiating it thereafter in a series of reports (Bruun et al., Reference Bruun, Edwards, Lumio, Mäkelä, Popham, Room, Schmidt, Skog, Sulkunen and Österberg1975; Edwards et al., Reference Edwards, Anderson, Babor, Casswell, Ferrence, Giesbrecht, Godfrey, Holder, Lemmens, Mäkelä, Midanik, Norström, Österberg, Romelsjö, Room, Simpura and Skog1994; Babor et al., Reference Babor, Caetano, Casswell, Edwards, Giesbrecht, Hill, Holder, Homel, Osterberg, Rehm, Room and Rossow2003) which espouse a model commonly referred to as the ‘public health’ or the ‘total consumption’ approach. This public health approach, which evolved from a range of empirical and theoretical research undertaken by social and biomedical scientists, began by arguing axiomatically that alcohol is a drug which is toxic, addictive and an intoxicant, and went on from this to argue that this drug puts all its consumers at risk of a spectrum of social and health problems (not just at risk of ‘alcoholism’). Policy underpinned by the disease concept was selectively aimed at those individuals deemed to have a specific biological predisposition to alcoholism; the public health approach, however, has a universal focus, arguing that the prevalence of alcohol-related problems can only be reduced by environmental strategies aimed at reducing levels and altering patterns of alcohol consumption in the population as a whole. What critics might term the paternalistic or ‘nanny state’ features of the public health perspective have come increasingly to the fore in formal statements of this perspective, and the most recent WHO synopsis (Babor et al., Reference Babor, Caetano, Casswell, Edwards, Giesbrecht, Hill, Holder, Homel, Osterberg, Rehm, Room and Rossow2003) reiterates that the most effective, evidence-based policies are those of a regulatory or control nature which include:

• • raising the retail price of alcoholic drinks by means of tax increases;

• • regulation of the physical availability of alcohol, both through restrictions on numbers of retail outlets and on hours of sale;

• • controls on advertising and promotion of alcohol;

• • strict enforcement of legislation on underage drinking, drunk-driving and the serving of alcohol to intoxicated customers.

This report also confirmed that more liberal policy measures, such as those aimed at creating awareness of alcohol problems among the public (or specific alcohol education of school children), were of little preventive value, and that treatment systems for problem drinkers made a relatively modest contribution to reducing the total societal burden of alcohol-related problems. Unlike the disease concept, which implied that only the health sector need concern itself with alcohol problems, the public health approach explicitly called for an integrated, cross-cutting policy response in which all sectors collaborate in the implementation of these evidence-based strategies.

Table 1 presents a summarised chronology of the main occasions on which the public health perspective on alcohol was articulated in health policy discourse in Ireland. The first such occasion was when, in the wake of the WHO report Alcohol Control Policies in Public Health Perspective (Bruun et al., Reference Bruun, Edwards, Lumio, Mäkelä, Popham, Room, Schmidt, Skog, Sulkunen and Österberg1975), Irish researchers participated in a seven-nation collaborative study of changing patterns of alcohol consumption and alcohol control experiences. The two major publications (Makela et al., Reference Makela, Room, Single, Sulkunen and Walsh1981; Single et al., Reference Single, Morgan and de Lindt1981) from this project had limited circulation and little immediate impact in Ireland, but through the participation of the Irish researchers the concept of alcohol control policies was gradually introduced into health policy discourse here. One of these researchers, Dermot Walsh (a psychiatrist and epidemiologist), subsequently served on a committee which drew up a national mental health plan The Psychiatric Services: Planning for the Future (Department of Health, 1984), and it may be surmised that it was his ideas about alcohol control policies which were the dominant influence in that report's chapter on alcohol problems. This chapter, which was based upon the new WHO orthodoxy that the prevalence of alcohol-related problems was related to population consumption levels, was forthright in its dismissal of the disease concept and its insistence that priority should be given to prevention – rather than to expanding treatment systems for those already experiencing such problems. It concluded that ‘Because of the involvement of alcohol in many aspects of our society ranging from trade to health, a national policy can be instigated only by an inter-departmental body, representative of all Government departments concerned’ (Department of Health, 1984: 112), and argued specifically that consideration be given to the preventive value of raising alcohol taxes, restrictions on advertising and on retail availability and strict enforcement of existing legislation on drunk-driving and underage drinking.

TABLE 1.

