The Alcohol 'Problem' Podcast

Drinking behaviour, risks and causes with Professor Tony Moss

November 18, 2022 James Morris / Tony Moss Season 2 Episode 3
The Alcohol 'Problem' Podcast
Drinking behaviour, risks and causes with Professor Tony Moss
The Alcohol 'Problem' Podcast
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In this episode Professor Tony Moss talks about key drivers of drinking behaviour and alcohol-related risks, problems and causes. This covers how alcohol use can develop into addiction, and the complex nature of associated problems and the range of psychological, social and sometime biological factors involved.

Prof Tony Moss is a  Professor of Addictive Behaviour Science in the Centre for Addictive Behaviours Research at London South Bank University. He has conducted a range of research related to the psychology of alcohol use and drinking behaviours. Prof Moss set up a 'pub lab' to improve validity of alcohol experiments and has appeared on multiple TV shows exploring the subject. He has recently co-edited a book on Evaluating the Brain Disease Model of Addiction and can be found on Twitter @tonymossuk

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James Morris:

Thanks for joining me Tony. Can you just tell me a bit about what you do and what your background is?

Prof Tony Moss:

Yes, my name is Tony moss. I'm a professor of addictive behaviour science at London Southbank University in the Centre for Addictive Behaviours Research. My background in addictions research particularly focuses on alcohol use. Obviously, they work in gambling and more broadly around public health. My particular interest in terms of alcohol related harm has been focusing on diction less about those people that are at the more extreme end who have developed really significant problems with addiction, where when we talk about alcohol problems, that's what people tend to think about it think about those people that are most heavily dependent. My interests have been more around the prevention side of things and that much larger group of people who are experiencing some degree of harm from alcohol use, but actually wouldn't in any way consider themselves to be a problem drinker, or to have a problematic relationship with alcohol. And that's a sort of an often overlooked area, I think, in our field. And

James Morris:

So if we're thinking about what causes alcohol problems, and I guess we should start with what we're including in that definition of problems. And there's lots of different ways to do that. But broadly, we'd say, you know, as a continuum of alcohol use and harms, and the recommended guideline, kind of 14 units a week, fairly arbitrary, in a sense, but it is sort of derived from a lot of population data shows kind of the more you go above that risk level of 14 units as an average, healthy adult, the more risks go up. And then there'll be a range of factors when they're sort of individually and environmentally that would influence the degree to which someone would develop a range of different problems, whether those be sorts of related to addiction or dependence. Or they might be just kind of problems associated with their general functioning or mood or well being. Yeah, like, is it possible to start with a broad question and say, what causes alcohol problems? Or is that just trying to bite off more than you can chew?

Prof Tony Moss:

Well, I'll give it a go. I mean, I suppose the first thing I'd kind of come to is that question about what we think an alcohol problem is or what problems could arise from alcohol use. And I think that is something that that's often misunderstood. And partly because we tend to think about the most extreme problems for from alcohol use, including things like psychological and physical dependence or cirrhosis of the liver, and so on. One of the things that I'm particularly because of the sort of cultural space that alcohol occupies in a way that most other drugs that are associated with addictions, and other things tend not to occupy that similar spaces, that there's this sort of assumption that alcohol just occupies an everyday part of our lives. And it's a necessary component in social interactions in lots of different aspects of people's daily lives. And the thing that I think is often misunderstood, is that this idea that there can be sort of safe levels of alcohol use, one of the one of the key things I'd always say about alcohol in terms of our relationship with it, whether you drink or not, is to understand that it's not, it's not part of a healthy diet, it's not one of your five a day, there's there's no sound argument to say that you're, if you're a non drinker, you should start drinking a little bit, because it'd be better for you in the long run. It's something that you know, bit like fast food and other things, and high fat, salt, sugar foods. So that is not adding anything in terms of health. That's not to say that any amount of alcohol is going to cause you serious harm. But I think that the way that it needs to be understood is that the more that you drink, the more you're exposing yourself to some risks of harm or adverse consequences in the long run. And I think that that, when we when we talk about these sorts of harms and risks, it's useful to maybe think about what that universe of harms could be. So I've already mentioned things like, you know, psychological and physical dependence, cirrhosis of the liver, the things that people might think about as being associated with very heavy alcohol use, the alcohol also increases risks of cancer, it's going to put you at risk of long term chronic health issues, even down to things like putting on weight, you know, there's a lot of calories and alcohol and so the more alcohol that you're consuming, the more calories you take on more weight you put on so, you know, I overall, the risk of alcohol use can be in the longer term detrimental to our health in many ways. But then in the short term, the kind of the acute effects of drinking alcohol, even if you're not drinking necessarily a huge amount on a daily basis, but you're drinking we might describe as a binge drinker. So people that when they drink tend to get really quite heavily intoxicated, you'll then put yourself at risk of kind of acute harm. So things that might happen, you know, falling over and breaking an arm or not being able to function the next day at work because of a hangover and so on. That kind of acute effects and also the longer term can have an effect in terms of mental health. So if you're suffering with anxiety, or other forms of mental health distress, then alcohol won't help with that. So there's a number of ways in which alcohol can cause these these different types of harm and it's again all by degree you know, some people may have had a bit of a hangover and that may not be for them a massive kind of problem in their lives. But if it's if it's happening on a regular basis and impacting on relationships or work, or mental well being, then that becomes more of a problem. So I think that that's a key thing is to start from this understanding that that alcohol use is in and of itself, not something that you should think of it as a sort of, you're doing yourself some good by having it that needs to be an acceptance that any amount of alcohol that you're consuming is increasing your risk slightly. And that just comes back into that sort of universe of risk, if you like the people might make for themselves on a routine basis, you know, people, people engage in sorts of things that expose them to risk.

