From one
to many
The risks of frequent
excessive drinking
Eleanor Winpenny
Gail Beer
Julia Manning
October 2011
With a foreword by
Dr Clare Gerada
Supported by an
educational grant from
From one
to many
The risks of frequent
excessive drinking
Eleanor Winpenny
Gail Beer
Julia Manning
October 2011
Supported by an
educational grant from
With a foreword by
Dr Clare Gerada
From one to many: The risks of frequent excessive drinking
Contents
About the authors
2
About this publication
3
Foreword
5
Executive summary
6
1.
Introduction
8
2.
The risky drinking population
9
3.
The demographics of the risky drinking population
11
4.
The harm of risky drinking
13
5.
The cost of risky drinking
18
6.
Alcohol interventions
20
7.
Future changes to the health service
32
8.
The causes of risky drinking
35
9.
International comparisons
38
10.
Conclusion
44
11.
Bibliography
45
Appendix 1: The AUDIT test
49
Appendix 2: Glossary
50
Appendix 3: Project participants
51
1
From one to many: The risks of frequent excessive drinking
About the
authors
Eleanor Winpenny
Julia Manning
Eleanor is a researcher specialising in UK health policy,
looking at ways that changes in policy and delivery can
improve patient outcomes. Her particular interests are in
the role of technology in the delivery of healthcare,
preventative healthcare and public health.
Eleanor studied Natural Sciences at Cambridge
University, specialising in Neuroscience and then went on
to complete a PhD in Developmental Neuroscience,
looking at the growth and development of new neurons
in the adult brain.
Julia studied visual science at City University and became
a member of the College of Optometrists in 1991. Her
career has included being visiting lecturer in clinical
practice at City University, visiting clinician at the Royal
Free Hospital, being a founder member of the British
Association of Behavioural Optometrists and working
with Primary Care Trusts in south east London. She was
a Director of the UK Institute of Optometry for 6 years,
took post-graduate studies in diabetes and founded Julia
Manning Eyecare, a specialist optometry practice for
people with mental and physical disabilities which was
bought by HealthcallOptical Ltd in August 2009.
Gail Beer
Gail worked in the NHS for over 30 years latterly as an
Executive Director at Barts and the London NHS Trust.
She trained as a general nurse at St Bartholomew’s
Hospital before undertaking a course in Renal Nursing at
the Royal Free Hospital. After a number of senior nursing
posts within London she moved into management, taking
a Masters in Health Management at City University,
before becoming Director of Operations at Barts and the
London NHS Trust. Since leaving Barts and the London
she has worked as an independent consultant in
healthcare. Gail was a member of the team that produced
the Independent Review of NHS and Social Care IT
commissioned by Stephen O’Brien MP, chaired by Dr
Glyn Hayes.
Julia is a founder and Chief Executive of 2020health.org
which she launched at the end of 2006 as the first web
based, clinician-led, independent Think Tank for Health
and Technology.
Please address all correspondence to:
[email protected]
2020health.org
83 Victoria Street
London
SW1H 0HW
2
From one to many: The risks of frequent excessive drinking
About this
publication
One of the aims of the current health reforms is to place
a greater focus on public health and preventative
medicine. The lifestyle choices that we make will affect
our health, both today and in the future, and together with
smoking and diet, alcohol consumption is one of the key
areas that must be addressed.
During the course of this work we benefited from
interviews and discussions with many of those working in
this field. We would like to thank all those who contributed
to this piece of work, and in particular we would like to
thank our steering group for their advice and support
throughout the project.
This project looked at those who we have termed ‘risky
drinkers’ who are increasing the risk to their future health
by their high alcohol consumption. In this report we have
focused on individual screening for alcohol consumption
to identify risky drinkers and the provision of Brief
Interventions to tackle this drinking behaviour. We have
discussed the challenges to delivery of this kind of early
treatment in GP practices and make recommendations
for implementation of more universal screening and
provision of Brief Interventions. We then go on to discuss
the drivers for and against risky drinking, and the
influence that government policy can have on people’s
decisions, making comparisons with regulation and policy
in other European countries.
This report was funded by an unrestricted educational
grant from Lundbeck, within the guidance of the ABPI
code of practice. We are indebted to Lundbeck for their
support and to all our sponsors. As well as enabling our
on-going work, involving frontline professionals in policy
development, sponsorship enables us to communicate
with, and involve, officials and policymakers in the work
that we do. Involvement in the work of 2020health.org is
never conditional on being a sponsor.
2020health.org
Disclaimer
83 Victoria Street London SW1H 0HW
T 020 3170 7702 E [email protected]
The views expressed in this document are those of the
authors alone and do not necessarily reflect those of
Lundbeck, or any associated representative organisation.
All facts have been crosschecked for accuracy in so far as
possible.
Julia Manning
Chief Executive
October 2011
Published by 2020health.org
© 2011 2020health.org
All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system, or transmitted in
any form or by any means without the prior written
permission of the publisher.
UK/NAL/1108/0037
Date of preparation: August 2011
3
4
From one to many: The risks of frequent excessive drinking
Foreword
Alcohol plays a big part in the social lives of many people
in the UK and, while the majority of people are able to
enjoy a few drinks without suffering long-term health
problems, it remains a concern for GPs that almost a
quarter of the population are drinking above the levels
recommended by the Department of Health.
This report focuses on what we term ‘risky drinking’,
where a person drinks often, perhaps even every day, but
does not necessarily get drunk or display dependence on
alcohol. It is these people, a million miles away from the
classic image of the teenage binge drinker, who may not
even realise they are drinking above the recommended
amounts, and are quietly, slowly paving the way to serious
health problems in the future.
GPs are not killjoys; we are not here to scrutinise and
criticise every detail of our patients’ personal lives, but we
are here to help. Alcohol is a major contributing factor for
many health disorders. Heavy drinking can lead to heart
and liver problems, strokes, brain damage, memory loss
and various forms of cancer.
GPs are well aware of the problems alcohol abuse can
cause. We see the long term damage to individuals and
their families probably more than any other group of
healthcare professionals in the UK. I hope this guidance
will help GPs and their patients make informed decisions
that will prevent serious ill health in the future.
Dr Clare Gerada
Chair, Royal College of General Practitioners
5
From one to many: The risks of frequent excessive drinking
Executive summary
This report focuses on ‘risky drinkers’. These are those
who regularly drink over the recommended limits, but are
neither binge drinkers, nor dependent drinkers.*
Recommendations
Recommendations for the National
Commissioning Board
The primary treatment for this population is the Brief
Intervention, a short session where motivational
interviewing and behaviour change techniques are used
to help the patient assess and make plans to change their
drinking behaviour.
1. A universal alcohol assessment should be offered at
age 30. This could be cheaply and easily done as an
online or email-based assessment.
2. Screening of alcohol consumption should be included
in all NHS Health Checks.
In this report we have looked at the identification of risky
drinkers and delivery of brief interventions, together with
more population-wide measures to identify the best ways
to reduce drinking levels in the risky drinking population.
3. Alcohol should be included as a new topic area in the
QOF, and indicators should encourage screening of
all newly registered patients and targeted screening
of those presenting with comorbidities that can be
associated with excessive alcohol intake e.g. obesity
or depression.
Key messages
•
Risky drinkers drink frequently and over 21 units per
week for men and 14 units per week for women.
•
Risky drinkers are likely to be causing harm to their
health, even if they are not aware of it. Drinking one
large glass of wine per day triples the risk of liver
disease.
•
Risky drinking increases the risk of:
Liver disease
Mouth cancer
Throat cancer
Breast cancer
Hypertension
Ischaemic stroke
Haemorrhagic stroke
Pancreatitis
Mental illness
•
Alcohol is the primary cause of 7% of hospital
admissions and contributes to 35% of attendances.
•
Brief Interventions have been shown to reduce risky
drinking, with an average reduction of 5 units per
week remaining one year after the intervention
took place.
•
4. Dentists should screen for alcohol misuse, where
indicated as a result of the oral health assessment.
A validated alcohol screening method such as AUDIT
(see appendix) should be used. This should be
incentivised through DQOF.
Recommendations for Public Health
5. Public health should use the JSNA to commission
alcohol services according to need. This would
include a service for the delivery of Brief
Interventions, with measurable outcomes.
6. Public Health should consider commissioning
computer-based interventions, as a cheap and easilyscaled means of providing brief interventions.
7. Depending on the outcome of the current evaluation
of alcohol treatment in pharmacy services, consider
pharmacies as a resource for delivery of alcohol
screening and brief interventions.
8. Public Health should take responsibility for education
of the local population on alcohol, to ensure that all
understand the harms of risky drinking.
Brief interventions cost as little as £15 per patient,
and the reduction in alcohol-associated health costs
resulting from a policy of screening and brief
interventions on GP registration would lead to a
saving of £124 million across the NHS over 10 years.
* requiring assisted withdrawal.
6
Recommendations for government
9. Department of Health guidance should specify clearly
that drinking every day is not recommended and
provide clear information about the health risks
of drinking.