Public health recommendations on alcohol in Irish health policy discourse – a chronological record

Despite the detailed rationale offered in support of these recommendations for a new approach to alcohol policy, no steps were taken to implement them and it was not until 1990 that, in the context of what was presented as a radical reorientation of health policy towards health promotion, the newly established Advisory Council on Health Promotion was asked by the Minister for Health to draft a comprehensive national alcohol policy (Kelleher, Reference Kelleher1992; Butler, Reference Butler2002). At this time, health policy discourse in Ireland was awash with the rhetoric of health promotion, with constant reference to the WHO's (1978) Health for All by the Year 2000 as well as its Ottawa Charter for Health Promotion (1986), which appeared to offer the ideal context for a national alcohol policy based upon public health principles. However, it was to be six years (and several changes of Minister) later before a policy document, National Alcohol Policy – Ireland (Department of Health, 1996) was approved by Cabinet and officially launched by the Minister for Health. The content of this document was broadly reflective of the public health approach, particularly in its recommendation of environmental alcohol strategies, but even a cursory reading of its ‘action plan’ made it clear that its authors had failed to set in place the intersectoral or cross-cutting structures necessary for the implementation of these recommendations. The political ambivalence surrounding the National Alcohol Policy was further highlighted at its launch when, in response to criticisms that it lacked ‘teeth’, the Minister expressed discomfort with the idea of alcohol control strategies, reverting to the more liberal ideal of consumer sovereignty:

Given this Ministerial unease at the idea of paternalistic alcohol policy, it was not surprising that National Alcohol Policy – Ireland had little influence on ongoing policy events or, most significantly, that it made no impact on the policy debate leading to the enactment of the Intoxicating Liquor Act, 2000, legislation which increased the availability of alcohol to Irish consumers through its liberalisation of pub opening hours. The Minister for Justice, who had introduced this new licensing act, followed up immediately by appointing a Commission of Inquiry on Liquor Licensing, which was asked to review the entire licensing system and to make recommendations for ‘a system geared to meeting the needs of consumers, in a competitive market environment, while taking due account of the social, health and economic interests of a modern society’ (Commission of Inquiry on Liquor Licensing, 2001: 20). Membership of this commission was heavily tilted towards those who favoured further liberalisation, if not complete deregulation, of the licensing system, with just one shared place from the original membership of 21 going to the health and educational sectors. However, early in its deliberations it recommended that a separate committee be established to bring forward proposals for the prevention of alcohol-related problems (Hope, Reference Hope2006: 472); this recommendation was accepted by the Minister for Health when he established the Strategic Task Force on Alcohol, a committee dominated by public health advocates which went on to publish two reports (Strategic Task Force on Alcohol, 2002, 2004). These latter reports, which were launched and apparently endorsed by the Minister for Health, again reflected the WHO public health approach to alcohol policy. The first report provided detailed comparative data on Irish drinking habits and related problems, while also summarising international research on the effectiveness of various preventive strategies; the second report presented broad policy objectives (the first objective being the need ‘To reduce total per capita consumption to 9 litres per annum, the EU average. To reduce harmful consumption at the individual level, especially binge drinking and regular heavy drinking’), along with ten specific recommendations – with a heavy emphasis on regulating the availability of alcohol and putting in place statutory regulations governing its advertising and promotion. There was considerable media coverage of the work of the Strategic Task Force on Alcohol, and, in particular, of its detailed overview of how consumption had increased in this country during the 1990s, as the so-called ‘Celtic Tiger’ economy had gained momentum:

The two reports of the Strategic Task Force on Alcohol explained increased alcohol consumption in Ireland as a function of: its relative affordability (in an economy where personal disposable incomes had never been higher); increased availability (by virtue of a greater number of retail outlets and longer opening hours); and cultural normalisation (especially through advertising and promotions which successfully presented alcohol as an everyday commodity). In analysing policy developments during these early years of the new millennium, perhaps what is most noteworthy is that despite the apparent commitment to cross-cutting management or joined-up government, this was a time when the Irish state was running two parallel alcohol policy processes: the Strategic Task Force on Alcohol argued that the public good demanded major state intervention into the alcohol market place, while, simultaneously, the Liquor Licensing Commission favoured free trade and consumer sovereignty. Finally, two reports – one from the Health Research Board and one from the Health Service Executive – were published in late 2007. The former (Mongan et al., Reference Mongan, Reynolds, Fanagan and Long2007) detailed the increases in alcohol-related health problems which had accompanied increased consumption, while the latter (Hope, Reference Hope2007) showed that alcohol consumption in Ireland (at 13.4 litres per adult) for the year 2003 was the third highest country – behind Luxembourg and Hungary – in a comparison of 26 countries within the expanded European Union.

The Intoxicating Liquor Act, 2008

In January 2008, in line with his promised alcohol policy initiative, the Minister for Justice appointed a committee known as the Government Alcohol Advisory Group, charging it with the task of making recommendations to guide new legislation on public order aspects of alcohol consumption. This committee reported at the end of March, leading to the enactment of the Intoxicating Liquor Act, 2008, which came into effect on 30 July 2008. From a public health perspective, this most recent policy initiative might be seen as something of a mixed blessing: not of all of the committee's recommendations were incorporated into the new legislation, and not all sections of the new legislation were given immediate legal effect. In particular, the committee's recommendation for ‘the development and implementation of an overall national strategy on alcohol in order to ensure a consistent and coherent approach to alcohol-related matters across Government departments and other public bodies’ (Government Alcohol Advisory Group, 2008: i) had a hollow, tokenistic ring to it and, not surprisingly, has not led to any legislative or administrative actions. On the other hand, the legislation curtailed the opening hours of off-licence outlets, set in place court procedures governing the granting of new wine-only off-licences and gave authority to the police to seize alcohol from minors or anybody whose possession of alcohol seemed likely to lead to public disorder. However, those provisions of the new legislation governing the structural separation of alcohol sales in supermarkets, convenience stores and filling stations were not implemented immediately, nor were the provisions relating to the test purchasing of alcohol under police surveillance by under-18 year-olds.

