The Wrong Conversation

Why UK Alcohol Policy Keeps Talking About Price - While the People Dying Keep Talking About Pain

The subject of mental health and substance use has been part of my life for almost a decade now. Academically, through my research, but also professionally, through years of practice in the NHS. I never stop looking for something that challenges how I think about it, something that unsettles the assumptions I’ve built up, because the moment you stop being unsettled is the moment you stop learning.

So one evening I was scrolling through YouTube looking for material I could use in a lecture, and I came across a roundtable discussion by the Society for the Study of Addiction, titled ‘Eight experts discuss the need for a new national alcohol strategy,’ published on 25th March 2026. The panel was impressive: an addiction psychiatrist, a hepatologist, a director of public health, a professor of alcohol policy, a former director of addictions at the Department of Health and Social Care, the chair of the IAS, and a lived experience advocate. Between them, decades of clinical practice, research, and policy development. I settled in and watched the whole thing.

And I want to be upfront: I genuinely enjoyed it. I have immense respect for these professionals and the work they do. The evidence they present on minimum unit pricing, on marketing restrictions, on availability controls is robust and important. They are not wrong about what they discuss. But here is what kept nagging at me as I watched. They are discussing one layer of the problem with such intensity that the deeper layers remain almost entirely unexamined. Ninety minutes of expert conversation about alcohol harm, and almost nobody asked the question that, to me, sits underneath all of it: why do people drink in the first place?

Let Me Give You Some Numbers

Because I think context matters here. While I was watching this discussion, I kept thinking about the data, and the data tells a story that should unsettle anyone working in this space.

In 2006, there were 5,050 alcohol-specific deaths in England. By 2023, that figure had risen to 8,274. That is an increase of 63.8%, the highest rate of alcohol-specific mortality since records began. Even 2024, which saw the first drop since the pandemic, still left us at 7,673 deaths, which is 32% above where we were before Covid. The average age of death from alcohol-specific causes? 57.2 years. The average for all causes? 78. Twenty years of life, gone. And the deprivation gradient is savage: people in the most deprived areas are seven times more likely to be admitted to hospital for alcohol-specific conditions than those in the least deprived.

Now, here is what struck me. Those figures span the entire period during which the evidence base discussed at the roundtable has matured. The systematic reviews have been published. The World Health Organisation has issued its guidance. Minimum unit pricing has been introduced in Scotland and Wales. Alcohol duty has been reformed. Treatment funding has increased. The ‘best buys’ are well established. And the deaths have risen by nearly two-thirds.

I am not saying this is simply a failure of implementation, though implementation has been woeful. I am saying it is a failure of framing. The conversation remains anchored in reducing population-level consumption through pricing, availability, and marketing controls. These are necessary. But they are not sufficient. And the reason they are not sufficient is that they address everything that surrounds the person without ever entering the experience of the person those conditions surround.

What the Roundtable Covered

To be fair to the panel, they covered a lot of ground. Affordability: alcohol is 72% more affordable now than it was in 1987, and pricing mechanisms have demonstrable effects on consumption. Availability: reducing hours and days of sale reduces harm, and the explosion of home delivery has created 24/7 access with zero safeguards. One panellist described people dying after multiple alcohol deliveries in a 24-hour period, with no checks on whether they were already intoxicated. Marketing: the industry spends vastly more on promotion than public health can spend on counter-messaging, and the normalisation of alcohol across media, sport, and everyday life is relentless.

They also talked at length, and convincingly, about industry influence. How the alcohol industry shapes the policy environment through narrative control, through access to civil servants and politicians, through legal threats that delay and dilute regulation, and through the strategic framing of alcohol harm as an individual responsibility rather than a product problem. Alice Wiseman, the director of public health, named this directly: the ‘responsible drinking’ narrative is an industry construction designed to locate the problem in the person rather than the product. Peter Rice described pre-empting industry tactics with Scottish ministers by predicting exactly what the industry would talk about, and being proved right a week later. The discussion also covered alcohol care teams, no and low alcohol products, labelling, and the encouraging decline in youth drinking.