James Morris:

So obviously, I'd agree with everything you say, I guess, I do feel from the public's point of view, people are much more aware of all those risks. Now, whether that's cause of, probably not because of responsible drinking campaigns and so on, but the dialogue and recognition around alcohol as a drug rather than just something, you know, it's kind of part of what we do, or shopping or whatever, when has shifted quite a bit. And I don't think it's necessarily a lack of awareness or understanding about alcohol as not being fundamentally healthy. Although I think, there are a group of people who would still say, you know, red wine is good for you or in moderation is fine and define their own moderation by how much they drink off and anything to do with recommended guidelines. I would say that the general problem is more that people place a lot of value on what they know, are the positive benefits or personally experienced positive benefits, and prize those in the moment benefits at least particularly above those risks. So yes, I don't disagree with that. I just think as a public health message as a way of kind of changing behaviour, just just kind of highlighting that even Yeah, alcohol problems are more complex than or less severe than necessarily the stereotypes, still isn't necessarily certainly going to change people's drinking or not necessarily problem drinkers, have addiction dependence, but still placing health at risk. I mean, maybe that's not true to some extent, like brief interventions. We do know work well, in a health professional does essentially point out some of the risks and some of the benefits of cutting down. Yeah, I guess I'm just trying to say people also very aware of the benefits, and whenever we start explaining the costs, I think does tend to just sort of switch many people off, because they're just sort of say, well, I know it's not good for me, but I value it for these reasons.

Unknown:

I take the point, I think the information out there around alcohol and harms is is perhaps better than it than it used to be. I'd I disagree that most people. So, I think certainly the evidence work we've done around gambling, for example, suggests that a significant number of people who gamble, do not agree that gambling is something that carries any inherent risk. So not not asking people do you think that that you personally have are experiencing harms from gambling? But just inherently Is there anything particularly risky about that about gambling? There was some work a few years back, I think it may have been from from colleagues in the Institute of alcohol studies, but I might be misremembering that, showing that actually unprompted, the majority of people actually don't identify most of the harms that can come from alcohol use. So may have been that same study. I think, if you ask people just to sort of list what the harms of alcohol are, most people miss most of them. If you prompt people and say, well, here are some things that could be problems with alcohol, then the recall can be a little bit better. So I'd argue that actually, there is there is weirdly for a drug, if you like that's been around for for such a long time. I think there's a huge deficit in public understanding about what those risks are. An even bigger hurdle to get over is even if you get people to accept that alcohol is inherently risky, getting them to accept that they are personally exposed to those risks. We know from lots of other areas of health communication, that that's really difficult to do. So even if you get somebody to accept that, yes, if you drink alcohol, it will slightly increase your risk to cancer, even if you're a sort of a moderate, sort of a fairly light drinker, it will slightly increase your risk of cancer. People can kind of know that information, but not personally apply it to themselves. So there's there's multiple hurdles to get over. And they really think that there is this that alcohol for many people is still allowed to occupy this kind of special place in their lives, that it's almost in the same way that people could be very, very sort of health aware in terms of their food and be looking at, you know, how many carbs they're having, how much sugar and saturated fat and so on and so forth. You know, it's my truth not uncommon for people to then at the same time, not have any interest almost in alcohol from that sort of nutritional perspective. And so I do think that alcohol because of that very strong cultural tie, it has certainly, you know, encouraged by the alcohol industry is allowed to occupy this kind of no man's land in a sort of a Nutrition and Dietary sense and remember risk perspective. So, yeah, I think I'm not aware of any evidence that suggests that actually public understanding of the harms of alcohol, even like theoretically not apply to themselves is very good. I think the majority of people are actually unaware of the range of problems that can arise from heavier, longer term alcohol use.

James Morris:

But I suppose my point is, even if we raise awareness, you know, we know that people who drink above the guidelines are much more likely to to discount them and to say that they don't apply, or they are not based in science, or to employ psychological biases, like defensive avoidance, you know, like, where people, you know, smokers famously look away, you know, subconsciously look away from graphic health warnings, they just, you know, the tendency of avoidance of it is really strong. So I think, yeah, this is not just about, you know, filling a deficit to whatever extent it exists in the public understanding about the risks and harms of alcohol use. I agree, that's a starting step. And we can always build on that. Yeah, I'm sure you agree that we need to be much more nuanced and do a lot more than just kind of increase public understanding. And I guess just to go back to that, go back to the point about why many people or particularly people who might drink levels above the guidelines are in a problematic or risky way or whatever, are more motivated to discount, probably because they've placed higher personal value on the role that alcohol plays in their lives, in terms of, you know, the positive motivations for using alcohol, as a social lubricant, de-stressor, or just something even less consciously articulated. They just know, on some level when they drink, they still feel good in the moment.