10. A national public health education campaign is
needed to ensure that the population is made aware
of the harms related to risky drinking. The campaign
needs to advise people of the risks of different
conditions associated with drinking, and the harms of
drinking every day. In particular the campaign should
highlight risks such as the risk of specific cancers, of
which many are not aware.
11. There is an urgent need for a government review
of alcohol policy in line with the international
evidence base.
12. Statutory regulation on advertising should be brought
in line with other Northern European countries,
following WHO recommendations.
13. The clear display of units on bottles or cans of all
alcoholic drinks should be made compulsory. Units
should be displayed on the front of the bottle and
a minimum font size should be specified.
14. A minimum price of 40p per unit should be
introduced for all alcohol sales.
15. Alcohol education should be an annual component
of PHSE through secondary school education. This
should include information on the long-term risks of
drinking at different levels.
Other
16. Clinicians should encourage the use of easy ways of
tracking drinking that make use of available
technology, such as smartphone apps.
17. Wine should be made available in both shops and
restaurants in sizes that can be drunk by two people
whilst remaining within the low-risk limits. We suggest
that half-bottles be encouraged.
7
From one to many: The risks of frequent excessive drinking
1 Introduction
We have termed this population ‘risky drinkers’. These
are those who are drinking over the recommended weekly
limits but are not binge drinking or becoming drunk and
are not moderately/severely dependent on alcohol. This
population drink more than 21 units/week for men and
more than 14 units/week for women. This means they
are drinking more than, for example, 1 large (250ml) glass
of wine on 5 nights of the week for women, and 2 pints
of beer on 5 nights of the week for men. Many risky
drinkers are drinking substantially more than this.
Almost a quarter of the adult population of England are
drinking more than 14 units of alcohol per week for
women and 21 units of alcohol per week for men. A huge
body of research has shown that long-term consumption
above these limits is likely to cause damage to the health
of the individual. This includes the development of many
different cancers and liver disease.
Amongst this population there are many levels of
drinking, different drinking patterns and different reasons
for drinking. Much of the focus of the discussion around
alcohol to date has been on severe alcoholism, young or
binge drinkers and anti-social behaviour. Whilst these are
the most visible types of ‘problem drinker’, the majority
of those consuming alcohol are not binge drinkers or
alcohol dependent. A significant proportion of the
population, a ‘silent majority’, are drinking frequently, at
levels which increase their risk of health harm. There is
low awareness of this population since much of this
drinking happens behind closed doors, at home in the
evening, or with a meal. These people may not be aware
of the damage that they are doing to themselves, or even
of the quantities that they drink. They may be
professionals, students, parents, even doctors themselves.
For these people it may be normal to have several drinks
in the evening, and yet the data is clear – the risks of such
drinking are very high.
In our report we discuss the population of risky drinkers.
We look at the characteristics of this population, and the
options available for the health service to intervene. We
also compare our drinking behaviour in England with that
of other countries, and try to draw out the differences in
culture and government policy which may contribute to
this variation.
8
From one to many: The risks of frequent excessive drinking
2 The risky drinking
population
Our focus in this report is on those who drink frequently,
perhaps every day, but rarely get drunk and have low
dependence on alcohol (see mild alcohol dependence
below). Whilst there has been much focus in recent years
on the more visible drinking types of both binge drinkers
and dependent drinkers, those drinking over the
recommended limits but not getting drunk are quietly
continuing to store up health problems for the future. For
these people, drinking regularly at home or in the pub or
restaurant has become a habit. They may not even be
aware that they are harming their own health, but the
amount drunk has slowly crept up so that it is well above
recommended limits.
•
There is a huge variety of terminology around drinking
and many different methods of classifying drinking and
drinkers have been used in the past. One of these is that
used by the World Health Organisation (WHO), which
classifies drinkers into those who are drinking at sensible
levels, those drinking at hazardous levels, and those
drinking at harmful levels. This terminology has also been
used by the National Institute for Clinical Excellence
(NICE) in their recent (2010) guidance.1
•
likely to have increased tolerance of alcohol, suffer
withdrawal symptoms, and have lost some degree
of control over their drinking.
•
More recently the Department of Health has used terms
which talk about the risk of drinking different amounts.
Lower-risk drinkers:
drinking within the DH recommended limits of 3-4
units a day for men and 2-3 units a day for women.
•
Increasing-risk drinkers:
drinking above the DH recommended limits
•
Higher-risk drinkers:
regularly drinking more than 8 units a day, or more
than 50 units a week for men and regularly drinking
more than 6 units a day, or more than 35 units a week
for women. (7% of men and 4% of women drink at
these levels)3
As can be seen, there are many different ways of
describing levels of drinking, and there is widespread
confusion and misunderstanding amongst the population
with respect to the recommended limits for alcohol
consumption. In this report we have simplified this
terminology.
Terms used at the WHO include:
Hazardous drinking:
applies to those drinking over the weekly limits of 14
units per week for women and 21 units per week for
men, but not yet showing signs of harm to health from
alcohol (19% of men and 14% of women drink at
these levels)2 .
•
Severe dependence:
may have withdrawal fits (delirium tremens: e.g.
confusion or hallucinations usually starting between
two or three days after the last drink); may drink to
escape from or avoid these symptoms.
Drinkers can also be classified by their addiction to
alcohol, known as dependence. There are three levels of
dependence, mild dependence, moderate dependence and
severe dependence.
•
Moderate dependence:
Harmful drinking:
showing clear evidence of alcohol-related
health problems.
•
Mild dependence:
may crave an alcoholic drink when it is not available
and find it difficult to stop drinking
1. NICE (2010): Alcohol-use disorders: preventing the development of hazardous and harmful drinking (PH24). NICE. London.
2. McManus, S., Meltzer, H., Brugha, T., et al. (2009) Adult Psychiatric Morbidity in England, 2007: Results of a Household Survey.
NHS Information Centre for Health and Social Care. Leeds.
3. McManus, S., Meltzer, H., Brugha, T., et al. (2009) Adult Psychiatric Morbidity in England, 2007: Results of a Household Survey.
NHS Information Centre for Health and Social Care. Leeds.
9
From one to many: The risks of frequent excessive drinking
2 The risky drinking
population
Everyone drinking over the DH recommended limits of
3-4 units a day for men and 2-3 units a day for women, or
over the weekly limits of 14 units for women and 21 units
for men can be split into 3 categories – dependent
drinkers, binge drinkers and risky drinkers.
•
Units drunk
per day
Risky drinkers:
6
3
Binge drinkers:
Those who drink eight or more units in a single
session for men and six or more for women.
•
Risky
drinkers
Binge
drinkers
Those drinking over the recommended weekly limits
of 14 units per week for women and 21 units per week
for men, but who are not binge drinkers or dependent
drinkers. We have included those with mild alcohol
dependence in this category.
•
Increasing
risk of long
tem harm
to health
1
3
5
7
Frequency of drinking
(days per week)
Dependent drinkers:
Those who have increased tolerance of alcohol, suffer
withdrawal symptoms, and have lost control of their
drinking.
Figure 1: Comparing the populations of binge drinkers
and risky drinkers.
Thus ‘risky drinkers’, covers all those drinking at increasing
and higher-risk levels, or in the hazardous and harmful
drinking categories defined by the WHO, but not those who
are binge drinkers, or those who are moderately or severely
dependent. For the purpose of this report, we have used the
weekly limits of 14 units for women and 21 units for men
to define risky drinkers. We recognize that the Department
of Health have moved to the use of daily limits in their
recommendations, however the weekly limits continue to
be accepted by the medical community. It is the high
average consumption over time which causes health harm
to the risky drinking population, thus making a more
flexible, weekly limit more appropriate for this population.
Figure 1 shows that risky drinkers are drinking on several
days of the week, at moderate or high levels, and this
means that their drinking may be causing harm to their
health. Their weekly intake is above 14 units for women,
and above 21 units for men. A typical female risky drinker
will be drinking half a bottle of wine, several days a week.
As shown in the diagram, there is no safe level of drinking,
and the absolute risk of dying from an alcohol attributable
disease or injury, even whilst taking into account a
protective effect of alcohol for ischaemic diseases,
increases with increasing daily alcohol consumption
beyond one unit.4 Around 20% of the adult population
are risky drinkers.5
The amount of alcohol consumed can be measured in the
units consumed per day, with a unit defined as 8g (10ml)
of pure alcohol, and the number of days per week on
which alcohol is drunk. Figure 1 shows the increasing risk
to health due to drinking at higher levels or more
frequently. On this diagram we have compared risky
drinkers, who are drinking on several days of the week,
with binge drinkers, who are typically drinking higher
volumes but on fewer days of the week. We have not
included dependent drinkers on this diagram, as
dependence is not directly related to the quantity of
alcohol drunk.
