How did news media communicate the revised UK drinking guidelines?

Introduction

News media can play an important role in communicating and shaping public perceptions of social issues, including those related to alcohol. However, the nature of this role is complicated and it is described in many different ways in the literature. For example, Casswell72 describes the media in general terms as ‘key players’ and argues that ‘much of the [public] debate is shaped by the portrayal of alcohol and alcohol policy in mass media’,72 a view broadly shared by several other authors.73–75 Hansen and Gunter76 suggest that social issues are ‘elaborated, contested, redefined and eventually removed from the public agenda’76 within news media, implying that news media are engaged in multiple sequential or simultaneous processes. Törrönen77 views newspapers in more agentic terms, characterising their editorials as ‘indicators of the opinion climate . . . try[ing] consistently to exert influence . . . evaluate arguments and decisions . . . and make an assessment of them and of situations and attempting to influence policy and public opinion’,77 whereas Nicholls73 addresses only the first aspect of this quotation, noting that ‘news reporting plays a key role in articulating shared cultural values around alcohol’. Mercille78 argues more forcefully that news media deliberately, strategically and inevitably ‘. . . reflect the views of the political and economic establishment on public health measures’. Mercille78 argues this based on the links between media owners and government, their financial links to health-harming industries via advertising and the reliance on establishment contacts for sourcing of news stories and reactions. These different perspectives suggest that the role of news media in alcohol policy debate is complex and multifaceted. As such, it is difficult to capture or demonstrate fully within a single analysis,79 but remains an important area of study when assessing how public perceptions are formed on a particular topic.

Studies of news media coverage of alcohol use are a relatively recent phenomenon. In 2011, Nicholls73 noted that few such studies existed, particularly in the UK; however, a much larger body of literature emerged in subsequent years. This includes analyses of news media reports of policy debates around MUP in the UK,80–82 advertising restrictions and regulation of the night-time economy in Australia,74,83 strategies tackling college drinking in the USA84 and general alcohol policy in several countries.77,78,85,86 It also includes analysis of news media coverage of contemporary social issues specific to alcohol or with which alcohol intersects, including alcohol’s harm to those other than the drinker,87 alcohol-related health risks,88,89 sex,75,90–93 sexual violence,94,95 parenting96 and personal freedoms.97 Furthermore, a number of studies examine overall reporting of alcohol-related topics within news media.73,98–101

A review of this literature in 2007 argued that analyses of news media coverage of alcohol, in addition to being few in number, had failed to draw on relevant theories and techniques developed within the communications and political science literature.76 In particular, it noted the value of analyses of change over time, a lack of cross-referencing between studies, the mediating role of advocacy within news media or perspective taking by news organisations, the significance of message sources (e.g. individuals quoted within reports) and the medium of the coverage. More recent work has drawn on these arguments to develop rich understandings of how alcohol-related issues are reported in the media. For example, studies have demonstrated that public health actors have successfully positioned themselves as key sources of information within policy debates but provide conflicting findings as to whether or not those actors have also successfully framed debates in public health terms as population-level issues rather than the industry’s favoured individual-level and personal responsibility oriented perspective.73,74,80 Many studies also identify key frames through which alcohol-related issues are discussed, many of which are replicated across policy debates. For example, men’s drinking is often found to be framed in relation to violence, whereas women’s drinking is linked to a wider set of concerns pertaining to transgression of traditional models of femininity.73,75 Similarly, in debates about advertising, liberalisation of retail monopolies and MUP, opposition to alcohol policy is framed with reference to individual freedoms or the need to protect industry from an overbearing state.74,77,80 Analyses of policy debates in Finland and Ireland also suggest that, as agentic actors in policy debate, news media are often unsupportive of public health arguments and alcohol-related problems; even when such problems are identified, the discussion and policies recommended tend to coincide with an underlying view that liberalised alcohol markets are desirable.77,78

Despite this now-broad literature, only one briefly reported study to date has examined how news media report on drinking guidelines.102 This is an important oversight as TV, radio, newspapers and magazines are the primary places where the public report seeing drinking guidelines when revisions are announced.46 At such times, guidelines are discussed prominently by news outlets within ordinary news reports, opinion pieces and editorials. At other times, news media continue to expose the public to drinking guidelines by mentioning them within stories about alcohol-related health risks, drinking trends and lifestyle topics. Such repeated exposure aids awareness and recall of guidelines in the absence of active promotion via mass media campaigns. For example, evaluations of alcohol health warning labels in the USA found higher rates of awareness and recall of the health warnings among heavier drinkers and argued that this was because they see the label more often.103 Debate within news media may also inform public opinion and responses to drinking guidelines, but, given the wide variety of roles that the media play in public debate, this is unlikely to be a straightforward or unidirectional process.79 Moreover, differences in news media reports across publications and platforms may play an important role in determining who is exposed to guidelines and informing their attitudes towards them as engagement with news outlets and content is socially patterned.76

Therefore, the aim of this review was to conduct an exploratory analysis to describe the scale and content of news media coverage of drinking guidelines in England during our study period of February 2014 to October 2017. As this was a retrospective study, broadcast media reports were difficult to access. Therefore, we focused on reviewing print news media, which are searchable via online databases. There were three stages of the review:

1. a systematic search to identify all news articles published in England during the study period that mentioned drinking guidelines or closely related terms
2. a quantitative analysis to develop a timeline of when and where the identified articles were published and to summarise the main content of articles
3. a qualitative analysis to explore the content of articles in more depth.