Prof Tony Moss:

Yeah, I mean, I think there's, there's definitely I mean, that's, that's the big problem with something like alcohol, as with many things, to which, unsurprisingly, things that people can develop unhealthy relationships towards is that all of the all of the benefits are usually immediate. So people are not consuming alcohol, and then the next morning waking up, and that's when they have the sort of positive experience, the negatives come later, positive come earlier. So in the moment, when someone's having a drink, if it's if they're drinking, to enhance a social situation, if they're drinking, to cope with stress, whatever the motivation might be, usually, that's been fulfilled there. And then, and just from a sort of a human learning perspective, we learn, we learn behaviours much more quickly. And those behaviours become a lot more kind of solidified if you like, when, when the reward is associated closely with the behaviour that you're doing. When the negative consequences are further in the future, from a sort of a psychological perspective, they have a much weaker impact or a weaker pull on our behaviour. So the fact you know, the people sort of sometimes why come calm, never drinking again, the reason that often they'll end up doing it again, is because in terms of that kind of learning process, the negative consequences happened in time, a lot later than the behaviour that they did. Now, I suppose one that one of the things that that does interest me in terms of why is that people may think the way they did about alcohol use and you know, to your point about Is it is it kind of almost justifying or rationalising their relationship with alcohol, ignoring the negatives focusing on the positives, that for me, one of the really big factors in this is that it's just really difficult to change your behaviour. And so we understand that, you know, there's lots of evidence to show the the ways in which people drink alcohol. So for those people that do consume alcohol, those kinds of beliefs, and motivations, you know, take a really, very typical example. There are lots of different motivations for drinking alcohol, you can drink because you think it enhances social situations you can drink, because it's something you do to cope, you can drink because you're conforming with other people around you. Those motivations are developed many years before you ever encounter alcohol. So socially, because alcohol is so present in so many people's lives, even in the younger childhood, were developing the sorts of thoughts and beliefs about alcohol that will be very similar to you know, parents and other people around us when we're young. So that when we then encounter alcohol for the first time, it's almost like the people that recognises that our self fulfilling prophecy you engage with alcohol in the way that you've seen it engaged with before. And one of the sort of the fallacies about kind of personal control and responsibility. And the idea that people sort of choosing or if they're not choosing there must be in denial is that even if you're not, even if you accept that you've got in some way a relationship with alcohol that you would like to change? It's really, really difficult to do, because it could be you're in your mid to late 20s, or your 30s and your 40s. And you think, you know, maybe maybe I do need to sort of reset my relationship with alcohol in some way, whether that's choosing not to drink, whether it's, you know, choosing to cut down or moderate. The problem is you have got years and years and years of learning that those kind of automatic implicit associations about how you drink, but you can't just click your finger and undo and so when you're in situations where you're drinking, it can be really easy to revert a type that you the reason that you end up drinking in the water. Have you always have done is simply because that is what you always have done. And of course, the pharmacological effects, psychopharmacological effect is that it explicitly impairs those parts of the brain that help us to make more conscious effortful decisions. And so we've become more reliant on just kind of acting out those habits if you like that we've got. And so for me, that's one of the big the bigger reasons, if you like as to why it is that people after the fact, if you ask them, why is it that you're drinking in the way that you do, they may, consciously kind of expressed to you the reason I do it is because you know, I enjoy it, it's not been causing any harm. But actually, I don't think that's the reason I think that for a lot of people, the reason they don't change is that changing behaviours of this client is not an easy thing to do. It's certainly possible and there are loads of people that have changed, and continue to change their relationship with alcohol. But the idea that it's something that is just a matter of making a decision and going, that's it, I'm gonna, I'm gonna sort of reset it is just completely flawed. But it's, it's not helped because alcohol does occupy this, this kind of cultural space. You know, it's different in different societies. But it's, it's present in most, that there are certain expectations about drinking, there are certain social norms about drinking, that really have this big impact on how people engage with it.

James Morris:

And I think there's a good body of evidence that shows most people who change from problematic or heavy alcohol problems often do so when there's a kind of clear emergence of physical health problems or, you know, some serious consequences. That really, you know, they may, you know, one study suggested people were kind of aware that they're drinking was deemed would be deemed problematic level, you know, for maybe 10 years before making a change. But it wasn't until kind of consequences really caught up on that person. Probably the same was true of something like smoking, smoke for many years, knowing full well that it's harmful for them, until we actually internalise maybe a diagnosis of cancer, or colitis or whatever, that might not trigger change. So don't like suddenly, Robert West, I've heard say No, all behaviour is a competition of motivation. So it kind of makes sense to me in that way that, you know, it's not until the harms are present, that it actually sort of impinges on our kind of motivation to use alcohol for the reasons that you've explained with implicit cultural or just experienced as positive moments. Do you agree with that?

Prof Tony Moss:

Yeah, definitely. And I think there's, you know, I think for some people, they can experience harms as a result of their use of alcohol over a longer period. And even when they experience the harms, they still may not recognise that it's in any way links to the to the relationship with alcohol. And that can even be missed by healthcare professionals. So to take a hypothetical example, if I if I was to drink half a bottle of wine every night regularly, I'd be drinking significantly above the the low risk drinking guidelines and a number of different sort of health consequences, chronic health problems as I get older. The problem is, if I'm drinking half a bottle of wine every single night regularly and saved, let's just say hypothetically, I'd never go out and never get kind of drunk drinking half a bottle of wine on a regular basis, you'll never actually get yourself really drunk, you've never experienced being white, really intoxicated, because that level of alcohol use once you develop a sort of a tolerance to it, you won't feel impaired, if you drink half a bottle of wine, that would be it. If I did that for 20 or 30 years, then it's going to have all sorts of effects on my body. So not just the effects of the alcohol itself is probably going to be associated with weight gain, because it's just those additional calories every single day on top of an ordinary diet. And so am I getting to midlife and start to experience you know, various different sorts of health or health problems, increased risk of stroke, cardiac problems, and so on and so forth. But there's never going to be a trigger where I kind of think it's because of my alcohol use, because my alcohol use will have sort of appeared almost kind of non problematic throughout my life, I might be thinking, Oh, maybe I just need to change my diet a little bit. And it's back to this idea that I think alcohol occupies is protected space, people might think, oh, I need to start eating more healthily, or sort of, you know, start exercising or something. And I think that's the challenge is that there is for when we talk about these longer term problems that are associated with alcohol use, there isn't always that immediate trigger. There's not that, you know, I got really drunk and I blacked out. I don't know what you know, I woke up somewhere or whatever, where you might you know, that that could be a wake up call the next day and you think, oh, you know, just went overboard or something, that there can be these harms that happen over a very, very long period that will never get connected to their alcohol use.