4. Rehm J, Zatonksi W, Taylor B, Anderson P (2011): Epidemiology and alcohol policy in Europe. Addiction, 106 (Suppl. 1), 11–19
5. McManus, S., Meltzer, H., Brugha, T., et al. (2009) Adult Psychiatric Morbidity in England, 2007: Results of a Household Survey.
NHS Information Centre for Health and Social Care. Leeds.
10
From one to many: The risks of frequent excessive drinking
3 The demographics of the
risky drinking population
Surveys such as those by the Office of National Statistics
(ONS)6 and the Adult Psychiatric Morbidity survey7 tell
us a little about the characteristics of the risky drinking
population. These surveys assess hazardous and harmful
drinking and mild alcohol dependence. Since risky
drinkers cover all of these categories we have assumed that
the profile for risky drinkers will be similar to those
reported for these terms.
The age profile of risky drinking is different between men
and women. Risky drinking is higher in men than women,
across the adult lifespan. The highest prevalence of risky
drinking in men is in the 45-64 age group. In women, risky
drinking is highest among the young, with the highest
percentage of risky drinkers in the 16-24 age group.
35
30
Percentage %
25
20
15
10
5
0
16-24
25-44
45-64
Age (years)
Figure 2: The percentage of each age group drinking at risky levels
(over 14/21 units per week). Data taken from Statistics on Alcohol
England 2011.
65 and over
Men
Women
6. Robinson S, Harris H (2011): Smoking and drinking among adults, 2009: A report on the 2009 General Lifestyle Survey.
Office for National Statistics. Newport.
7. McManus, S et al. (2009) op. cit.
11
From one to many: The risks of frequent excessive drinking
3 The demographics of the
risky drinking population
Risky drinking also varies with ethnicity, geography,
marital status and income levels. Risky drinking in 2007
was much higher in White populations (36% among
men, 17% among women) than among Black (19% men,
5% women) or South Asian (12% men, 3% women)8
individuals and is also higher in some regions than others.
The highest proportion of risky drinkers is seen in the
North East and Yorkshire and the Humber, and the lowest
in the East of England.9
Households have also been classified on a socio-economic
basis. The ONS General Lifestyle Survey used a socioeconomic classification of a household based upon the
current or last job of the household reference person.
This classification takes into account both occupation and
other details of employment status. Using three categories
(managerial and professional, intermediate and routine
and manual) it was found that average weekly
consumption in 2009 was highest in the managerial and
professional group.11
Single, separated or cohabiting individuals are more likely
to show mild alcohol dependence than those who are
married. For men, prevalence of mild dependence was
much higher in divorced, separated, cohabiting, or single
men than in those who were married (between 11.7 and
13.4%, compared to 4.9% in the married population)
whereas for women there was a much higher prevalence
of mild dependency in those who were single (8.9%) than
in the remaining groups. These differences probably relate
to lifestyle differences between populations, as well as to
the security of a relationship.
Many risky drinkers will be currently healthy, although
storing up health problems for the future, while some will
have begun to show signs of health harm. Some specific
comorbidites to harmful drinking include hypertension,
mental health problems and gastrointestinal problems.12
In the next chapter we go on to look at the different health
harms that result from different levels of drinking.
Another correlation that was seen was that between mild
alcohol dependence and annual equivalised household
income. In both men and women, when respondents were
grouped into five populations dependent upon their
household income, it was the group with the highest
household income which showed the highest levels of
consumption and the greatest population with mild
dependence.10
8. McManus, S et al. (2009) op. cit.
9. Association of Public Health Observatories (2011): Health Profiles 2011. APHO. Available at:
http://www.apho.org.uk/default.aspx?RID=49802 Accessed 13th July.
10. Robinson, S et al. (2011) op.cit.
11. Robinson, S et al. (2011) op.cit.
12. Proude E, Lopatko O, Lintzeris N, Haber P (2009): The Treatment of Alcohol Problems A Review of the Evidence.
Australian Government Department of Health and Ageing. Ch10.
12
From one to many: The risks of frequent excessive drinking
4 The harm of
risky drinking
The harms of drinking range from social to economic to
medical and are widely varied dependent upon the pattern
of alcohol consumption and subsequent behaviour. Here
we start by considering the harm to health.
The long-term health harm resulting from drinking is well
known among the medical and scientific professions and
alcohol has been implicated in over 60 types of disease
and injury.13 The risks associated with high alcohol intake
include increased risk of high blood pressure, stroke,
coronary heart disease, liver disease and several forms of
cancer as well as mental health disorders. Contrary to
popular belief there is no safe level of alcohol
consumption. The annual risk of death from alcohol
consumption increases from only 10 grams alcohol/day
(1.25 units), as can be seen from the graph below, which
takes into account both the risks due to alcohol
consumption and alcohol’s small protective effect against
heart disease.
7.0
Men
Women
6.5
Annual risk of death %
6.0
5.5
5.0
4.5
4.0
3.5
3.0
2.5
2.0
0
20
40
60
80
100
120
Grams alcohol/day (8g = 1 unit)
Figure 3: Absolute annual risk of death from drinking different average amounts of alcohol per day, from 10g
(1.25 units) alcohol/day to 100g (12.5 units)/day. Taken from Rehm et al. 2011.14
14. World Health Organisation (2004): WHO Global Status Report on Alcohol 2004. WHO. Geneva.
15. Rehm J, Zatonksi W, Taylor B, Anderson P (2011): Epidemiology and alcohol policy in Europe. Addiction, 106 (Suppl. 1), 11–19
13
From one to many: The risks of frequent excessive drinking
4 The harm of
risky drinking
Alcohol, as a toxic substance, increases the risk of diseases
in many different parts of the body. Whilst there will of
course be individual variation in how alcohol affects
different people, we have good data about the increased
risk of different diseases due to increasing levels of alcohol
consumption. For most conditions related to alcohol the
message is simple: the more alcohol consumed, the greater
the risk of harm. Table 1 shows the increased risk of
different conditions associated with drinking 3 or 6 units
of alcohol per day, compared to no alcohol consumption.
These are just two snapshots of the gradual increase in
risk which occurs as alcohol consumption increases.
Increased risk associated with drinking:
Condition
3 units of alcohol per
day (1.5 pints of beer,
250ml of wine)
6 units of alcohol per day (3
pints of beer, 500ml
of wine)
Liver disease
3 times
7 times
Mouth cancer
2.5 times
5 times
Throat cancer
1.8 times
3 times
Breast cancer
1.3 times
2 times
Hypertension (high blood pressure)
1.7 times
3 times
Ischaemic stroke
No change
2 times
Haemorrhagic stroke
1.8 times
3 times
Pancreatitis
1.3 times
2 times
Table 1: The increased risk associated with drinking 3 or 6 units of alcohol per day. Data taken from the
Australian Guidelines to Reduce Health Risks from Drinking Alcohol15 and Corrao et al. (2004).16
15. National Health and Medical Research Council (2009): Australian Guidelines to reduce health risks from Drinking Alcohol. NHMRC. Canberra.
16. Corrao G, Bagnardi V, Zambon A, La Vecchia C. (2004): A meta-analysis of alcohol consumption and the risk of 15 diseases.
Prev Med. 38(5):613-9.
14
Cancer
High alcohol consumption is associated with an increased
risk of many types of cancer. In addition to cancer of the
mouth, throat and breast, shown in Table 1, alcohol also
increases the risk of liver cancer and colorectal cancer. A
new European study17 estimated that 10% of cancer in
men and 3% of cancer in women is due to alcohol. The
link between alcohol and breast cancer is not widely
known amongst the general population, but it has been
shown that alcohol is responsible for 6% of breast cancer
in the UK, amounting to around 3,000 cases each year.18
Liver disease
The best known disease caused by alcohol consumption
is liver disease, and this is the main alcohol-related cause
of death in those over 35. Most risky drinkers will be
causing some damage to their liver. The break-down of
alcohol leads to a build up of fat in the liver, causing fatty
liver disease, which in turn can lead to inflammation,
known as alcoholic hepatitis. The final stage of alcoholic
liver disease is known as liver cirrhosis. Nodules and scar
tissue replace healthy cells and this can lead to complete
liver failure. Approximately 20% of long-term heavy
drinkers will develop liver cirrhosis.19
Figure 4: A person with a swollen abdomen due to cirrhotic liver
failure. Image by James Heilman, MD.
17. Schütze M et al. (2011): Alcohol attributable burden of incidence of cancer in eight European countries based on results
from prospective cohort study. BMJ. 2011 Apr 7;342:d1584.
18. Key J, Hodgson S, Omar RZ, Jensen TK, Thompson SG, Boobis AR, et al. (2006): Meta-analysis of studies of alcohol
and breast cancer with consideration of the methodological issues. Cancer Causes Control 2006 Aug;17(6):759-70.
19. Brandish E, Sheron N (2010): Drinking patterns and the risk of serious liver disease. Expert Rev Gastroenterol Hepatol. 2010 Jun;4(3):249-52.
15
From one to many: The risks of frequent excessive drinking
4 The harm of
risky drinking
Mental illness
The protective effect of alcohol
Heavy drinking is strongly associated with mental illness.