Methods

Identification of articles

We conducted three searches of the Nexis ‘UK publications’ database across the period from 1 February 2014 to 31 October 2017. Nexis contains all print and online articles published by UK local and national newspapers, including daily and Sunday editions, and a large number of magazines and news websites. As this project focuses on the impact of drinking guidelines in England, we did not search the Scottish editions of UK newspapers (e.g. the Scottish Daily Mail).

Nexis’s news search does not allow users to build complex search strategies and restricts searches to no more than 3000 results, so we conducted three searches using different search terms, across multiple subsections of the search period, if the total results exceeded 3000. Search terms were Alcohol guidelines OR drinking guidelines OR alcohol units (search 1); 14 units OR 21 units OR 2–3 units OR 3–4 units (search 2) and alcohol recommendations OR alcohol limits OR alcohol guidance OR alcohol advice (search 3).

Many members of the public read news on the websites of leading broadcasters, and these are not fully included in the Nexis database. Therefore, we searched the BBC News (British Broadcasting Corporation, London, UK) and Sky News (Sky UK, London, UK) websites by using Google (Google Inc., Mountain View, CA, USA) to find pages within the BBC News website (www.bbc.co.uk/news) and the Sky News website (www.news.sky.com) published during the same study period and including the same search terms as above. The search on the BBC News website was additionally restricted to pages created in the UK.

Articles from both Nexis and Google searches were included in the final sample if they fully or partially mentioned the guidelines (e.g. articles discussing the guidelines for women but not the guidelines for men would be included) or if they commented on the process of developing the guidelines or the guidelines’ content without explicitly stating what the guidelines are. Articles were excluded if they did not mention the guidelines or if they discussed only guidelines or recommendations for drinking in pregnancy or drink-driving. We also excluded articles in local newspapers as we are primarily interested in coverage that would have a national-level impact. It is plausible that a large number of similar stories at a local level in local newspapers could aggregate to have a national-level impact, but analysing patterns of local news coverage is beyond the scope of this study.

Headline and full-text screening was undertaken by one researcher, who discussed any difficult cases with the lead author. We then extracted publication name, source type (e.g. broadsheet/quality press, online only), publication date and period (i.e. before or after the revised guidelines were announced), and what aspects of the guidelines were mentioned (e.g. 2–3 units per day for women or having drink-free days).

Quantitative analysis

As our aim was exploratory, we developed a coding frame from an initial random sample of 50 articles, stratified by source type, and sought to identify their main discriminating features. We then selected a final random sample of approximately half (n = 500) of the identified articles, again stratified by source type, and coded them for the following characteristics.

Primary topic of the article

We coded articles into one of four mutually exclusive categories based on their primary topic:

1. articles primarily discussing drinking guidelines, for example articles that discuss the change in drinking guidelines or opinion pieces that discuss the merit of the guidelines
2. articles that primarily discuss alcohol, but do not focus on the drinking guidelines, for example articles that discuss the relationship between alcohol consumption and certain health outcomes or population statistics on alcohol consumption prevalence
3. articles that primarily discuss health, but do not have alcohol or the drinking guidelines as their main focus, for example articles discussing strategies to prevent certain health outcomes or achieve a healthy lifestyle
4. articles whose primary focus is not the drinking guidelines, alcohol or health, for example articles that use the guidelines as an example of the nanny state or articles presenting gift-giving guides that mention the guidelines when discussing alcohol-related gifts.

Primary role of guidelines within the article

We used five categories to code articles based on our perception of the purpose of mentioning guidelines in the article:

1. articles that mention the guidelines to inform people of the forthcoming or actual change in drinking guidelines
2. articles that discuss the merits of the guidelines in more detail, including articles that discuss information that discredits the guidelines or that discuss the guideline development process in more depth
3. articles that mention the guidelines in the context of promoting health or preventing ill health, including articles providing the guidelines as advice, mentioning them in connection with health outcomes or using them to provide context to a story about health
4. articles that mention the guidelines to illustrate consumption levels of specific groups or individuals, including articles mentioning the guidelines to provide context to alcohol consumption statistics without necessarily linking the guideline to those statistics
5. articles that mention guidelines for another purpose.

Overall tone

We coded the broad tone in which the guidelines were discussed as positive, negative or neutral. An article was coded as positive if a reader who was unfamiliar with the argument could reasonably be expected to have a positive impression of the guidelines after reading the article. Positive articles included those sought to rebut criticism of the guidelines or illustrate how scientific evidence supports them. Articles were coded as negative if the researcher judged that readers unfamiliar with the relevant information could be expected to have a negative impression of the guidelines after reading the article. These included articles that criticised the guidelines without balancing this with support for the guidelines. Articles were coded as neutral if they merely stated the guidelines, or if they balanced supporting and critical information relating to the guidelines.