James Morris:

Yeah, of course, and, you know, people can always rationalise their drinking, and I've agree, you know, occupies this very protected space or culturally normalised space and some of the work we've done together that points to how, you know, certain stereotypes are of alcoholism in inverted commas, you know, drawn on by people who maybe would still argue, not problem drink, or, however, wouldn't frame it that way, but because they are still in control of their drinking, and even, you know, some qualitative research showing how, you know, binge drinkers will say, I'm not problem because you know, I don't drink for most of the week, I just come out and have a bit of fun when I drink, it's the people that drink on their own indoors on a daily basis, or whatever. So there's always someone else to either, and I agree, but I'd still sort of think that that that's motivated by other means motivated, not just by the fear of wanting to protect oneself from a stigma of being labelled a problem drinker, but also because, you know, on some level they value value their drinking, and those kinds of non tangible future or and yet as yet unexperienced or identified health problems, in particular, are just not going to be sufficiently powerful enough to motivate them to give up or they really value and maybe they overvalue alcohol, maybe in some ways you could argue they undervalued depending

Prof Tony Moss:

on person. Yeah, I mean, it's back to their kind of cultural context as well. But I think it's not necessarily even always about motivation, unless you expand your definition of motivation to mean anything that a person does. To the extent I think sometimes it can be completely habitual. So it can be that in certain situations, people just assume that they're going to drink because they've been invited to a party or friends popping around or whatever it might be. So sometimes, I think it can be quite banal and uninteresting as to why it is that someone's choosing to drink, but almost because they've just not considered the alternative, which is maybe why don't have a drink. So I think absolutely those kinds of motivations, and the more explicit valuation or value valuing of alcohol plays a role. That is certainly not the only role. I think this is back to this idea that as humans, we are creatures of habit. Now, behaviours in many different respects don't tend to change dramatically like for you, throughout the course of our lives, unless something significant changes in our life. So like you said, about people experiencing more serious harms that become quite salient and almost sort of unavoidable. I certainly hear that a lot in the addictions, literature, for recovery stories, people talking about having moments of clarity, or epiphanies or spiritual awakening, but but I think that in the absence of those sorts of experiences, people's behaviour very often just goes on down this track, which is the thing that they've always done. Yeah, absolutely. Another, I think that's always, in the sense of our people might ordinarily understand what we say people have been motivated, or as a motivation for it, I think, in the ordinary sense of understanding that it's much more. It's a much more banal and boring. It's just, you know, I kind of did it, because I just thought that's what was happening. Or was in a situation where I always drink when I'm in that situation, someone just did.

James Morris:

But it does seem like there is, I think, you know, obviously, within younger generations changes in what they're expectancies are around alcohol. And, you know, obviously, it's very hard to unpick The reason or reasons behind these declines in young people's drinking. But I suppose interesting to say, why is it happening amongst young people they're drinking as a whole is lessening, middle aged and older groups, not maybe part just because drinking habits are more embedded, not experiencing the same kind of changes in all the other things that are going around much more dramatically affecting younger age

Prof Tony Moss:

waves? Yeah, I mean, I think there's, you know, there's there's a lot that I don't think we've got a clear answer yet as to why it is that there is that change in alcohol use among younger people, is almost certainly going to be a complicated answer that, you know, there's big cultural changes that have happened to me. You know, even when you think about social media and the connections that people make and awareness of health, and so on and so forth. I'd like to think that to some extent, those things have played a positive role in particularly demonise social media and people's use of the Internet and so on. assume it's always a bad thing. But there does, there is an element that is also providing a space to kind of liberate information even think about when I was younger, it'd be really hard to find out any information about you know, alcohol use thinking back to my parents, if they wanted to find out something of the internet wasn't around. So you know, there's business, there's a lot of a positive to that. You know, I know that there are people that have argued that there is a sort of great health awareness, even young people and so on to the other question as to why is the older adults aren't necessarily trying to drink and I guess I'll revert back to what I said before, which is, it's because most people most of the time don't make really significant changes to their, to their behaviour in almost all areas of their life, you know, unless you're making a special effort if you if you might, so you're making a special effort to change your diet by going, you know, joining Weight Watchers or Slimming World or something like that, you know, people, people can make very concerted efforts to change their behaviour. They can often be unsuccessful in that, you know, certainly in the context of dieting, you know, there's lots of evidence around people sort of a yo yo dieting, almost just going from one sort of you attempt to lose weight putting weight back on and so on. And that, again just reflects how difficult it can be to just change that, you know, get get off of that path of least resistance. I think with alcohol is that there is that sort of competing if, if it's if somebody who is if somebody is not experiencing any kind of acute or obvious or salient harm, or they're experiencing acute or salient harms, which to them simply sort of seem almost like within the realms of acceptability, sort of thinking, oh, yeah, I'll do once a week hangover, but I enjoy that night out so much that I kind of wouldn't want to give it up. So, you know, people could be making that, but it could well be making those sorts of judgments, be able to make that concerted effort to change your alcohol use is, is tough, as with any behaviour change, coupled with the fact that it can be socially difficult to do that, because suddenly, people are asking you questions about, you know, why you're not drinking? Is it because you're on antibiotics, you know, have you caught religion, whatever it might be, you know, people will often and people that try to make changes to their drinking very often experience that very often experience that kind of social pressure. We did some work on this a few couple of years ago, looking at peer pressure amongst adults, I mean, it's a fascinating area, because we just associate peer pressure with kids, we think, you know, kids are the only ones that get pressured by their peers. But there's actually some really interesting work out there looking at the role of peer pressure in adult drinking, and this idea that people end up sort of caving into expectations from other people and the difficulties that they have navigating that, you know, whether it's explaining to other people, other people, and maybe taking your views about alcohol use, as a criticism of their own people sort of thinking is the way that I do this just to not socialise with these group of friends anymore. You know, it's a real challenge. And I think it's, it's, and certainly from a research perspective, it's an understudied area. And I think just socially in general, I don't think we kind of talked enough about that. But if you want to change your behaviour, like alcohol use, which is for many, many people, very connected with their social interactions with friends and loved ones, that that actually trying to make changes on your own. In that context, when no one else is trying to make a challenge, there's going to be another explanation as to why it is that you know, why are older adults experiencing more harm and not changing their alcohol use? It's for those sorts of reasons.