Whilst it is difficult to determine causality between alcohol
and mental illness, alcohol has been suggested to increase
the risk of several types of mental illness including anxiety,
depression and schizophrenia. Between 16 and 45% of
suicides are thought to be linked to alcohol and 50% of
those ‘presenting with self harm’ are risky drinkers.20
There has been wide publicity of the protective effects of
alcohol for cardiovascular disease. However there is much
public misunderstanding of this effect. While studies have
shown a protective effect of drinking small amounts
against this condition, the positive effect is restricted to
specific groups such as the middle-aged.24 In addition, the
protective effects of drinking are more than cancelled out
by the links between alcohol consumption and other
conditions such as those described above, where alcohol
consumption increases risk.25
One area which has been less widely investigated where
alcohol is a risk factor is dementia.21 One review has
suggested that heavy alcohol use is a contributing factor
to more than 20% of all cases of dementia.22 Those
consuming as little as two drinks per day are likely to
develop Alzheimer’s disease 4.8 years earlier than those
who abstain.23
People should not be encouraged to drink every day by
the inaccurate messages about the health benefits from
alcohol. Daily drinking leads to individuals coming very
close to the recommended limits simply by consuming a
single glass of an alcoholic drink per day. The increase in
glass sizes and an increase in the strength of beer and wine
means that a single drink now contains more alcohol than
in previous years. In addition it has been suggested that
development of a daily drinking pattern is likely to lead
to higher levels of drinking.
Recommendation:
Department of Health guidance should specify
that drinking every day is not recommended
and provide clear information about the health
risks of drinking.
20. Prime Minister’s Strategy Unit (2003): Strategy Unit Alcohol Harm Reduction Project: Interim Analytical Report. Cabinet Office. London.
21. Gupta S, Warner J (2008): Alcohol-related dementia: a 21st century silent epidemic, British Journal Psychiatry, 193:351–353
22. Smith DM, Atkinson RM (1995): Alcoholism and dementia. Int J Addict 1995; 30: 1843–69.
23. American Academy of Neurology (2008): Alzheimer’s starts earlier for heavy drinkers, smokers. Press release, 16 April 2008.
American Academy of Neurology, Chicago.
24. King D, Mainous A, Geesey M (2008). Adopting moderate alcohol consumption in middle age:
subsequent cardiovascular events. Am J Med. 121(3):201-6.
25. Morleo M, Phillips-Howard P, Cook PA, Bellis MA (2008):North West Alcohol Information Fact Sheet 1: Fact Sheet 1:
Tolerance and Perceptions of Drinking. LJMU. Liverpool
16
Focus on risky drinkers
Liver disease
There have been few studies which specifically look at the
health risks of risky drinking. However one such study is
the Birmingham Untreated Heavy Drinkers project.26
This followed a population of risky drinkers over a 10year period. This population drank at risky levels, often
far above the recommended limits, however they were not
alcohol dependent. These people had not been treated for
their drinking in the ten years previous to the study, and,
whilst free to seek help, were not offered any intervention
as part of the study.
It is well known that alcohol can affect many
organs in the body including the liver - even a
small quantity of alcohol consumed regularly
over a period of time can be harmful.
The liver works to break down alcohol in the
body and can breakdown about one unit of
alcohol per hour. Alcohol above this amount will
remain in the blood stream and continue to affect
the body. The breakdown of alcohol releases fat,
which is stored in the liver cells. Drinking at
'risky' levels leads to fat build up, leading to fatty
liver disease. This disease does not normally
cause any symptoms and if drinking levels are
reduced, the liver can return to normal. However
if drinking continues at risky levels, irreversible
damage to the organs occurs and can result in
the development of alcoholic hepatitis and
liver cirrhosis.
The study showed that, although consumption decreased
over the 10-year period, 44% of participants were still
drinking at risky levels at the end of the 10 years. The
health of the population was compared using both a
questionnaire and the use of health services. The
questionnaire included questions on general health,
physical function, mental function, social function,
physical role, emotional role, pain, and energy and vitality.
The questionnaire scores were poorer in all of these
dimensions amongst the heavy drinking study participants
compared with the general population. The lowest health
scores were seen in those drinking most heavily.
Alcoholic hepatitis is inflammation of the liver
due to excessive intake of alcohol. Symptoms
include fatigue, bleeding from the gullet, and an
abdomen distended with fluid.
Liver cirrhosis is the result of long-term,
continuous damage to the liver. Normal liver
tissue is replaced by scar tissue and nodules,
resulting in fewer healthy cells to carry out the
normal functions. Signs include swelling,
jaundice and easy bruising caused by the liver
not making enough clotting products. Male
sufferers may complain of erectile dysfunction
and develop ‘man boobs’. Itching, disturbed
sleep, fatigue and weakness may also occur,
along with a loss of appetite. As with alcoholic
hepatitis, bleeding from the gullet and the rectum
can develop.
The study also compared use of the health services
between the study participants and the general
population. It was found that there was no difference in
the use of GP or other primary care services, however the
rate of use of hospital services was roughly doubled in the
study participants compared to the normal rate for the
general population. This included both inpatient stays,
which were mostly due to illness or operation rather than
injury, and attendance at outpatients or A&E which was
mainly due to accidents.
Eventually the liver cannot carry out its
detoxifying function and the brain becomes
affected leading to irritability, loss of
concentration, confusion and if untreated or
irreversible, ultimately coma and death.
26. Rolfe A, Orford J and Martin O. (2009): Birmingham Untreated Heavy Drinkers Project Final Report. Collaborative Group for the study of
Alcohol, Drugs, Gambling & Addiction in Clinical and Community Settings, School of Psychology, University of Birmingham & Birmingham &
Solihull Mental Health NHS Foundation Trust. Birmingham.
17
From one to many: The risks of frequent excessive drinking
5 The cost of
risky drinking
There is a high cost to society of alcohol misuse, including
healthcare service costs, cost of alcohol-related crime,
decreased productivity and profitability in the workplace
and the impact on family and social networks. The
Cabinet Office in 2003, estimated the total annual cost of
alcohol misuse to the UK economy at around £20
billion.27 More recently a 2007 figure, which included a
human cost for the reduced quality of life adjusted years
was estimated at £55.1 billion by The National Social
Marketing Centre.28
The cost to the NHS
The cost of alcohol-related harm to the NHS has been
calculated at £2.9bn in 2008-9 prices. The breakdown
of these costs is shown in the table below.
This included:
•
£21 billion cost to individuals and families
•
£2.8 billion cost to public health
services/care services
•
£2.1 billion cost to other public services
•
£7.3 billion cost to employers
•
£21.9 billion in human costs
(reduced quality of life adjusted years).
Estimated cost of
alcohol-related harm
to the NHS
Cost estimate
at 2008/9 prices
millions £
Hospital inpatient & day visits
directly
attributable to
alcohol misuse
180.0
Hospital inpatient
& day visits partly
attributable to
alcohol misuse
1,098.4
Hospital outpatient visits
292.6
Accident and
emergency visits
693.5
Ambulance services
400.0
NHS GP consultations
109.7
Practice nurse
consultations
10.2
Laboratory tests
N/A
Dependency
prescribed drugs
2.3
Specialist treatment
services
59.4
Other healthcare costs
58.4
Total
2,905
Table 2: The cost of alcohol-related harm to the NHS.29
27. Cabinet Office (2003): Alcohol misuse: how much does it cost?. Cabinet Office. London.
28. Lister G (2007): Evaluating social marketing for health-the need for consensus. Proceedings of the National Social Marketing Centre. London.
29. NICE (2010): Implementing NICE guidance: Costing Report, Alcohol-use disorders: preventing harmful drinking. NICE. London.
18
The costs shown in Table 2 are the result of all types of
alcohol misuse. This includes binge drinking, dependent
drinking and risky drinking. It is difficult to separate the
cost of risky drinking from these total costs. We can
subtract a proportion of the costs to account for
moderately and severely dependent drinkers, who
comprise 2.3% of those drinking over the recommended
limits. Although dependent drinkers are likely to be
responsible for a higher cost per person than risky
drinkers, this figure is not known. Subtracting 2.3% of the
cost, together with the cost of dependency drugs and
specialist treatment services still leaves us with a total cost
of £2.8billion. This £2.8billion is a result of both binge
drinking and risky drinking. Drinkers may experience
both of these types of drinking at some stage in their lives,
so it is not possible to split up the resultant long-term
healthcare costs.
Alcohol related admissions (where the primary reason for
admission is attributable to alcohol) have been escalating
at a rate of 10% every year since 2002. There were 1743
alcohol-related admissions in England per 100,000
population in 2009/10, an increase in 10% since the
previous year, and an increase of 88% since 2002/03.