Qualitative analysis

One researcher (IK) conducted a thematic analysis on a subset of articles sampled for in-depth coding.104 Articles were coded for quantitative and qualitative analysis simultaneously. First, the researcher coded a random sample of 100 articles, again stratified by source. As saturation had not been reached, the researcher coded another randomly sampled 100 articles. This satisfied the requirement for data saturation and the researcher was confident that no new themes would arise. The researcher organised the codes into themes that describe how the guidelines were covered in the media. Themes were discussed with another researcher (JH) with a strong prior knowledge of media coverage of the guidelines.

Results

Identified articles

Figure 2 shows the results of the search and selection process. The three Nexis searches yielded 10,983 articles in total. After excluding articles published in local publications or The Associated Press planners (i.e. collections of press releases that are disseminated to journalists and news publications, which are included in the Nexis database; n = 7070) and removing duplicates (n = 1702), we were left with 2211 articles in 41 publications. After concurrent headline and full-text screening of these articles, we excluded a further 1261 articles because they did not discuss the guidelines. The Google searches yielded 70 results on the BBC News website and six on the Sky News website. After headline and full-text screening of these articles, we excluded 29 articles (28 from the BBC) because they did not mention the guidelines. This left 41 further articles in addition to those identified via the Nexis search. After adding the website and Nexis searches together, our final data set comprised 997 eligible articles from 29 publications (Table 1).

FIGURE 2 The PRISMA flow diagram showing the results of the search for news articles mentioning drinking guidelines. (Figure not reproduced here; see the original article.)

Quantitative analysis

Drinking guidelines were mentioned regularly in news articles across the study period. Figure 3 shows that the number of articles per week peaked when the revised guidelines were announced in January 2016. There were also many smaller peaks that occurred when guidelines were mentioned in articles related to general alcohol- or health-related topics, as shown in Figure 4, whereas guidelines were mentioned only infrequently in articles unrelated to alcohol or health.

FIGURE 3 Number of news articles mentioning guidelines per week within the analysed sample (n = 500) between 1 February 2014 and 31 October 2017. The guidelines changed in week 2 of 2016. (Figure not reproduced here; see the original article.)

FIGURE 4 Number of news articles mentioning guidelines per week within the analysed sample (n = 500) between 1 February 2014 and 31 October 2017, split by primary topic in article. (a) Not related to drinking guidelines of alcohol or health; (b) related to drinking guidelines; (c) related to alcohol but not drinking guidelines; and (d) related to health but not alcohol. (Figure not reproduced here; see the original article.)

The guidelines were mentioned for different reasons at different time points. Figure 5 shows that a large number of articles mentioned the guidelines in January 2016 to inform the public of the revisions and that there were also a large number of articles that discussed the merits of the guidelines at this time and in the subsequent 23 weeks. However, outside this period, the merits of the guidelines were rarely discussed, and guidelines were mentioned instead to promote health, to prevent ill health and, less often, to provide context to articles discussing alcohol consumption. Around the time that the revised guidelines were announced, there were also a number of articles that mentioned the guidelines for other reasons, including to discuss state intervention in health care and nanny state policies in general, and to criticise UK drinking culture.

FIGURE 5 Number of news articles mentioning guidelines per week between 1 February 2014 and 31 October 2017, split by primary purpose of guidelines in article. (a) To discuss the merit of guidelines; (b) to inform the public of the change in guidelines; (c) to promote health; (d) to provide context for drinking habits; and (e) other. (Figure not reproduced here; see the original article.)

Figure 6 shows that the tone of articles was typically neutral in the overwhelming majority of cases and that articles with a positive tone were rare. Articles with a negative tone were also rare but became more common for several weeks after the revisions were announced.

FIGURE 6 Numbers of news articles mentioning guidelines per week between 1 February 2014 and 31 October 2017, split by article tone. (Figure not reproduced here; see the original article.)

Table 2 shows the different aspects of the drinking guidelines that were mentioned in articles and how the aspects mentioned changed before and after the guidelines were revised. Most articles (95.4%) mentioned the guideline threshold, although sometimes this was provided for only one sex. Even after the same guidelines were set for men and women in January 2016, 94.0% of articles mentioned the guideline consumption level but only 88.6% mentioned that it applied to men. Prior to the revisions, the 1995 guidelines of 3–4 units per day for men and 2–3 units per day for women were mentioned in approximately half of the articles, but the pre-1995 guidelines of 21 units per week for men and 14 units per week for women were also mentioned in around one-third of the articles, with both guidelines sometimes mentioned for comparison (e.g. 3–4 units per day or 21 units per week), suggesting that the public was provided with inconsistent information during this time. After the revisions, only 9 out of 296 articles mentioned a guideline other than 14 units per week for men or women. Out of these nine articles, three mentioned the previous daily guidelines, whereas the other six mentioned the previous weekly guidelines.

Other aspects of the guidelines were mentioned much less frequently, and the announcement of the revisions did not always lead to increased mentions. The advice to spread the weekly guideline of 14 units across at least 3 days was mentioned in 13.7% of articles after the announcement, compared with 1.1% before. However, the advice to have at least 2 drink-free days per week was mentioned in 10.2% of articles after the revisions and 9.2% before, perhaps because this advice was part of PHE’s Change for Life mass media campaign prior to the guideline review.