In short, depending on one's perspective, the Intoxicating Liquor Act, 2008, might be seen as incremental progress along the public health spectrum or, alternatively, as further evidence of governmental unwillingness to fully embrace the ideal of an integrated alcohol policy.

Failure to implement a national alcohol policy in Ireland: the broader social policy background

It is clear, therefore, that for almost 30 years the ideal of a national alcohol policy – in which control strategies aimed at reducing per capita alcohol consumption play a central role – has been presented repeatedly and with increasing coherence by public health advocates in Ireland. Although there is no evidence of any political attempt to censor any of these public health proposals, such as happened infamously when the newly elected Tory government in England suppressed the report of the Central Policy Review Staff in 1979 (Thom, Reference Thom1999: 118), neither, it should be added, is there any evidence of anything other than nominal political support for their implementation. In fact, as a general comparative comment, it seems fair to say that public health criticisms of the state response in England focus on the way in which English alcohol policy proposals ignore the research evidence and opt for strategies known to be ineffective (Room, Reference Room2004; Anderson, Reference Anderson2007), while criticisms of the state response in Ireland are more likely to make the point that evidence-based policy proposals are given nominal political acceptance but never subsequently implemented (Butler, Reference Butler2002; Hope, Reference Hope2006).

In order to understand this refusal on the part of the state to accede to the demands of the public health lobby, it is useful in the first instance to consider this issue in light of the broader social policy climate, with particular reference to the capacity of the Irish state to dictate lifestyle or impose a specific version of the good life on its citizens. Unlike the Nordic states of Finland, Norway and Sweden, which for much of the twentieth century operated comprehensive alcohol control policies, including state alcohol monopolies (Holder et al., Reference Holder, Kuhlhorn, Nordlund, Öusterberg, Romelsjö and Ugland1998; Sulkunen et al., Reference Sulkunen, Sutton, Tigerstedt and Warpenius2000), as part of their general welfare state regimes, the Irish state which emerged following independence from Britain in 1922 enjoyed considerably less freedom in this regard. While residual suspicion of and opposition to government in a post-colonial society may have played some part in curbing any latent tendencies towards the development of a highly interventionist state, social scientists and historians have primarily emphasised the role played by the Roman Catholic church in Ireland – and its fears about excessive state encroachment into the lives of individuals, families and communities – as a major restraining influence on social policy during the first half-century of self-government (Whyte, Reference Whyte1971). Cultural opposition to ‘big government’ during this period was driven not so much by an underlying belief in laissez faire economics as by Catholic social teaching on the importance of subsidiarity: that is, the avoidance of decision-making or regulation at high governmental level where such activity could be conducted at regional, local or familial levels. In any event, as a predominantly Catholic country, Ireland did not have what Levine (Reference Levine, Lader, Edwards and Drummond1992) has described as a ‘temperance culture’, a concept used to refer to Protestant societies in which much of the alcohol was drunk in the form of distilled spirits, and where religious-based temperance movements in the late nineteenth and early twentieth centuries continued to exert influence over state alcohol policy. The Pioneer Total Abstinence Association, which is the mainstream Catholic temperance movement in Ireland, had been founded in 1898 and continued to be highly successful until the 1960s, a success which is still reflected in the fact that in comparative terms Ireland has a higher proportion of total abstainers than is to be found in other European countries (Ramstedt and Hope, Reference Ramstedt and Hope2005). However, in ideological terms the Pioneer Association is a moderate movement which advocates voluntary abstinence for religious motives and does not primarily see itself as a Catholic lobby for a drier alcohol policy (Ferriter, Reference Ferriter1999). Against this background, therefore, it comes as no surprise to note that successive Irish governments did not implement highly interventionist alcohol policies comparable to those of the Nordic states. In considering the changes which took place within Irish social policy as the influence of the Catholic Church declined from the early 1990s onwards (Inglis, Reference Inglis1998), the main question to be addressed here is whether any of the newly emergent policy trends and events were likely to facilitate alcohol control strategies of the type proposed by public health advocates. There are two key policy trends which came to fruition during the 1990s – the first being the institutionalisation of the ‘social partnership’ approach to the negotiation of economic and social policy, and the second being the explicit concern with ‘cross-cutting’ management contained in the Strategic Management Initiative, Ireland's version of New Public Management – which will be briefly reviewed in terms of their relevance to Irish alcohol policy.