All of this matters. None of it is wrong. But notice what is almost entirely absent.

What Nobody Talked About

Trauma. Distress. Adverse childhood experiences. The phenomenology of need. The function alcohol performs for the person using it. The reason someone reaches for the bottle at two in the morning, not because it is affordable or available or well-marketed, but because it is the only thing that makes the noise stop.

Nobody talked, in any sustained way, about what alcohol does for the people who are dying from it.

And I want to be careful here, because this is not because the panellists are unaware of these issues. Of course they are. It is because the dominant policy discourse does not have a place for them. The conversation is structured around the product, the price, the promotion, the availability, the industry, the regulation. It is structured around everything that surrounds the person except the person themselves. And when you spend ninety minutes in that structure, the person disappears.

There were two moments where the deeper question surfaced, and both times I found myself leaning forward. Aunee Bhogaita, the lived experience advocate, spoke powerfully about trauma. ‘The majority of people who go down that line of addiction, there’s trauma in their past,’ she said. And then she asked the question that, for me, should have reoriented the entire discussion: ‘Why did I have to nearly die to get to the help that I needed?’ Julia Sinclair, the addiction psychiatrist, described patients with alcohol-free drinks who were ‘trying to suck something out of it that is absolutely not in there.’ That is not just a clinical observation. That is a phenomenological description of need. The substance is gone, but the need that drove the person to the substance is still there, still searching.

In both cases, the conversation moved on. The policy discussion resumed. The deeper question was left hanging.

I want to name what happened there, because I think it matters. The one person in the room with direct lived experience of alcohol addiction raised the question that the entire policy framework cannot answer, and the conversation redirected to territory where professional expertise holds authority. Nobody did this deliberately. Nobody was being dismissive. It is simply what happens when a discourse has been structured in a particular way for long enough: certain kinds of knowledge get heard, and certain kinds do not. The philosopher Miranda Fricker calls this epistemic injustice, the systematic exclusion of certain ways of knowing from the spaces where decisions are made. I watched it happen in real time, and I do not think anyone in the room noticed.

You Cannot Price Your Way Out of Pain

The policy-first approach rests on an assumption that feels intuitive: reduce consumption, reduce harm. At a population level, there is some truth in this. But it breaks down precisely where it matters most, which is among the people whose drinking is not a lifestyle choice but a survival strategy.

Think about it. If someone is drinking to manage distress, to numb the aftermath of trauma, to create bearable distance from unbearable conditions, then increasing the price of alcohol does not address the distress. It addresses the mechanism of coping without addressing the need to cope. And when one mechanism becomes more expensive or less accessible, the need does not disappear. It finds another route. Heroin. Crack cocaine. Prescription medication. Gambling. Self-harm. Or simply deeper isolation, which carries its own mortality.

This is not speculation on my part. A study published in The Lancet Public Health examining trends in alcohol-specific deaths in England between 2001 and 2022 found that deaths increased even when per-capita consumption and alcohol sales were falling. Read that again. Deaths went up while drinking went down. If the relationship between consumption and harm were as straightforward as the policy discourse implies, this should not be possible. But it is, because the people dying are not dying from consumption in the abstract. They are dying from consumption that serves a specific function, in the context of lives shaped by deprivation, trauma, and the absence of anything better.

The roundtable touched on what researchers call the ‘alcohol harm paradox’: the finding that more deprived groups drink less on average but suffer higher rates of harm. John Holmes, the chair, raised it and acknowledged that we do not fully understand what drives it. I would push back on that, gently. I think we understand it rather better than the policy discourse admits. What drives it is that deprivation is not merely a statistical category. It is a lived condition. Chronic stress. Poor housing. Limited access to green space and social connection. Adverse childhood experiences. The systematic erosion of the material and relational conditions that make life bearable without chemical assistance. In that context, the question is not why deprived communities experience more alcohol harm. The question is why we keep being surprised by it.