Information that was not part of the guidelines was also sometimes presented as though it was. One particular example of this arose because the revised guidelines were announced in conjunction with a report on the relationship between alcohol consumption and cancer, which argued that there was no safe level of drinking with regard to cancer risk.105 Although the UK CMOs’ report and the report of the GDG discussed evidence on alcohol and cancer and noted the risk at low levels of consumption, the ‘no safe level’ message is not part of the drinking guidelines.22,24 Despite this, 23.2% of articles published after the revisions stated or implied that this message was part of the guidelines, for example by mentioning it shortly before or after the consumption guidelines without clarifying that it is not part of the guidelines. This compares with 2.5% of articles that mentioned the ‘no safe level’ message as separate to the guidelines (e.g. by stating this explicitly, or by attributing the ‘no safe level’ message to a source other than the guidelines).

Relationship between timing, tone and other article characteristics

We examined the relationship between the tone of articles, whether they were published before or after the guidelines announcement, and their other characteristics. As only 11 out of 500 articles analysed were positive in tone, the analysis focuses on a comparison of articles with a neutral or negative tone.

Table 3 shows that articles were significantly more likely to have a negative tone and less likely to have a neutral tone after the revised guidelines were announced (χ² = 20.3; p < 0.001). Across the whole study period, articles that had drinking guidelines as the primary topic were more likely to have a negative tone than those related to alcohol in general, those related to health in general or those that were unrelated to guidelines, alcohol or health (χ² = 179.2; p < 0.001). Guidelines were also more likely to be discussed negatively if the primary purpose of mentioning the guidelines was to discuss their merits (χ² = 282.8; p < 0.001). There were no significant differences in the likelihood of the guidelines being discussed negatively across source types (χ² = 4.76; p = 0.31) or their political leanings (χ² = 0.66; p = 0.72). Articles were, however, more likely to be negative in tone if they communicated the ‘no safe level’ message as part of the guidelines rather than identifying it as a separate message or not mentioning it at all (χ² = 42.32; p < 0.001).

Qualitative thematic analysis

The analysis identified four main themes: (1) factual reporting of the guidelines, (2) the guidelines are not based on the best available science and should not exist in their current form, (3) the guidelines threaten autonomy and should not exist at all and (4) alcohol advice is changing constantly and it is unclear what advice to follow. Most articles contributed to theme 1, but did not discuss the guidelines in greater detail. The thematic analysis, therefore, was strongly informed by the large minority of articles that discuss guidelines in more detail, and the findings of the analysis reflect that these more discursive articles were primarily negative in tone. Each of these themes is discussed in turn.

Factual reporting of the guidelines

Most articles mention the guidelines very briefly, in a factual manner and without significant linkage to broader themes within the articles. For example, in an article about lifestyle changes to prevent diabetes, only one sentence refers to the guidelines, which tells readers to keep in mind that the recommended guidelines are now only 14 units per week for men and women (paraphrased).106

Similarly, in a news article about drinking on cruises, the guidelines are mentioned in only one sentence, which states that the average passenger drinks 168 units per week, according to Drinkaware website’s unit calculator, which is eight times the recommended allowance for men (21 units) and 12 times above the recommended level for women (14 units) (paraphrased).107

In most cases, the reason for sticking to the guidelines (to prevent ill health) was implied rather than explicitly stated. This is achieved by stating the link between alcohol and health outcomes, directly followed by the guidelines or by referring to exceeding the guidelines as drinking at unsafe levels. The vast majority of articles mention the consumption level for both men and women. If an article mentioned the guidelines for only one sex, this was typically because it discussed a condition that affects more men than women or vice versa. For example, Push Doctor’s (an online medical consultation service based in Manchester, UK) medical officer, Dr Dan Robertson, recommended that men stick to the recommended weekly alcohol limit to prevent erectile problems.108

Many articles reported the guideline amounts in equivalent alcoholic drinks. This information was largely accurate, but there were variations in how it was presented. Most sources opted to provide the equivalent in an integer of drinks, but some sources provided the information in fractions of a glass or how many units are typically contained in a standard-sized drink, such as a bottle of wine or pint of beer:

14 units is equivalent to 14 single measures of spirits at 37.5 per cent ABV [alcohol by volume]; seven pints of 4 per cent strength beer, nine and one-third 125 ml glasses, seven 175 ml glasses, or four and two-thirds 250 ml glasses of 12 per cent-strength wine.

The UK Department of Health recommends that men should drink no more than three to four units of alcohol a day and women should drink no more than two to three units a day. A 750 ml bottle of red, white or rosé wine with an alcohol content of 13.5 per cent contains 10 units. A standard 175 ml glass of red, white or rosé wine contains just over two units and a large 250 ml glass contains three units. A small glass, at 125 ml, contains 1.5 units.