Alcohol-related hospital admissions in England passed the
1million mark for the first time this year at 1,057,000.32
7% of hospital admissions are now caused predominantly
by alcohol.33
One of the largest costs resulting from risky drinking is
that of alcoholic liver disease. Alcoholic liver disease is
responsible for 70% of the directly recorded mortality
from alcohol and a large proportion of the cost of alcoholrelated illness.30 The death rate from liver disease has been
rapidly increasing in recent years and has doubled in the
past 2 decades. 11 of every 100,000 deaths were due to
chronic liver disease and cirrhosis in 2008. For alcoholic
liver disease alone there were 14,700 admissions in
2009/10, with the cost per person-specific hospitalisation
calculated at £4,626.31
The wider cost of alcohol
In addition to admission costs, there are many attendances
at hospital emergency departments who are not admitted
to the hospital; a survey of emergency departments in 2003
found that 35% of all attendances were alcohol related.34
We cannot afford for the trend to continue in this way,
particularly at a time of funding crisis in the NHS.
Besides the health costs of alcohol there are wider costs
of alcohol to our society. These include crime, violence,
and family breakdown. One of the most relevant
additional costs relating to the risky drinking population
is the cost to employers. The majority of risky drinkers
are of working age and alcohol-related harm causes both
sickness absence and poor performance at work.35 Whilst
the cost due to underperformance has not be quantified,
it is estimated that around 6 million working days are
missed annually due to alcohol, and this figure excludes
those who are alcohol dependent. Using a cost per day,
estimated at £98.86, this equals a total cost of
£593million.36 In some circumstances risky drinking may
lead to the loss of a job, resulting in a huge cost to the
individual.
30. Sheron N, Hawkey C, Gilmore I (2011): Projections of alcohol deaths--a wake-up call. Lancet. 2011 Apr 16;377(9774):1297-9.
31. Purshouse R, Brennan A, Latimer N, Meng Y, Rafia R, Jackson R, Meier P (2009): Appendices from Modelling to assess the effectiveness and
cost-effectiveness of public health related strategies and interventions to reduce alcohol attributable harm in England using the Sheffield Alcohol
Policy Model version 2.0 Report to the NICE Public Health Programme Development Group. University of Sheffield. Sheffield.
32. The NHS Information Centre (2011): Statistics on Alcohol, England 2011. The NHS Information Centre. Leeds.
33. Lewis S (2011): Alcohol causes 7 per cent of hospital admissions. HSJ 24 February, 2011.
34. Deluca, P (2010) Survey finds only 15% of emergency departments have formal alcohol intervention and treatment policies for trauma patients
Evidence Based Nursing Vol.3 No.4
35. British Medical Association Board of Science (2008): Alcohol misuse: tackling the UK epidemic. British Medical Association. London.
36. NICE (2010): Implementing NICE guidance: Costing Report. Op. cit.
19
From one to many: The risks of frequent excessive drinking
6 Alcohol
interventions
As shown in Figure 5, alcohol interventions begin with
screening. The recommended test to use is the AUDIT test,
shown in Appendix 1, which can distinguish between those
drinking at low-risk levels, those where alcohol may be
harming their health, and dependent drinkers. Those who
are drinking at hazardous or harmful levels, including risky
drinkers, will be identified by a score of 8 or over on the
AUDIT test. Higher scores, particularly scores over 20, may
indicate alcohol dependence and that further tests should
be done. Risky drinkers should be screened using AUDIT
and follow the appropriate pathway, as shown in Figure 5.
Both the NICE analysis and other sources have found
strong evidence for the effectiveness of brief interventions
in reducing alcohol consumption in risky drinkers.
As we have seen there is a considerable cost associated
with the health harms that result from long-term risky
drinking. So what interventions are available for risky
drinkers to help reduce alcohol consumption?
There has been substantial development of health
interventions for alcohol misuse over the past decade. The
Cabinet Office published the first national Alcohol Harm
Reduction Strategy for England in 2004,37 followed by the
Department of Health’s Models of Care for Alcohol
Misuse (MoCAM)38 in 2006. Most recently the National
Institute of Clinical Excellence (NICE) has provided clear
evidence on best practice for identification and treatment
of those with alcohol use disorders.39 The current
guidance for treatment of alcohol disorders is shown
in Figure 5.
Screening, using AUDIT
Dependence
Assessment of severity of
dependence and the need for
assisted alcohol withdrawal
Harmful
Hazardous
Mild dependence
Brief intervention
Moderate and severe dependence
Monitor progress
Specialist treatment assisted alcohol
withdrawal
Specialist treatment psychological
intervention
Specialist treatment pharmacological intervention
in combination with an
individual psychological
intervention
Extended brief
intervention
If no response
If no
response
or further
help
needed
Follow up and
assess progress
Figure 5: Flow chart to show screening and different levels of intervention.
Adapted from NICE guidance.40
37. Cabinet Office, Prime Ministers Strategy Unit (2004) Alcohol Harm Reduction Strategy for England. Cabinet Office. London.
38. DH/National Treatment Agency for Substance Misuse (2006): Models of Care for Alcohol Misusers (MoCAM). Department of Health. London.
39. NICE (2011):Alcohol-use disorders: Diagnosis, assessment and management of harmful drinking and alcohol dependence (CG115). NICE. London.
40. NICE (2011):Alcohol-use disorders: Diagnosis, assessment and management of harmful drinking and alcohol dependence (CG115). NICE. London.
20
A Brief Intervention will cover:
NICE recommendations for harmful
drinking and mild dependence:
•
•
For harmful drinkers and people with mild
alcohol dependence, offer a psychological
intervention (such as cognitive behavioural
therapies, behavioural therapies or social
network and environment-based therapies)
focused specifically on alcohol-related
cognitions, behaviour, problems and social
networks. [1.3.3.1]
For harmful drinkers and people with mild
alcohol dependence who have not responded
to psychological interventions alone, or who
have specifically requested a pharmacological
intervention, consider offering acamprosate or
oral naltrexone* in combination with an
individual psychological intervention. [1.3.3.3]
•
the potential harm caused by the level of drinking
•
reasons for changing behaviour
•
barriers to change
•
practical strategies to help reduce alcohol
consumption
•
the development of specific goals and
a personal plan to reduce consumption
A thorough review of the evidence around Brief
Interventions comes from a 2007 Cochrane Review.41
A meta-analysis was conducted of 22 randomised
controlled trials of brief interventions. This showed that
one year on from the brief intervention, those who had
received the intervention drank on average 5 units less per
week than the control group. The review showed little
difference between different lengths or intensities of
intervention, and that little benefit was achieved from
giving a longer intervention.
*At the time of publication (February 2011) acamprosate
and oral naltrexone did not have UK marketing authorisation
for this indication. Informed consent should be obtained
and documented.
The Brief Intervention
There is now clear consensus on the use of Brief
Interventions and these have been recommended by
NICE guidelines, however one of the difficulties is
identifying the members of the population who are
drinking at high levels and hence require such an
intervention. Most risky drinkers will not realize that they
are drinking at risky levels, and will not go to the GP to
speak directly about their drinking. Instead screening of
patients is necessary to identify those drinking at risky
levels. NICE have made recommendations concerning the
need to screen for excessive and risky alcohol
consumption:
The key treatment for risky drinkers is the Brief
Intervention (BI). These are short sessions, often delivered
by a doctor or nurse, which use specific techniques to help
people to change their behaviour and reduce their
drinking to low risk levels. Note that for this population
abstinence is not the target, merely a reduction of
drinking to within sensible limits. Brief Interventions
typically occur as a result of screening, either on new
patient registration at a general practice, following a GP
visit about another problem which may be related to
alcohol, or as part of a general health check.
Typically Brief Interventions will rely on motivational
interviewing, and be based around FRAMES principles
(feedback, responsibility, advice, menu, empathy, selfefficacy) and can take as little as 5-10 minutes to deliver.
“NHS professionals should routinely carry out alcohol screening as
an integral part of practice. For instance, discussions should take
place during new patient registrations, when screening for other
conditions and when managing chronic disease or carrying out a
medicine review. These discussions should also take place when
promoting sexual health, when seeing someone for an antenatal
appointment and when treating minor injuries.” 42
41. Kaner EFS, Dickinson HO, Beyer F, Pienaar E, Campbell F, Schlesinger C, Heather N, Saunders J, Burnand B (2007): Effectiveness of
brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004148.
42. NICE (2010): Alcohol-use disorders: preventing the development of hazardous and harmful drinking (PH24). NICE. London.
21
From one to many: The risks of frequent excessive drinking
6 Alcohol
interventions
NICE calculates the benefit of an intervention in terms
of the number of Quality Adjusted Life Years (QALYs)
gained. One QALY is the equivalent of one year of life
in perfect health. If the future life years are in less than
perfect health then each year has a value between 0 and
1 to account for this lower health. The cost-effectiveness
of the intervention can be measured as an Incremental
Cost Effectiveness Ratio (ICER). This is the cost per
QALY gained.