James Morris:

Yeah. And I think that links to some of the evidence around by peer support works, because it provides people with a supportive environment towards that change and provide some social network and sense of belonging in an environment that yes, the the opposite, they kind of use it. And what about some of the others or risk factors for developing alcohol problems? So we've talked quite a bit about kind of cultural normality and social expectations or social pressures on drinking, but, you know, people obviously, obviously, interested in things like genetics, you know, probably fairly strong views on the, you know, the role of genetics being vastly overestimated by the general public. It's not, I don't think they play any role. And there are sort of genes that are associated with certain types of risk factors that may or cluster together and genes interact with the environment, it's not kind of nature or nurture, is it? You know, I think he's kind of genome wide association studies have kind of come up with this or missing heritability. The variance or the amount of drinking or drinking problems that can be attributed to genetics, I think now appears much lower than some of the figures that used to be divided. And twin studies.

Prof Tony Moss:

Yeah, I mean, so on that wider set of factors that influence the way people drink. So if you're thinking a bit from, you know, from a personal perspective, you're if you're reflecting on your own use of alcohol, why you drink alcohol in the way that you do whether or not that's because you have or have had more serious, more kind of severe outfall of alcohol dependence or something like that, or because you're just a really heavy drinker, and you're thinking maybe I need to cut back or wedding or whatever your relationship with alcohol is up to including being in a non drinker, is kind of almost a moot point as to the role of genetics plays, I think, you know, there's a lot of research on it. And people do tend to, they love a genetic study, because you know, suddenly headline in the newspaper, you know, the genetic, alcohol dependency is inherited, or, you know, their their brain disease causes or whatever else are these sorts of issues. So I guess, a simple thought experiment maybe helps to sort of put into context. And then I'll get onto actually the strength of the evidence. If there was a genetic role that that was played in terms of determining how a person chooses to or how a person ends up using using alcohol in their lives. If there was a genetic component to it. How useful would it be if somebody said, I've got a test this test, I'll tell you if you've got that gene or not. The problem with it is is that even if that test existed, and there are companies out there will say they'll do this and they'll give you the sort of genetic screening for that areas, different things, obviously playing them, of course, that if that if you can get that genetic test done, you get told you've got that gene, does that mean that therefore you just accept that however you interact with alcohol is just unchangeable, because you've got the gene. And that means that you're going to have this relationship with alcohol that's determined by your genes, well known as nonsense, you shouldn't accept that if you've got that particular genotype, that there's no way that you can change the way that you're using alcohol. And equally, if you get the test done. So the only other alternative is you get it done. And they say, you haven't got this gene for alcohol dependence on it, you might want to call it, does that mean that you don't have to worry about use of alcohol, you kind of go, I can do whatever I want with it, because I'll never develop a problem will of course, that's absurd, as well. So when people ask that question, you know, can you inherit alcohol problems and that sort of thing. It's because the relationship that we have with alcohol is so influenced by the culture that we live in the time that we live in the influence of so many different things, the influence of what we're seeing, when we're growing up, you know, those early childhood experiences, all of those different factors play such a significant role, that even if there was evidence that it was in any way linked to genetics, and the evidence is very, very weak. So you know, it's not that it's completely non existent, but he's very, very weak, in a practical sense, is not even worth thinking about. And it is problematic, in my view, to be thinking about that. And so when when people get really interested in so they'll get why people are interested in it. But when they start seeing it as being some really useful way of understanding the relationship of alcohol, it's that danger of almost biological determinism that either I've got the gene and it means that I can't change my behaviour, which is nonsense and untrue, or I haven't got the gene, therefore, I don't have to worry, which is nonsense and untrue.