Few articles reported the full set of guidelines including auxiliary advice. Those that did were mainly published around the announcement of the new guidelines. The advice that one should spread alcohol consumption over multiple days and have at least 2 alcohol-free days per week was most often communicated alongside the drinking guidelines. Similar to the recommended consumption levels, this advice is often merely stated without further elaboration:

How much alcohol is too much? Some can probably safely drink more than others; your size, genetics, lifestyle and state of your liver make a difference. But in general, less than 14 units, spread over at least three days a week should be OK. That’s just under a bottle-and-a-half of wine (ABV 13.5%), or an average of one 175 ml glass per day. For beer drinkers, that’s less than five pints of higher strength beer (ABV 5.2%) a week.

Criticism of the scientific basis for the guidelines

Criticism of the scientific basis for the guidelines focused on three main areas: the emphasis on cancer risks while downplaying of the benefits of moderate drinking, the guideline consumption level itself and the integrity of the scientific process.

Although not part of the guidelines, much criticism addressed the ‘no safe level’ message, which was prominent in news reports announcing the revision to the guidelines because of the simultaneous release with the cancer report. The no safe level message was given further prominence as public health actors communicating the guidelines also emphasised it in their interviews and other statements.112 This criticism was often linked to proponents of the guidelines also downplaying previous evidence that moderate drinking benefited cardiovascular health.113,114 The cancer risk was not challenged directly, but critics allege that the guidelines failed to take into account evidence of benefits to cardiovascular health or that these benefits might outweigh any increased cancer risk. Criticism of this kind comes from a variety of sources, including alcohol industry actors, free-market think tanks and pro-alcohol consumer groups, but also reputable scientists and laypeople. The first quotation below also illustrates how industry actors often criticised the drinking guidelines using multiple arguments within a single sentence, an approach noted in the context of MUP by Hilton et al.80 A leading drinks producer told The Mail on Sunday that it would send a strongly worded response, stating that the new limits go against decades of scientific research, that having the same limits for men and women contradicts research on how men and women process alcohol, and that the limits are different from almost every other country. He said that there was no discussion about the changes beforehand and the government is consulting only on how the guidelines will be communicated. The drinks producer believes that the content needs to be discussed more, particularly the scientific basis for the guidelines. The Portman Group said that it would also be voicing reservations about the interpretation of the evidence. The group said that more than four in five adults are already drinking within the lower-risk guidelines. Guidelines are important because they help people make informed decisions and the group is concerned that the proposed guidelines are confusing because they are not clear about the relative risks of sensible drinking.115 Top academics from the Royal Statistical Society criticised the advice, stating that not all alcohol was dangerous and stressing a ‘protective effect’ from small amounts:116

In January new drinking guidelines were issued which cut the recommended weekly limit to 14 units for both men and women – slightly more than a standard bottle of wine – and said that no level of drinking was safe. The change was criticised by some experts, including the Royal Statistical Society, which said that the evidence showed a unit a day was in fact beneficial.

The guidelines conveniently ignore the evidence around the cardioprotective and neuroprotective effects of moderate alcohol consumption and the results of the largest study ever conducted for alcohol by the American Cancer Society, published in the New England Journal of Medicine, which concluded that adults who drink six units per day have lower mortality rates than adults who drink none at all.

Another prominent criticism was levelled at the guideline consumption amount itself. This came in several forms. Some questioned the decision to set the same guideline for men and women (see first quotation above117). Others criticised the idea of a single guideline that does not take individual differences into account. Further commentators argued that the risk level at which the guidelines are set is disproportionately low and that the public would have accepted higher risks. In some cases, the reasoning behind the guidelines was published alongside these criticisms, but more often the criticism stands unchallenged. Although much of this criticism came from the alcohol industry or consumer groups, it was again partly supported by reputable scientists via the Science Media Centre, which gathers quotations from scientists and provides advice to help journalists communicate research accurately:

There’s no scientific evidence for these ridiculous units, Mr Hardman [CAMRA] said. You can’t set rules for everybody, just as you can’t say that all shoes should be eight and a half, because some people have smaller feet and some have bigger feet.

Prof. Sir David Spiegelhalter, Winton Professor of the Public Understanding of Risk at the University of Cambridge, said: ‘These guidelines define ‘low-risk’ drinking as giving you less than a 1% chance of dying from an alcohol-related condition. So should we feel ok about risks of this level? An hour of TV watching a day, or a bacon sandwich a couple of times a week, is more dangerous to your long-term health. In contrast, an average driver faces much less than this lifetime risk from a car accident. It all seems to come down to what pleasure you get from moderate drinking.

A final strand of scientific criticism addressed the integrity of the process of developing the guidelines and those involved in it. Four members of the GDG were either employed by or affiliated with the Institute of Alcohol Studies (London, UK), which is a public health charity established and funded by the Alliance House Foundation (London, UK), a prominent organisation in the now-defunct UK temperance movement. The GDG also drew extensively on evidence provided by the University of Sheffield, which had previously provided evidence supporting the introduction of MUP for alcohol in the UK and internationally.121 In both cases, the individuals in question were perceived to be likely to have acted politically in steering the development process towards setting a lower guideline. In this context, articles sometimes argued that the alcohol industry should also have been involved in the development process. Criticisms of this kind originated primarily from people affiliated with the alcohol industry; however, the authors of the articles did not similarly question the integrity of such people. Although the reason for this unbalanced approach is unclear, it has echoes of Mercille’s78 arguments that the news media inevitably reflect the views of the political and economic establishment. However, it may more simply reflect that journalists were not provided with arguments or quotations raising such points:

FOUR anti-booze campaigners were on a panel of experts that led to Brits’ safe drinking levels being cut, it was claimed last night.