The predominant setting for alcohol screening is in the
GP surgery and this is where the majority of attention has
been focused. However screening can also take place in
hospital settings, following A&E attendance, and in other
primary care settings such as general dental practice and
community pharmacy. Alcohol screening can also be done
in non-healthcare settings such as probation services and
social services. In these cases it is important to consider
communication with GPs, confidentiality and the
competence of the assessor.
Several scenarios have been investigated with different
people providing the screening and different lengths of
intervention. All scenarios were found to either lead to
cost savings over a 10-year period, or were highly cost
effective in terms of incremental cost effectiveness ratios
(ICERs).
Costs and savings of alcohol screening
and Brief Interventions
As part of the development of the NICE guidance on
alcohol, NICE have looked at the major costs and savings
related to implementing alcohol screening and brief
interventions. In particular, modelling commissioned from
the University of Sheffield43 has assessed the net costs
and benefits of different methods of screening and
intervention.
Net NHS/
PSS cost
(£m)
QALY gain
(‘000s)
ICER v do
nothing
Screening
staff
Length
of BI
GP registration
Practice
nurse
25 mins
Practice
nurse
-58.5
32.7
Dominates*
GP registration
Practice
nurse
5 mins
Practice
nurse
-124.3
32.7
Dominates*
GP consultation
GP
25 mins
GP
685.6
116.9
£5,865
GP consultation
GP
5 mins
GP
-51.5
117.2
Dominates*
Screen setting
BI staff
Table 3: The cost and gain of screening and brief intervention in different settings. Taken from Purshouse et al. (2009)44. *‘Dominates’
indicates that the savings resulting from the intervention are greater than the cost of providing screening and Brief Interventions.
43. Purshouse R et al. (2009) op. cit.
44. Purshouse R et al. (2009) op. cit.
22
Table 3 shows some of the results from the University of
Sheffield modelling studies. In all the cases shown it has
been assumed that the Brief Intervention results in a
reduction in alcohol consumption of 12% and that
alcohol consumption will gradually return to previous
levels over 7 years.
The role of GPs in screening and intervention
GPs, as the first point of contact for most healthcare
needs, are the obvious choice for delivery of alcohol harm
reduction services. GPs and practice nurses can deliver
alcohol screening and Brief Interventions. In addition, if
psychological therapies are not effective, GPs are able to
prescribe appropriate licensed drugs.
NICE recommends screening all patients at next GP
registration. This screening would be done by a practice
nurse, and has been calculated to cost £2.65 per patient
for screening and £11.50 for provision of brief advice (5
minutes) where necessary. This would lead to a total cost
of £7.3million per year across the NHS.45
About 98% of the population are registered with a GP48
and those aged between 16-64 consult their GP an
average of 4 times a year for men, and 6 times a year for
women.49 This frequency is similar in those with
risky drinking behaviour.50 In order to deliver alcohol
interventions it is first necessary to screen people to see if
they need this assistance. Alcohol screening should use a
validated screening questionnaire such as the AUDIT test.
Screening can either be targeted, focussing on screening
those with particular conditions which may indicate high
alcohol consumption, or could be applied universally to
all those visiting or registering with a GP.
Alternatively, the modelling has shown that the whole
population could be screened more quickly by screening
at next GP attendance. This would cost more due to the
increased cost of GP time compared to nurse time.
However since people attend their GP more often than
register with a new GP, this would allow 96% of the
population to be screened in a 10-year time frame,
compared to only 39% if screening took place at next GP
registration.46 Whilst this would theoretically be beneficial,
in practice this level of screening would be difficult due to
the tight constraints on GP time.
The NICE public health guidance on Preventing Harmful
Drinking,51 recommends screening patients:
Both of the above scenarios would ultimately lead to a
reduced cost of healthcare services due to a reduction in
the development of chronic conditions related to alcohol;
however there would be a time lag between delivery of a
brief intervention programme and the results of these
interventions. As can be seen from table 3, if implemented
nationally, screening at the next GP registration, assumed
to be done by a practice nurse and a 5 minute brief
intervention if required, would lead to a net saving for the
NHS of £124.3million over 10 years and a total QALY
gain across England of 33,000 life years.47
•
during new patient registrations
•
when screening for other conditions
•
when managing chronic disease or carrying
out a medicine review
•
when promoting sexual health
•
at antenatal appointments
•
when treating minor injuries
As part of our research a survey was commissioned to look
at GP awareness of alcohol as a problem and their
attitudes towards screening and brief interventions. This
survey was conducted by Opinion Health in July 2011.
The survey was completed by 154 GPs from across the
country.
45. NICE (2010): Implementing NICE guidance: Costing Report, Alcohol-use disorders: preventing harmful drinking. NICE. London.
46. Purshouse R et al. (2009) op. cit.
47. Purshouse R et al. (2009) op. cit.
48. The NHS Confederation (2010): Too much of the hard stuff: what alcohol costs the NHS. The NHS Confederation. London.
49. Dunstan S (2011): General Lifestyle Survey Overview: A report on the 2009 General Lifestyle Survey. ONS. Newport.
50. Rolfe A et. al. (2009) op. cit.
51. NICE (2010): Alcohol-use disorders: preventing the development of hazardous and harmful drinking (PH24). NICE. London.
23
From one to many: The risks of frequent excessive drinking
6 Alcohol
interventions
This survey showed that GPs understand the importance
of screening and are aware of the need for screening to
identify risky drinkers. 79% of those surveyed agreed that
screening for alcohol misuse is important for disease
prevention and 84% agreed that it is important to engage
with harmful and mild dependent drinkers to reduce
alcohol-related harm. Over half of GPs thought that the
‘risky drinking’ group should be made a priority for
screening and 71% thought that screening levels in their
surgery could be higher.
In this report we suggest that universal screening should
be carried out independent of GP appointments, through
a ‘Universal alcohol assessment’ at age 30 and as part of
other NHS health checks. This will allow the GP to discuss
alcohol when flagged up by these checks, and through
targeted screening when a particular condition suggests
that alcohol may be a problem.
Despite the agreement of 79% of GPs that alcohol
screening is important, and that general practice is the
best place for such screening to take place (71% of those
surveyed selecting GPs or nurses working in general
practice as the healthcare professionals best placed to
carry out alcohol screening) there is still very low
identification of risky drinkers in general practice.
Research published in 2008, comparing the prevalence of
alcohol use disorders in the population with the number
identified by GPs, showed only 2.2% of all those with
alcohol use disorders, and less than 2% of those showing
hazardous or harmful drinking behaviours were identified
by GPs.52 31% of respondents to a survey of PCTs in
2008 said that no GP practice in their area was providing
brief advice for alcohol misuse.53
However, the survey found that, in comparison with
smoking, alcohol misuse was not a high priority among
GPs. Whilst 62% of GPs stated they would always ask
patients about their smoking, only 18% would always
obtain information from patients about alcohol
consumption.
In addition we found that there was variation in the upper
limits of alcohol consumption recommended by GPs. In
response to a question asking about the level of drinking
above which the GP would advise a patient to reduce their
intake, 48% of GPs stated an upper limit of 21 units per
week for men, but 42% used various upper limits above
this amount. Similarly 54% of GPs agreed with an upper
limit of 14 units for women, but 40% would only advise
reduction of intake at higher levels.
Several studies have investigated the reasons for low levels
of screening by GPs.54 The following have been identified
as barriers to alcohol screening and interventions:
There is current debate on whether the delivery of alcohol
screening and treatment in primary care should be
through universal versus targeted screening.
The
Screening and Intervention Programme for Sensible
Drinking addressed this question and concluded that
universal screening was most effective in identifying the
wide range of drinkers in the population. However GPs
have told us that they feel uncomfortable bringing up the
subject of drinking in a consultation unless it has some
relevance to the patient’s original complaint. Hence they
are happier conducting targeted alcohol screening than
universal screening. 69% of GPs in our survey agreed that
targeted screening should be carried out whereas 48%
said that all patients should be screened for alcohol misuse.
1. lack of time
2. inadequate training
3. no incentives in the current contract
4. worries around availability and cost of
alcohol services
5. the perceived normality of heavy drinking
amongst health professionals
52. Cheeta, S., Drummond, C., Oyefeso, A., et al. (2008) Low identification of alcohol use disorders in general practice in England.
Addiction, 103, 766–773.
53. NAO (2008): Reducing Alcohol Harm: health services in England for alcohol misuse. The Stationery Office. London.
54. Lock C, Wilson G, Kaner E, Cassidy P, Christie MM, Heather N (2010): A survey of GPs’ knowledge, attitudes and practices
on alcohol interventions. AERC. London
24
increase in the number of referrals to services providing
tier two, three and four structured alcohol treatments as a
result of screening.”58
Lack of time
60% of the GPs who responded to the survey stated lack
of time with patients as the primary obstacle to increasing
alcohol screening. This was rated above all other suggested
barriers to increasing screening. The standard length of
a GP appointment is 10 minutes which leaves little time
for alcohol screening or other health checks on top of the
original reason that the patient made the appointment.
Many GPs completing the survey stated that more time
with patients would encourage them to screen and treat
more patients for alcohol misuse.