James Morris:

Yeah, and, you know, what he's kind of recent studies are showing is there's definitely no single gene that kind of plays any sort of significant role in that risk. But, you know, if you add up 1000s of genes together, there might be a slightly increase, or some of the figures between sort of single figures and some creepy into double figures. But yeah, I'd agree. And I think it does kind of go back to that need to try and make sense of or feel like, you know, there's certain things that are within or outside of our control, because those kind of beliefs can be kind of comforting. And you mentioned the sort of brain disease there as well, you've recently co edited a book on brain disease model of addiction. mean, do you have any particular observations in terms of how kind of brain disease model of idea of addiction, particularly relates to how car problems? I mean, obviously, there are variations of the disease model. And in a sense, it's, it's practical utility is to be able to say, Well, I have this disease, and therefore I need to just abstain from alcohol completely. And for many people, that's a very functional and useful role and also provides a kind of shared identity, perhaps within certain context. You know, science is probably less clear.

Prof Tony Moss:

Yeah, I mean, it's, I mean, the brain disease model, specifically, I think, is a is a reflection in certain certain parts of the scientific community, particularly in certain countries, United States, in particular, this tendency to want to medicalize all problems and kind of say, you know, is there is there some ultimate explanation as to why it is that some people can get with you, whether it's with alcohol or other drugs or gambling, they can get to a position where it appears, may feel to them, and it may appear to other people, that they've almost completely lost control over what they're doing, they're unable to stop, they're able to sort of give it up, or to change their behaviour. And the problem with that is it's just too simplistic and explanation. I mean, there's a whole big debate and the listeners could of course, buy a book and have a good read of it, because fantastic chapters for and against the brain disease model. But I think that the way that sort of sum it up is that, of course, the brain plays a role in our behaviour. It's not that the brand does not play a role in our behaviour. And absolutely, if you said there are people for whom, from a very personal, very individual level, seeing their relationship with alcohol, when it has become so extreme, and in some cases really destructive in their lives. Framing that problem as being a problem rooted in this sense of having a disease or thinking that they're in some sense different to other people, and that they can't have the same kind of relationship with alcohol that other people might appear to be able to have. If that helps a person with their journey through recovery or change. That's not something anyone should be kind of contesting. The problem is when it works the other way round, and the scientific community tries to impose that view and say this is this is something that everybody should be thinking, because actually the evidence isn't there to support that idea, the other negative consequences certainly from your own research in this area. The other negative consequence of thinking in that way is it goes back to this kind of biological determinism almost, but the consequence of that is it makes everything very binary and it means that people then have to think well, am I a problem drinker or not? And what I kind of began with was Talking about a kind of universe of different harms. And that sort of spectrum of harms that people can experience. The idea that there is this group of people in society who are the problem drinkers, and then everybody else is really unhelpful. It certainly plays into an industry narrative, this idea that the majority of people can use alcohol and experience no harm from it at all, it's all fine. And it's all good, fun, don't need to worry about it. And then we've got this really small proportion of people that we should worry about, because they're the problem drinkers, that that completely misrepresents the way that people should understand our relationship with it. And we also to a large extent, as well, for people that are kind of on on the margins of having periods in their lives where they're drinking more heavily than others, it sort of ignores this nuance, actually, people's relationship with alcohol can fluctuate from time to time, a good example of that would be people who have a strong motivation around drinking to cope. So if you're a sort of person who associate alcohol with dealing with stressful situations, and to be clear, not everybody does, there are people who do associate alcohol use, having a good time and having fun, and those people will tend to drink more heavily if they're at a party or down the pub or something in the company of friends. But there are people who associate alcohol with dealing with negative emotion, some people might, you might call it kind of self medication. And the problem for people who that that is a very strong motivator for their use of alcohol is, of course, what happens if they go through a period in their lives where they're under a huge amount of stress. If you've got that motivation, if you strongly associate alcohol with when I'm feeling anxious, if I'm feeling stressed, if I'm feeling low mood or that effect, then I find that alcohol helps or I think that alcohol helps, then, of course, if you go through a period in your life, where things are impacting on you that you can't do anything about, then you're naturally going to see your alcohol use increased. And so you can develop more problems in that kind of acute phase, if you like, where you're drinking more and more heavily. The alcohol, of course, is never going to actually solve any of the problems. They're still there the next day, but the alcohol use it, you know, things will spiral it starts to affect affect your mental health, because you can you will increase anxiety over time, and so on. So, you know, I suppose back to this idea that, you know, is it a brain disease or not? For some individual people, they may find that it's a useful way to frame their own understanding. And absolutely, some people may simply find that they get to a stage where their relationship with alcohol, their experience of using alcohol has become sort of almost traumatic in itself that it's caused. It's caused them such harm, they've got such strong associations and memories associated with their alcohol use that actually, it may well be the best thing for them in the long run to just try to never drink again. And then there'll be happier if they don't. And that's the journey that will best suit them. But I think having that kind of binary distinction, that there are those people that just shouldn't drink again, because they're alcoholics, and then everybody else who doesn't experience harm. It's a real problem. But it's what this brain disease model perpetuates this idea that there is this special group of people who have got a serious problem somehow rooted in the brain. And then everybody else doesn't need to worry.

James Morris:

But wouldn't Some argue that a brain disease is characterised by significant new adaptations, that means that the state of the brain as you know, obviously, Mark Lewis would just argue that the brain changes when we do all kinds of things. But an extreme form of change doesn't necessarily represent disease. But it sort of intuitively on one level, it does make sense to think that if your your brain has become so adapted, and so sensitised to how correlated cues or triggers, that will one level that doesn't make sense to sort of pathologizing say, that brain has become diseased as a result of prolonged heavy use of alcohol and all its associations with it.