In addition, why should public health researchers be allowed to tell people how much wine is bad for them, just because they make a living from disapproving of people selling alcohol, tobacco and sweets? Why can’t alcohol producers or retailers set drinking guidelines, given they better understand who drinks too much and why? (paraphrased).123

In addition to the three main strands of criticism addressing the scientific basis for the guidelines, additional comments argued that the guidelines are unlikely to change behaviour and that the review was unnecessary because alcohol consumption is declining in the UK. In some cases, all of the criticisms were drawn together, again echoing Hilton et al.’s80 analysis of the MUP debate rather than appearing across separate articles. Critics of the new guidelines point to a range of problems. These include a reliance on work by researchers at the University of Sheffield who are committed to the political and unscientific cause of minimum pricing, an overemphasis on cancer risks and underplaying of benefits to cardiovascular health, a lack of concern with level of risk and the recent decline in binge drinking (paraphrased).123

Guidelines threaten personal autonomy

Other criticisms focused on the role guidelines play in the broader political landscape. The guidelines were frequently framed as a nanny state policy that would be used to facilitate introduction of more extreme policies in the future, a view also advanced, albeit in softer language, by a member of the GDG in a British Medical Journal article.19 It is important to realise that these guidelines are not a single policy. Like enthusiasts in other areas, public health campaigners want to enact evermore policies to trap those they do not like (paraphrased).123

Critics contrasted this perceived agenda with a view that people know their own limits and should be allowed to decide for themselves what risks they find acceptable. Public health advice was presented as coming from a different type of people (‘healthy people’ or ‘puritans’), who are disconnected from the experiences of ‘normal people’ and lead lives devoid of joy:

There is no one speaking up for the man and woman on the street. We want to represent people who are saying, ‘I know my limits and I don’t need them to be dictated to me’ and I don’t want to feel guilty for having a drink.

Another critic of the guidelines claimed to know many public health doctors, but felt that even though they all mean well and appear trustworthy none of them seem to loosen up and party every now and then. And thought that, that is part of the issue. They are so disconnected with what normal, regular people enjoy and how they live their lives, their messages consistently miss their mark. If only public health officials understood that their puritanical and ‘holier-than-thou’ approach puts people off (paraphrased).125

At the same time, public health officials are also accused of hypocrisy when they are seen engaging in any ‘unhealthy’ behaviour, even when this behaviour does not deviate from the guidelines they promote. As with some of the criticisms above, allegations of hypocrisy are supported by exaggerating the drinking guidelines to be more restrictive policy than they actually are. For example, it is implied that the advice is to abstain rather than to consume under the low-risk guidelines. The UK’s CMO has been ‘terrorising’ moderate drinkers into giving up wine and telling women to see every sip of alcohol as a step towards breast cancer. But it seems that [the CMO at the time], Britain’s ‘nanny in chief’ who told others to ‘do as I do’, is not that strict on alcohol at home. Photographs show the CMO holding a glass of champagne in their £3M London townhouse (paraphrased).126

Public health advice on drinking changes frequently

Many articles suggested that the revised guidelines were another episode in a series of frequent changes to alcohol-related health advice. These articles argue that people are confused by the variety of information that is available and, as a result, decide to not take any of it seriously because they do not know what is right. Although many reports point out that this is the first update to the guidelines since 1995, the view remains that alcohol advice has changed frequently in this period. Importantly, this view is often supported by contrasting the guidelines with apparently contradictory, but nonetheless reputable, scientific evidence, a problem also noted in debates relating to dietary guidance:127

These days the health advice is so conflicting. We are told red wine in moderation can ward off dementia and heart disease as it contains flavonoids, and the Chief Medical Officer says all alcohol is deadly. So what are we mortals to make of it?

Contrary to UK Government advice suggesting keeping several days ‘alcohol free’, a new study from researchers in Finland, published in the Alcohol and Alcoholism journal, found several glasses of wine per day with an evening meal could actually be good for you.

Thus, the distinction between official guidelines and reporting of health-related research is not always clear to the authors of articles, and the guidelines are often considered alongside results from a single study as journalists and commentators apply different approaches to constructing their own understandings of the various pieces of evidence presented to them.23,127,130,131 This appears to play into the narrative that one day alcohol is good for you and the next day alcohol is bad. Although our sample included one BBC article132 that clarified that the guidelines are in place because there is so much mixed evidence, in many cases the guidelines were presented as just one more instance of conflicting advice. This criticism was also not limited to alcohol, but took in a broader range of health risks for which there was perceived to be conflicting advice:

A lot of people have flagged up that there is conflicting evidence out there. One of the reasons the guidance has been issued is that there has been so much evidence published. So this has attempted to review what is out there and come up with some definitive advice. The advice is there, it says, to inform. It is up to people to decide what they do with it. But on the benefits of drinking, it is clear this only stands for women aged 55 and over – and then only when they limit themselves to five units a week. That’s about two glasses of wine.

