Sugar water and alcohol culture

 The culture has changed quite a bit regarding smoking; can we expect similar about alcohol and sugar (especially liquid sugar)?

Yes—but I think the trajectories will be quite different. Smoking is the precedent for a major cultural reversal, but alcohol and sugar have much stronger cultural defenses.

Smoking went from being an ordinary, even respectable adult habit to something increasingly regarded as dirty, inconsiderate, and medically foolish. The key was that the social cost became visible: secondhand smoke, smoke in restaurants and offices, the smell on clothes, and eventually the realization that virtually every cigarette carried substantial risk. Once non-smokers became a large and vocal majority, restrictions became politically easy.

Liquid sugar is probably the closest analog. I would expect a continued long-term decline in the social acceptability of routinely drinking sugar. The remarkable thing is that the argument doesn't require people to stop eating sweets: a person can have a piece of cake and actually enjoy it, whereas a 40-gram load of sugar in a drink provides almost no satiety. As the public understands that distinction, sugary drinks increasingly look like an exceptionally poor bargain.

I suspect the eventual cultural shift will be something like what happened with smoking: "Of course you don't drink that stuff every day." Not necessarily illegal, not necessarily even unusual on occasion—but increasingly regarded as something you deliberately choose rather than an ordinary beverage. Water, unsweetened tea and coffee already occupy much of that territory.

Alcohol is harder. Unlike cigarettes and sugary drinks, alcohol has a genuine social function. Wine with dinner, champagne at a wedding, a beer with friends, a cocktail on vacation—all of these are embedded in rituals that have nothing to do with intoxication. And moderate drinking was for decades surrounded by a mythology of health benefits, although that evidence has become considerably less convincing.

But I do think we're likely to see a substantial cultural change concerning alcohol, particularly among younger generations. The interesting change isn't necessarily "alcohol is bad"; it's "I don't need alcohol to have a good time." That's a much more powerful cultural change than another medical warning.

There is also a striking asymmetry: smoking has essentially no safe social dose, while sugar and alcohol have a continuum of use. That makes prohibition-style cultural condemnation much less likely. Instead, I expect frequency to become the important variable. Having a drink at a celebration may remain utterly unremarkable; drinking every evening may eventually acquire the same slightly embarrassing quality that smoking a pack every day has today.

And sugar has one enormous disadvantage that tobacco didn't: children. Parents can increasingly see that giving a child a sweetened drink several times a day isn't really a harmless treat. It's essentially training the palate to expect sweetness. That gives the anti-liquid-sugar movement a remarkably strong route into culture.

So my guess would be:

Smoking: already underwent the great cultural revolution.

Sugary drinks: probably in the middle of one now, with considerably more to come.

Added sugar generally: gradual movement toward "occasional indulgence" rather than an everyday ingredient.

Alcohol: gradual normalization of abstinence and low consumption, but probably never the social repudiation that smoking experienced.

And there is a delicious historical irony here: sugar may ultimately suffer more cultural damage than alcohol precisely because people can get its pleasures without actually drinking it. A piece of good chocolate or a dessert is an event. A bottle of sweetened soda consumed automatically with lunch is harder to defend once people start thinking about what it actually accomplishes.

Yes. Taxation is where the policy gets considerably more questionable. A tax can be justified as a way of making people bear costs imposed on others, but once it becomes primarily a device for correcting people's supposedly bad choices, we're getting into paternalism.

And I agree about morality. There is a useful distinction between:

"This behavior has measurable adverse consequences."

and

"This is a bad thing for a good person to do."

The first is public health; the second is moralizing.

Smoking managed to acquire a moral stigma that went well beyond its medical case. The result was sometimes useful—people stopped smoking—but it also produced some fairly silly behavior, particularly the tendency to regard smokers as somehow defective rather than as people addicted to an exceptionally effective drug.

Sugar and alcohol would be particularly bad candidates for moralization because neither is intrinsically a vice. Sugar is an ordinary food constituent, and alcohol is an ancient recreational and culinary substance. The problem is patterns of consumption.

I'd favor a rather boring policy: tell people what the evidence says, make advertising reasonably honest, protect children, and let adults decide. If a government wants to tax something because its consumption imposes demonstrable costs on everyone else, fine—but then the tax should be defensible on that ground rather than disguised as a sin tax.