The perceived normality of heavy drinking
amongst health professionals
In some cases, GPs own views on drinking may affect their
willingness to engage with this problem. GPs are
candidates for risky drinking given their high income and
socioeconomic class, and a DH study in 2010 to look at
the health of health professionals59 reported that 7% of
GPs frequently used alcohol to cope with stress60 and that
one in 10 junior doctors was drinking at hazardous
levels.61 Whilst this is lower than the level of alcohol
misuse in the general population, their own drinking levels
may affect how some doctors interact with their patients.
20% of respondents to our GP survey agreed that GPs
regard harmful and mild dependent drinking as normal
drinking behaviour. Although 63% of survey respondents
disagreed with this statement, this is a worrying
proportion. GPs may be reluctant to speak with patients
about alcohol misuse if they themselves have a high level
of drinking or believe that risky drinking is normal
drinking behaviour.
Training
A survey of GPs carried out in 2008 showed that less than
half of GPs surveyed felt they had adequate training to
recognise alcohol related health problems in their patients
and only half had undertaken alcohol misuse training
during their basic medical training.55 In recent years more
focus has been given to alcohol misuse training in the
undergraduate curriculum. Meanwhile an e-Learning
tool has been developed, The Alcohol Identification and
Brief Advice e-learning project,56 with courses available
for both primary care and pharmacy. Our recent survey
found that 41% of GPs still felt that they needed further
training in supporting drinkers.
No incentives in current contract
In order to try to improve the prevalence of GP screening,
a new Directed Enhanced Service (DES) was introduced
in 2009, known as the alcohol-related risk reduction
scheme, providing an additional incentive of £8 million
for GPs to undertake Identification and Brief Advice for
newly registered patients.62 A DES is a nationally
negotiated service which GP practices can choose to
provide. The alcohol-related risk reduction scheme has
been continued and will now be available as a DES until
March 2012.63 The DES requirements include screening
of newly registered patients using versions of the AUDIT
test and, if necessary, delivery of a Brief Intervention or
referral to specialist services.
Concerns with regard to availability and cost
of alcohol services
One of the concerns about the introduction of increased
screening and identification of alcohol misusers is that
those most easily identified are the dependent drinking
population who will require referral to specialist alcohol
services. Research from the 2004 Alcohol Needs
Assessment found that the majority (71%) of alcohol use
disorder patients identified by GPs were felt to
need specialist treatment.57 NICE recommends that
“commissioners should make provision for the likely
55. NAO (2008): Reducing Alcohol Harm: health services in England for alcohol misuse. The Stationery Office. London.
56. Alcohol IBA e-Learning course. Available at: http://www.alcohollearningcentre.org.uk/eLearning/IBA/. Accessed 21 June 2011.
57. Drummond et al. (2005): Alcohol Needs Assessment Research Project (ANARP): The 2004 national alcohol needs assessment for England.
Department of Health. London.
58. NICE (2010): Alcohol-use disorders: preventing the development of hazardous and harmful drinking (PH24). NICE. London.
59. DH (2010): Invisible patients: Report of the Working Group on the health of health professionals. Department of Health. London.
60. Firth-Cozens J (1998): Individual and organisational predictors of depression in general practitioners.
British Journal of General Practice 1998; 48: 1647-51.
61. Birch D, Ashton H, Kamali F (1998): Alcohol, drinking, illicit drug use and stress in junior house officers in north-east England.
Lancet 1998; 352: 785-6.
62. NAO (2008) op. cit.
63. DH (2011): The Primary Medical Services (Directed Enhanced Services) (England) (Amendment) Directions 2011. Department of Health. London.
25
From one to many: The risks of frequent excessive drinking
6 Alcohol
interventions
However, the fact that the DES is optional results in a
postcode lottery around whether screening is offered, and
hence the likelihood of receiving assistance to reduce
alcohol consumption will depend upon where you live. We
believe that all risky drinkers should be offered help
dealing with their levels of drinking, and recommend that
rather than a DES, requirement for alcohol screening
should be incorporated in the QOF or the GMS contract.
Case Study 1:
Primary Care Alcohol
and Drug Service (PCADS)
in Islington
This service supports the care of alcohol misuse
patients in primary care.
A team of specialist nurses work with Islington
GPs and the Hospital A&E department to provide
treatment for all risky and dependent drinkers
in primary care. Typically the GPs perform the
screening and then any patients screening
positive for alcohol misuse are referred to
the service.
Despite the recent conclusion of the Independent Primary
Care Quality and Outcomes Framework Indicator
Advisory Committee that the alcohol screening indicators
that they were working on are “unsuitable for further
indicator development”64, we believe that alcohol
screening should be incorporated in the QOF, both as an
indicator within other chronic conditions, to encourage
targeted screening, and under a new topic area for
alcohol. Targeted alcohol screening within the
management of various chronic conditions was
recommended by the NICE public health guidance65 and
it is hoped that the Screening and Intervention
Programme for Sensible drinking (SIPS) will help with the
identification of groups for targeted screening.
The specialist nurses provide a variety
of treatments, including:
•
Brief Interventions to reduce drinking
•
Cognitive Behavioural Therapy (CBT)
•
Community-based alcohol detoxification
Any complex cases with co morbidities are
referred to the specialist substance misuse
services.
Recommendation
Alcohol should be included as a new topic area
in the QOF, and indicators should encourage
screening of all newly registered patients and
targeted screening of those presenting with
comorbidities that can be associated with
excessive alcohol intake e.g. obesity
or depression.
The specialist nurses working at PCADS also
provide training to GP practices, including a
yearly update on current practice, and training
in the RCGP accredited alcohol course (Part 1).
The provision of this primary care alcohol service
means that GPs can delegate alcohol treatment to
the PCADS nurses, freeing up their own time.
This service was set up by the PCT, but has now
been transferred to The Whittington Hospital
NHS Trust.
Patients who screen positive for risky drinking should be
given a Brief Intervention. These are generally expected
to be provided by the GP or nurse who carried out the
screening. However there may not be time for this during
the course of a normal consultation, and additional
appointments for Brief Interventions will increase the time
pressure on GPs and nurses. In several cases provision of
low-level alcohol services, commissioned through Public
Health, has helped GPs by providing a referral service for
risky drinkers. Case studies 1 and 2 give examples of such
services which are provided across many GP surgeries.
64. NICE (2011): Unconfirmed minutes of the 9th June 2011 QOF Indicator Advisory Committee. Available at:
http://www.nice.org.uk/aboutnice/qof/PrimaryCareQOFIndicatorAdvisoryCommittee.jsp Accessed 3.8.11.
65. NICE (2010): Alcohol-use disorders: preventing the development of hazardous and harmful drinking (PH24). NICE. London.
26
For this reason we advocate a ‘universal alcohol
assessment’ at age 30. This would then flag up those
drinking at risky levels, allowing a Brief Intervention to
be provided and follow up at a given time point. Such an
assessment would not require a visit to the GP practice.
The majority of 30-year-olds have access to a
computer or smartphone, and an online or email-based
questionnaire could be developed that would allow
patients to quickly and accurately supply the information
required. This would be of minimal cost in terms of
money and time and could link directly into GP electronic
patient record systems. The use of a population-wide
universal screen will take the pressure off GPs to do
universal screening, allowing them to focus their efforts on
targeted screening of those most likely to be drinking at
risky levels.
Case Study 2: Health-trainers
in Bolton GP surgeries
A new method of delivering alcohol Identification
and Brief Advice within a wider programme
addressing Health Inequalities in Primary Care.
This new programme, run across all GP practices
in Bolton is attempting to screen as many patients
as possible with the AUDIT-C test. Any patients
over the age of 16 who come into a GP surgery
may be screened for alcohol misuse, either by the
GP or a practice nurse.
Once screened, if the score is positive, the patient
is referred to a health trainer who is assigned to
each surgery. The health trainers have until
recently been managed by public health but
work within the GP surgeries. When a patient
is referred the health-trainers conduct the full
AUDIT test and deliver health-related behaviour
change advice and motivational interviewing.
Recommendation
A universal alcohol assessment should be offered
at age 30. This could be cheaply and easily done
as an online or email-based assessment.
All GPs have agreed to use this programme, and
are happy that once they have identified patients
with the AUDIT-C test, they are able to refer them
into an existing service. The health-trainers are
now being managed by the local acute trust,
following the recent transfer of provider services
from the PCT.
A further opportunity to screen patients for alcohol
consumption is the NHS Health Check currently being
rolled out across England. The NHS Health Check
programme assesses those between 40 and 74 for their risk
of developing heart disease, stroke, Type 2 diabetes and
kidney disease. The practitioner discusses life-style risks
with the patient, such as exercise and smoking and gives
personalised advice on how to lower their risk and
maintain a healthy lifestyle. The risks of drinking could
easily be incorporated into the NHS Health Check and
would be in line with the other preventative aspects of
the check.