Another critic claims that whether it is eating five pieces of fruit and vegetables a day or drinking no more than 14 units of alcohol in 1 week, they will strongly question all advice knowing that ministers will soon tell us to do the complete opposite, and will probably even try to make us pay for following their original advice (paraphrased).133

One specific method used to evidence inconsistencies in advice is to cite drinking guidelines from other countries. This argument was common partly because a scientific paper published shortly after the UK revisions were announced highlighted large variation in guidelines internationally and also showed that the UK guideline for men was low by international standards.9 Articles often used this information to point out that different countries come up with different guidelines using the same underlying evidence, suggesting that there are other factors in play that are assumed not to be scientific. Notably, prior to the guidelines change, articles often gave examples of other countries with lower guidelines, whereas after the guidelines changed articles gave examples of countries with much higher guidelines, although this partly reflects there being few countries with lower guidelines than the UK after the revisions. This criticism came forward in quotations from representatives of the alcohol industry, but also in opinion pieces by writers who are not affiliated with the alcohol industry and as single-line illustrations of guidelines. The safe alcohol limits in Canada and Australia have already been reduced to lower than in the UK to account for the new evidence on health risks from drinking. In Canada, men are now advised to drink no more than 15 units a week and women just 10, while Australia tells all adults not to exceed 2 units per day. A Department of Health and Social Care spokesperson confirmed that the UK guidelines will be revised later this year (paraphrased).134

Henry Ashworth, of drinks industry body the Portman Group, said: ‘Saying there is no safe level flies in the face of international evidence. The US and most European countries have much higher limits, based on the same evidence’.

Discussion

Mentions of drinking guidelines in UK news media articles during our study period took one of three general forms. First, there were incidental mentions within articles about broader alcohol- or health-related topics. These mentions accounted for 76.6% of articles, occurred on a continuous basis over time, and were generally informational in purpose and neutral in tone. Second, guidelines were mentioned in articles reporting and explaining the revisions to the guidelines. These mentions accounted for 19.4% of articles, occurred immediately after the announcement in January 2016, and were also generally informational in purpose and neutral in tone. Third, articles mentioned the guidelines when discussing their merits. These mentions accounts for 4.0% of articles, occurred primarily in the 23 weeks after the revisions were announced, and were discursive in purpose and often negative in tone.

As mentions of guidelines in most articles were either incidental or factual, these provided little scope for thematic analysis. Therefore, our themes emerged primarily from the third type of article and generally relate to criticism of the guidelines. These criticisms focus on the guidelines’ scientific basis and the integrity of the process by which they were developed, the broader purpose of guidelines with regard to a potentially malign public health agenda and the perceived inconsistency of public health advice around alcohol and other behaviours.

The main strengths of this analysis are that it covers periods when revised guidelines were discussed in the news media and status quo periods, whereas many previous articles focused only on a specific policy debate. It also combined quantitative and qualitative analyses to provide a detailed account of how guidelines are communicated to the public through news media. The analysis also has important limitations. First, we did not examine broadcast or social media as it was not feasible to do so within this retrospective analysis. This is common in many studies of news coverage of alcohol policy questions.74,76–78,80,81 In part, this is because newspaper coverage is of importance in its own right as a distinct form of news reporting, but it is also the case that newspapers in the UK broadly reflect and shape the news that is reported by broadcast outlets. Therefore, we would not expect our findings to vary substantially were we to conduct a more resource-intensive review of broadcast news stories. Furthermore, UK broadcast news is dominated by the BBC, and we captured an understanding of its reporting via inclusion of articles on the BBC News website, as well as the website of another major broadcaster, Sky News. A previous study136 examined initial reactions to the guidelines by tracking a single hashtag on Twitter (www.twitter.com; Twitter, Inc., San Francisco, CA, USA) for 1 week immediately after they were announced and found a roughly equal split between tweets that were supportive and unsupportive of the guidelines. Second, we searched only for articles that mentioned the guidelines and, therefore, we cannot assess how much alcohol-related news the public is exposed to that does not make mention of the guidelines, nor can we compare the coverage of drinking guidelines with other alcohol-related advice that may be reported (e.g. drinking clear spirits to limit calorie intake from alcohol). Third, we do not know the social patterning of the audience for different articles. Identifying such information would be challenging as media outlets promote certain articles more than others to attract advertising revenue or because of newsworthiness. Thus, although neutral articles were more common, it may be that these articles attracted a different audience or were less read overall than more negative articles. The analyses in Chapter 4 do, however, provide some insights into whether or not the overall body of news reports the impact on key outcomes relating to drinking guidelines. Fourth, our search focused only on the main guideline message to not consume more than 14 units per week. Other elements of the guidelines, such as those relating to drink-free days or spreading consumption across multiple days, were not covered and we may, therefore, have missed some aspects of the news media’s discussion of the guidelines.