Prof Tony Moss:

I think, I think there's a difference between. So when we talk about neuro adaptation, that's not a pathological process. And your adaptation in itself is what the brain constantly does. It's how we learn and develop the brains passing. Mark says that more eloquently than I would certainly the other analogies, whether we're talking about literal damage caused to the brain. So in more extreme cases, verdicts and Korsakoff syndrome, and so on. So you know, but that in itself doesn't constitute a brain disease of addiction. And I think they're the argument that if you say some people wouldn't make this argument for some people, perhaps the, perhaps in your adaptations become so profound, that it makes sense to pathologize it and talk about it as a disease. The problem is, again, almost back to that kind of clinical and practical utility. So we're sort of stretching our definition of what disease would be so much the same way that someone developing degenerative age related brain disease and Parkinson's, Alzheimer's and so on, you can put somebody into an MRI scanner at certain point identify structural and functional changes in the brain and an experienced clinician would be able to look at your brain scan and say without even meeting the person, this this looks like a brain where outsiders or Parkinson's is developing. The problem is that we cannot do that with alcohol. The other the other sort of challenge is is how it is that so many people have been able to spontaneously recover as it were. So there's sort of this notion that addictions are for completely kind of uncontrollable, if you like that you literally lose control. And once you're an addict, you've got this brain disease, and you simply can't stop. There are many people who get really very heavy psychological and physical dependence, who actually managed to overcome that, without any structured help or support. So there's what we call a spontaneous or natural recovery. So if they had a brain disease, it simply wouldn't be possible to do that. You can't simply choose to not have Parkinson's or Alzheimer's anymore. So if if we accept that those are brain diseases, and then we say that addiction is a brain disease, then the question would be, well, how can somebody spontaneously recover and simply choose to change. And it's much more complex than that, you know, the sort of factors that impact on spontaneous or natural recovery is not simply just the person going on just going to change now, there'll be lots of other factors, social and psychological, and, you know, all these other things that are impacting on the way that people's behaviour is being shaped. But yeah, I think it's a, it's, it's a simplification of a really complicated area. But you know, why your people use alcohol is, is, of course, it's going to be influenced by the physical response that you have to alcohol. So our bodies are different. There are loads of differences between people in terms of, you know, the extent to which they experience more or less severe hangovers, you know, there's just natural biological variations between people, none of which are pathological. It's not that people who don't experience really bad hangovers have got a pathology with their body, it's just that that's their biological makeup differs slightly from other people's. And so all of those sorts of factors can play into how a person uses alcohol, and so on and so forth. And again, it's this, what we tend to do when we talk about complex issues, I think, just generally, is to almost kind of get down to that there must be one thing, it must be what really, can we just say it's that can we just say it's, you know, it's just your your traumatic upbringing, or it's a brain disease or something, the reality is that there'll be people for whom that may well be true. But it will also be people for him, it's not our explanation of alcohol problems, how they develop, why they develop, how people can change that. And our explanation of all of those things has to be complicated, because it is complicated. Like, it's complicated, and lots of people have what might seem to be very similar experiences that have led them to a similar place. But when you dig down, you find out that actually, there are massive differences in the experiences and things that people have had.

James Morris:

And then just finally, briefly, I know you pretty well, we've, we've had a drink together sometimes, but you know, what, what do you get from alcohol? And how do you sort of view your drinking?

Prof Tony Moss:

Yeah, I mean, I think I fall generally into that camp of drinking for enhancement, like it's, which is a blessing and a curse. And I'll sort of come on to that. And that sort of thing about drinking is close, if I'm sort of experiencing, you know, more pressure at work, I'm feeling more stressed out, or, you know, thinking back to when my kids were younger, or even a tail now, I've never really associated drinking alcohol with, with dealing with negative emotions, if anything, if I'm sort of feeling stressed or anxious or something, I'll be, I'll be less inclined to want to have a drink. When I think back to my childhood growing up, alcohol wasn't really sort of consumed quite heavily in front of me, you know, that I don't remember, sort of ever seen my parents drunk or you know, sort of family was drunk. It wasn't, it wasn't the people didn't drink by them. And then the sort of seeing people drinking really heavily. But I also have like really positive memories, when I was growing up about sort of family get togethers particularly so you know, aunts, uncles, on my mom's side, and we'd have sort of Christmas parties are birthday parties, where people would be drinking, that everyone would be having fun. And they've been I don't ever remember there being a fight or ever remember, there being, you know, someone's sort of passing out throwing up or anything like that. So that's that sort of thing about your early childhood experiences, if you like, have a really formative impact on your own alcohol use, and I think that certainly is, you know, is part of my own relationship with alcohol. The challenge for me with that, I think, is that over the years, I've found that I can go overboard if I'm enjoying the situation too. So you know, kind of going out for a quick drink. Certainly remember, during my PhD sort of, you know, quite regular thing popping out after a drink after work just for a quick one. And what will tend to happen is that I'll keep having one quick one after another until eventually the public closed. And what I've tried to do over the years over here thinking about because that was never great, like, you know, drinking too much, or getting home late or spending more money than I wanted to, or could afford at the time as a student. And one of the things in terms of my own. Maybe again, that's reflecting on this idea that behaviour can be really hard to change, because I've tried to do things quite consciously before like if I'm going to go out for a drink. We're always kind of except that that's something that's a bit of once I've had a few drinks, I'll be there and I'll be in the company of friends in a really good time. And it just won't want to go because I'm enjoying it like why would why would I want To get up and go, so to speak, but what I'll try and do is make sure that I actually eat, you know, that was one of the big things for me is it going for a quick drink afterward, I'm gonna have a couple and then I'll be home is that you don't need all the food, because I'm not saying for that long, but one of the practical consequences of not eating is you'll get intoxicated more quickly, and so on. So, you know, there are things I've done over the years, I choose where I can to drink a lot of strength beers, you know, try to avoid drinking spirits, I've never been that sort of that big into wine, as you know. And you know, there are those things, it doesn't mean that sometimes I don't still slip, you know, I might still kind of sometimes kid myself, I'm going to pop out for a quick one, and then I'll go straight home, sometimes I manage it, and sometimes I don't. But yeah, that's sort of the relationship I have with alcohol, in moderation, for me, serves a kind of a positive purpose in terms of like, you know, going out and having a laugh and all the rest of it. But I'm mindful of the fact that I have got a bit you know, if, if I'm having too much fun, then that was once I've had a few drinks that really mitigate against me thinking, you know, I should probably leave, you know, sort of some friends yourself included, they can just sort of go, Yeah, I've had enough. I'm gonna go home. Now, I might get familiar. I've experienced that I don't have that off button. In those situations. But yeah, that's