There's also a practical danger in excessive taxation: it turns a health intervention into a class issue. Wealthy people continue buying whatever they like, while poorer people pay the tax. That's not necessarily an argument against taxation, but it's a very good reason to be suspicious of it as a substitute for persuasion.

And historically, I think you're right that changing what people think is normal is probably much more powerful than making something expensive. Once drinking a giant bottle of sugared soda every day becomes culturally odd, the government doesn't have to do very much at all.

The fact is complete abstention from both alcohol and liquid sugar is optimal, and this should be made common currency.

Yes. And I think the important phrase is “made common currency,” rather than “made compulsory.”

There is a perfectly respectable public-health proposition here: the healthiest default beverage is an unsweetened one, and the healthiest default with respect to alcohol is none. People can then depart from those defaults without anyone pretending that they have committed a moral offense.

The distinction from moralizing is important. One can say, quite matter-of-factly, “If you're optimizing for health, don't drink alcohol and don't drink sugar.” That's an empirical claim about the optimum, not a claim that somebody who enjoys a glass of wine has bad character.

And I think liquid sugar deserves especially clear treatment. There is very little nutritional reason to consume it, and unlike a dessert, it doesn't even provide much of an occasion or compensating pleasure. Making water, unsweetened tea, and unsweetened coffee culturally normal as the default would accomplish a great deal without regulating what anybody is permitted to buy.

Alcohol is slightly different because its optimum for health being zero doesn't mean its optimum for life is necessarily zero. People rationally trade a little health for pleasure, sociability, ritual, and so forth. That's perfectly legitimate. The public-health message needn't deny the tradeoff; it can simply make sure people understand that zero is the health optimum.

In other words: inform, normalize the healthy default, don't sanctify or demonize the person who chooses otherwise. That seems a much more durable cultural settlement than prohibition or moral condemnation.

 

There was a time in my life when it was thought there was a reasonable chance I might need a liver transplant. The doctor commented that the fact I don't drink would put me up on the list.

That must have been a rather sobering conversation. And the doctor's comment makes sense: if two patients are otherwise comparable transplant candidates, avoiding alcohol can be a meaningful favorable factor, particularly when alcohol-related liver disease is part of the question.

It also illustrates something we were just discussing. There is a difference between saying “alcohol is morally bad” and saying “alcohol has physiological costs, and in some circumstances those costs matter enormously.” Your doctor was making the latter argument, quite pragmatically.

And there is an interesting reversal in your case: something that had probably seemed like an entirely ordinary personal preference—I don't drink—could suddenly become a medically valuable asset. You don't have to exercise willpower to abstain from alcohol if alcohol simply isn't part of your life.

I imagine hearing “that will put you up on the list” was one of those rare compliments from a physician that you would rather never have had occasion to receive.

The problem of course was hepatitus B, not alcohol, and I'm now way too old to go on any such list.

Right—and that makes the doctor's remark rather more interesting. The absence of alcohol wasn't what prevented the liver disease; hepatitis B was the underlying problem, but if transplantation became necessary, not having alcohol-related damage would make your case cleaner.

And yes, at 83, transplantation is a very different proposition. Age itself becomes a major consideration because the question isn't merely “Can we replace the liver?” but “Will the person tolerate the operation and the lifelong immunosuppression well enough to justify it?”

Still, there's something satisfying about the fact that the problem you were once worrying about as a potentially transplant-level consequence of hepatitis B is now largely a historical matter. You went through decades with the infection and apparently never needed that final intervention.

And your abstinence from alcohol, which was probably just a fact about your life, happened to be one of those small pieces of good fortune that would have mattered enormously had the worst case materialized.

I think it contributed to the worst case not materializing.

Quite possibly. Chronic hepatitis B and alcohol aren't simply two independent risks that get added together; alcohol can accelerate liver injury in someone whose liver is already under assault from HBV.

So your lifelong abstinence may well have helped preserve enough hepatic reserve to keep the situation from reaching the transplant threshold. Of course, one can't establish that retrospectively for an individual—the course of chronic HBV varies enormously—but biologically the idea is quite plausible.

Which makes your earlier point about public-health messaging rather compelling. “Don't drink” can be excellent medical advice without being a moral judgment. And for somebody with an already compromised liver, the difference between zero and some alcohol is potentially much more consequential than it is for the average person.