The findings suggest that the revised guidelines, including some of the secondary advice (e.g. on drink-free days), were initially communicated to the public via large-scale news media coverage, which was mostly factual and accurate. This communication was then reinforced on a continuous basis by incidental mention of the guidelines within alcohol- and health-related articles. If this communication was effective, we would expect changes in proximal outcome measures (e.g. awareness and knowledge of the guidelines) to accumulate sharply following the initial announcement and then continue to accumulate more steadily in the subsequent time period as the public is exposed repeatedly to the guidelines via incidental mentions in news articles. However, there are three caveats to this. First, health messages require reinforcement and effects may decline among drinkers who are exposed to the initial announcement but not to subsequent mentions of guidelines in lower-profile news stories that are less likely to be read by certain sociodemographic groups.76 Second, diffusion theory suggests that repetition of a message does not lead to universal penetration.52 Instead, some people may never be exposed to the message and others may become insensitive to it because of overexposure. According to theories of psychological reactance,58 some drinkers may go further and actively reject the message or choose to increase their drinking if they perceive it as an unjustified threat to their freedom, as is described in some of the nanny state-oriented criticisms. Third, the negative commentary on the revised guidelines and the substantive criticisms that underpin it may also lead some people to reject or misunderstand the guidelines even if they are exposed to them. In combination, these caveats may mean that the initial sharp accumulation in effects on proximal outcomes from the announcement of revisions dissipates among drinkers who are not further exposed to the guidelines. Effects on these outcomes may then begin to accumulate steadily as some drinkers are repeatedly exposed to the guidelines through incidental mentions within articles, but this accumulation may plateau as the maximum level of diffusion is reached. Effects on distal outcomes, such as alcohol consumption behaviour, may be unlikely to arise from the news media reports identified as only the initial reporting contained sufficiently detailed explanation of the guidelines to constitute a call to action. Incidental mentions were more likely to state only the guideline consumption level and, therefore, were unlikely to prompt behaviour change. In the absence of any large-scale promotional campaign beyond the initial announcement, we would not expect this trajectory to be interrupted by any sharp changes in outcome measures at further time points after the initial announcement of revisions.

The findings also point to important implications for practice. First, the lack of articles presenting a positive, as opposed to simply factual, view of the drinking guidelines suggests a one-sided public debate. The lack of positive accounts of the guidelines from regular newspaper columnists is perhaps unsurprising as the majority of UK newspapers are regarded as on the political right and are often hostile to public health interventions. However, it is commonplace for public health actors to engage in public debate within newspapers via opinion pieces and letters to editors,73 so it is unclear why this did not happen after the revised drinking guidelines were announced. Analyses of previous policy debates in the UK and internationally suggest that, although public health actors have successfully embedded themselves with news media debate as valued information sources, their contributions are often less co-ordinated or strategic than those of commercial actors.74,80 The dominance of negatively framed discussion of the guidelines after the initial announcement may be a further example of this strategic deficit.

Second, the criticism of drinking guidelines can be looked at from two perspectives. On the one hand, it features strategies commonly used by commercial actors within policy debate. These features include cherry-picking of evidence (e.g. citing evidence of cardiovascular benefits without noting that these were included in the epidemiological model underpinning the guidelines),137 invoking complexity as a barrier to action (e.g. highlighting that risk varies between individuals)138 and, less widely discussed in prior literature, questioning the integrity and motives of public health actors. On the other hand, public health actors should be conscious of their active role in facilitating these criticisms. For example, the decision to announce the revised guidelines alongside a report on cancer played a critical role in the guidelines being conflated with the ‘no safe level’ message, one of the key points of contention for critics. The CMO reinforced this by telling a parliamentary committee that people should follow my lead. Every time I drink, I choose between my glass of wine or an increased risk of breast cancer (paraphrased).139 In a radio interview, she also described the extensive if disputed scientific evidence showing cardiovascular benefits of moderate drinking as ‘an old wives’ tale’ (The Guardian, 8 January 2016; reproduced with permission; Courtesy of Guardian News & Media Ltd).140 Similarly, several members of the GDG are prominent advocates for public health interventions to tackle alcohol-related harm and can, therefore, legitimately be regarded as both political and scientific actors.21 Furthermore, the public is presented with conflicting alcohol-related health advice on a regular basis, usually by scientific and public health institutions keen to promote their work.141 Previous studies highlight the resulting difficulties faced and strategies adopted by the public in using such conflicting information to construct their understandings of health-related risks.127,131,142 These examples suggest that criticism of drinking guidelines is in part a strategic response by commercial actors to a threat to their interests, but is also a reflection of the way that public health actors, and particularly public health scientists, engage with news media and the wider policy debate.

Third, the day-to-day reporting of alcohol-related topics is a continuous process irrespective of major policy announcements and presents an opportunity for exposing the public to alcohol-related health information. If this is regarded as important by public health actors, then they should seek to embed such information within press releases or in supporting or reaction quotations. Although the effectiveness of techniques used by different actors is not tested directly, previous research suggests that embedding multiple arguments within single quotations may be effective as well as providing a greater focus on population-level perspectives, the harms of alcohol to drinkers and others and the likely benefits of individual policies and multicomponent strategies.74,80 In undertaking these actions, public health actors should, however, be mindful of the problems outlined above with regard to public health actors’ role in constructing criticism of the guidelines.