The Layer Nobody Is Looking At

My own work, and I should declare my position here, is grounded in critical realism, Margaret Archer’s morphogenetic theory, and phenomenology. What that means in practice is that I am interested in how the structures people are born into shape the choices they appear to make freely, and how the experience of living inside those structures, the felt reality of it, gets systematically ignored by the systems that claim to help.

Archer offers a way of thinking about this that I find genuinely useful. She distinguishes between structural conditioning, the material and institutional context you inherit, and social interaction, the ways you navigate and respond to that context. Policy interventions like minimum unit pricing operate at the level of structural conditioning: they modify price, availability, and marketing. Fine. But they leave untouched the deeper conditioning, the trauma, the deprivation as lived experience, the epistemic silencing, that determines how people actually interact with those structures in the first place.

The result is that the same people keep arriving at the same harms through slightly different routes. You can raise the price of a unit of alcohol, and the person whose drinking is a response to childhood sexual abuse will find the money, or find another substance, or find another way to not be present in their own body. You can restrict the hours of sale, and the person whose evening drinking is the only thing standing between them and the full weight of their grief will simply buy earlier. You can put a cancer warning on a label, and the person who already knows alcohol is killing them, because their doctor has told them, because their body has told them, will continue drinking because the alternative, which is to be fully conscious of a life shaped by trauma and deprivation without anaesthetic, is worse.

I know this is not a comfortable argument for public health. It complicates the clean lines of policy evaluation. It resists the kind of population-level modelling that generates headlines about lives saved. But I believe it is closer to the truth of why people are dying, and therefore closer to what an effective response would actually require.

So What Would Actually Work?

An alcohol strategy that took lived experience seriously would need to operate across multiple levels at the same time. At the structural level, yes: pricing, availability, marketing controls, and protection of policy from industry influence. The roundtable panellists are right about all of this and I am not asking them to stop advocating for it.

But alongside that, at the institutional level: integrated, trauma-informed services that are accessible before people reach crisis, not at the point of near-death. Services that treat co-existing mental health difficulties and substance use as interconnected responses to suffering, rather than as discrete pathologies to be addressed by separate teams in separate buildings with separate referral criteria and separate waiting lists. And consider this: only 22.4% of the estimated 608,416 people with alcohol dependence in England are currently in treatment. Roughly one in five. The system is not just fragmented. It is barely reaching the people it exists to serve.

And at the experiential level: a willingness to engage with what substances mean to the people using them. What function they serve. What they are a response to. And what would need to be in place for that function to be met in less harmful ways.

Aunee Bhogaita put it more simply than any of us academics ever could. She was given trauma-informed therapy when she was given twelve months to live, and it worked. Her question, the one the roundtable did not follow, was: why was that therapy not available when she first disclosed the trauma? Before the addiction. Before the organ damage. Before the twelve-month prognosis. The answer is that the system is not designed to respond to distress. It is designed to respond to symptoms. And by the time the symptoms are severe enough to trigger a response, the person is often already dying.

The Conversation We Actually Need

I do not want this piece to be read as a dismissal of the roundtable or its participants. I have said it already and I will say it again: the work they do matters. The policies they advocate for save lives. I am not their opponent. But the conversation they are having is incomplete, and the incompleteness is not a minor gap. It is, I believe, the reason the strategy keeps failing. It is the reason that two decades of increasingly sophisticated evidence, increasingly clear policy recommendations, and some genuine implementation successes have coincided with a 64% increase in the number of people dying.

The conversation we need is one that holds both the structural and the experiential at the same time. One that asks about pricing and about pain. One that models the population effects of duty reform and sits with the person for whom a 50p minimum unit price is an irrelevance because they would sell their furniture to keep drinking if that was what it took. One that names the alcohol industry’s tactics and names the trauma that the industry exploits but did not create.

The hard road will take you home. But only if you are walking towards the right destination. At the moment, the UK’s alcohol policy conversation is walking competently, even impressively, in the wrong direction. It is time to turn around and face the person.