James Morris:

about if, if you've come out in those situations without drinking, what is it about the alcohol it's enhancing or adding denies it? How much of that is psychological association or placebo?

Prof Tony Moss:

I honestly think it's, the majority of it is psychological. And I've certainly so actually, even just this Halloween just gone. So we went to a Halloween party around my older brothers and took the kids with us. And because I was driving, I drank alcohol free beers, I had just as much of a good time I've done that loads before, like it doesn't, you know, I have, so I don't tend to do it in pubs, partly because there's not usually a decent selection of it will be Beck's blue, which tastes just as bad as Beck's normal. But there are other bad days and the anti product placement there. But you know, you tend not to get a good selection of alcohol free drinks. But if I'm, you know, family gatherings and stuff, I'm really quite happy to not drink, you know, just as much of a good time. You know, I think I probably would do that more often in a pub setting, if the if there was the sort of alcohol free drinks that I like, but absolutely, like I'm not, I don't feel that if I'm in the company of other people, that drink certainly didn't miss these Halloween just come in no way kind of felt like I was outside of the bubble or you know, not on the same level as other people. And then the weird thing about alcohol free drinks is that you get the full full impact of that placebo effects, even though you know, like it's not, it's not a sort of a secret placebo, just finished regular sort of. It's a funny anecdote, it's an anecdote, and other people can judge it. It's funny. I didn't learn to drive until about my mid 20s. I think it's partly been in London and just constantly on public transport and cars too expensive to park in the East End of London and get insurance when you were at, certainly, for me, at least. So I think learn to drive for quite a few years. And my now wife and I were together. But in relationship she was driving and I didn't pass the driving test. And we went out for lunch one day, and I've driven this is probably only a few months after I got the licence. And it's really hot summer's day, we sat in this garden, this kind of pub garden or something. And we both had an alcohol free drink, you know, she said, it gets off the job, lemonade, or something I said I'll might get one of these having the next blue. And I had two of them. And I remember saying to do my driving, because I actually feel a little bit. And it was partly that that, you know, it was really bizarre, but that sort of feeling of just being a bit chilled out and a bit more relaxed and all the rest of it. Combined will also you know, when you've just passed your driving test, you're a little bit more, you know, everything's a bit more kind of, you're a bit more sort of conscious of it, but genuine she drove aside because I honestly felt like I don't know if I should drive. And I don't absolutely know that sort of placebo effect, someone going into a pub having a drinking. That that the pharmacological effects of alcohol when you drink it can take up to an hour to get into your bloodstream and certainly getting enough so yeah, I think that, for me is is very much a sort of psychological thing.

James Morris:

It's funny actually knew someone when I was an undergrad going back quite a while ago, he hadn't he was a mature student and hadn't drank for I think about 10 years and then tried some Kaliber. And he said Oh, I feel really weird. And I think it was some kind of effect of feeling like in some way he had in inverted commas relapsed creating this feeling of sort of weirdness and other psychological effects rather than probably

Prof Tony Moss:

what makes alcohol as a drug so entirely unique, but But I mean, I mean, actually not entirely new but fairly unique, in terms of the effect that it has is that it is so much mediated by by psychology and by culture and by previous experiences. You know, it's the same way Isn't that one person who when they get drunk and get, you know, really friendly and sloppy and almost, you know, another person can bring the exact same amount of alcohol and get really argumentative and aggressive. It's not that there's no single effect that the drug ethanol has on a person. It's all really heavily mediated by those kind of seasoned beliefs and so on. And it can even vary from one person from one situation to the next. You know that if in certain situations you think it's going to make you cry into the bottom your glass and be on board live in other situations, it might make you life and soul of the party like the same. Literally the same drug can have different impacts on you at different times. That's why

James Morris:

people find it so hard to believe when you tell them certain drinks don't make you this way. I mean exception if it's got caffeine in or whatever. You say the active ingredient is ethanol, but try and convince someone who thinks that they go crazy on white why that's not the case. It's a difficult thing. Brilliant press dynamos. Thank you so much.

Prof Tony Moss:

Thank you

What are alcohol harms or problems?
Public awarness of risk and harms from alcohol
Risk and drinking behaviour
Motivation and change in drinking
The role of genetics?
The role of the disease model
Personal drinking motivations
Placebo and psychological effects of drinking