Screening through Universal Health Checks
It is important to identify alcohol misuse and risky
drinking patterns early so that timely intervention can
prevent the development of problems that are more
chronic and difficult to treat.66 Researchers at
Southampton have shown that those treated for alcohol
liver disease are generally already drinking heavily and
frequently by the age of 24,67 however by the time
that they are seen for liver disease it is too late to change
their behaviour.
Recommendation
Screening of alcohol consumption should be
included in all NHS Health Checks.
66. Cheeta, S et al. (2008) op. cit.
67. Hatton, J, Burton, A, Nash, H, Munn, E, Burgoyne, L and Sheron, N (2009): Drinking patterns, dependency and life-time drinking history
in alcohol-related liver disease. Addiction, 104: 587–592.
27
From one to many: The risks of frequent excessive drinking
6 Alcohol
interventions
Whilst we would welcome greater involvement in alcohol
screening by primary dental services, barriers to this have
been identified including lack of time, lack of funding and
insufficient training.75 Most dentists are already trained to
recognise early signs of mouth cancer, by visual screening
of the oral mucosa,76 however there may need to be
further training of dentists or dental nurses in the delivery
of alcohol screening and Brief Interventions.
The role of dentistry
Alcohol is a strong risk factor for mouth and throat
cancers and therefore alcohol misuse is of interest to
dentists, who are concerned with their patients’ oral
health.68 The incidence of oral cancer in the UK is
increasing and long-term survival rates for this condition
remain poor.69
Dentists are well-placed to provide alcohol screening
because of their coverage of the well population. 76% of
adults in England reported attending the dentists at least
once every two years, with 50% attending at least once
every six months.70 McAuley et al (2011)71 have
commented: “The frequency and length of a typical
dental appointment puts the dental team in a potentially
ideal position to identify harmful/hazardous drinkers
opportunistically and promote and/or deliver appropriate
interventions.” Modern dental care is based on a
preventive philosophy with patients expecting to receive
advice on oral hygiene. In addition to this patients were
found to be happy to accept questions and advice from
their dentist on alcohol consumption.72
Recommendation
Recommendation: Dentists should screen for
alcohol misuse, where indicated as a result of
the oral health assessment. A validated alcohol
screening method such as AUDIT should be used.
This should be incentivised through DQOF.
Although currently routine screening and intervention
relating to alcohol consumption is not usual in dental
practice,73 there are developments in this direction.
Private payment plans such as Denplan already include
preventative care such as examining and scoring the
health of oral soft tissues as part of their dental care.
Starting this summer NHS dental practices will trial a new
dental contract, a core component of which is an oral
health assessment, the Primary Dental Care Patient
Assessment (PDCPA). This is a comprehensive assessment
of a patient’s oral health status and involves collection of
standardised information which supports decisions about
prevention, treatment and recall frequency.74 Dentists will
be required to discuss risk factors with the patient and for
soft tissue health these would be likely to include smoking
and alcohol. This is a powerful opportunity for education
as many people would not expect their dentist to comment
on their alcohol intake.
Figure 6: Mouth cancer. Image taken from Pastore et al. 2008 77
68. Tramacere I, Negri E, Bagnardi V, Garavello W, Rota M, Scotti L, Islami F, Corrao G, Boffetta P, La Vecchia C (2010): A meta-analysis of alcohol
drinking and oral and pharyngeal cancers. Part 1: overall results and dose-risk relation. Oral Oncol. 2010 Jul;46(7):497-503. Epub 2010 May 4.
69. McAuley A, Goodall CA, Ogden GR, Shepherd S and Cruikshank K (2011): Delivering alcohol screening and alcohol brief interventions within
general dental practice: rationale and overview of the evidence. British Dental Journal 210, E15
70. Chenery V (2011): Adult Dental Health Survey 2009 – England Key Findings. The NHS Information Centre. Leeds.
71/72/73. McAuley A et al. (2011) op. cit.
74. DH (2011): Dental Quality and Outcomes Framework. Department of Health. London.
75. McAuley A et al. (2011) op. cit.
76. McAuley A et al. (2011) op. cit.
77. Pastore L, Fiorella ML, Fiorella R, Lo Muzio L (2008) Multiple Masses on the Tongue of a Patient with Generalized Mucocutaneous Lesions.
PLoS Med 5(11): e212. doi:10.1371/journal.pmed.0050212
28
A systematic review of the evidence80 on this topic found
three small scale studies which showed (non-significant)
reductions in alcohol consumption, however larger,
controlled studies are needed and are currently being
developed. Two randomised controlled trials are currently
in process in London (to assess the effectiveness of
pharmacy BI) and Grampian (pilot feasibility trial), and
the North West Pharmacy Project is working to analyse
and evaluate the provision of Brief Interventions in
pharmacies across the North West.
The role of community pharmacy
A wide sector of the population visit pharmacies, with on
average each person visiting a pharmacy 12 times every
year.78 Hence, this is an opportunity to target the well
population, those that do not attend their GP surgery and
those not registered with a GP. In some areas of the
country, particularly in the north-west, pharmacies are
already delivering alcohol services. These services are
commissioned by PCTs but may run only for short periods
of time e.g. 6 months.
Community pharmacy services can include education,
raising awareness of the risks of drinking by distributing
leaflets, questionnaires or unit calculators. In addition
pharmacies can provide screening and Brief Interventions
(BI) for alcohol risk. Screening has ranged from screening
everyone who comes into the pharmacy, to targeting those
with requests that may relate to drinking such as buying
medication for hangovers, stomach problems, depression
or sleep problems, or offering BI to those diagnosed with
chronic health conditions which would place them at a
higher risk of developing alcohol related problems. It has
also been suggested that alcohol screening could be added
on to other services such as cardiovascular screening, or a
medicines use review, since many medicines interact with
alcohol. These services are conducted in private
consultation rooms located within the pharmacy, so the
confidential conversation is not heard nor observed.
Recommendation
Depending on the outcome of the current
evaluation of alcohol treatment in pharmacy
services, consider pharmacies as a resource
for delivery of alcohol screening and brief
interventions.
As yet there is little evidence around the effectiveness of
delivery of Brief Interventions for alcohol in pharmacies
as research in this area is relatively new. However,
pharmacies have gained expertise in providing smoking
cessation services and there is now strong evidence on the
effectiveness of Brief Interventions for smoking cessation
delivered by community pharmacists. This suggests that
pharmacists may be able to build on this experience to
provide effective alcohol services. Feasibility studies
showed that pharmacy customers responded well to being
approached to discuss their drinking levels in this setting.79
78. Tully MP, Temple B (1999): The demographics of pharmacy's clientele - A descriptive study of the British general public.
International Journal of Pharmacy Practice 7 (3), 172-181.
79. Dhital R, Whittlesea CM, Norman IJ, Milligan P. Community pharmacy service users' views and perceptions of alcohol screening
and brief intervention. Drug Alcohol Rev 2010;29;596–602
80. Watson M, Blenkinsopp A, Harrison A, Neilson E (2008) Community pharmacy and alcohol-misuse services: a review of policy and practice.
Royal Pharmaceutical Society of Great Britain. London.
29
From one to many: The risks of frequent excessive drinking
6 Alcohol
interventions
Whilst many research studies have been conducted
concerning the efficacy of IBIs, these have not always
been of high quality. A recent meta-analysis82 found that
a mean difference of alcohol consumption of 26g of
alcohol per week (just over 3 units) was achieved by IBIs
compared to minimally active groups. This is only slightly
less than the 38g reported by the Cochrane review as a
result of standard face-to-face brief interventions.83
Kingston PCT are currently using the IBI ‘Down Your
Drink’. Initial results suggest a reduction in alcohol
consumption of over 50%. For more details see Case
Study 3.
Computer-based alcohol interventions
Internet-based interventions (IBIs) for problem drinking
have been in existence for more than a decade, and it is
felt that these are now beginning to move into mainstream
use. Typically an IBI will include screening of alcohol
intake and provide personalised feedback with help in
reducing consumption.
The benefits of IBIs over standard face-to-face
interventions include cost, scalability, and the potential to
address a larger population who may not wish to access
conventional services. Since the marginal cost per
additional user is low, the service, once designed, can easily
be extended to more users. For the patient, the IBI
approach has the benefit of convenience. 73% of
households had an internet connection in 2010 and 62%
of all adults shopped on the internet.81 In recent years
with the development of smartphones there is increased
access to mobile internet. For many, accessing the internet
is much easier and more convenient than a trip to the
doctor’s surgery.
Recommendation
Public Health should consider commissioning
computer-based interventions, as a cheap
and easily-scaled means of providing brief
interventions.
Recommendation
Clinicians should encourage the use of easy ways
of tracking drinking that make use of available
technology, such as smartphone apps.
81. Office for National Statistics website http://www.statistics.gov.uk/CCI/nugget.asp?ID=8 Accessed 4 Aug 2011.
82. Khadjesari Z, Murray E, Hewitt C, Hartley S, Godfrey C (2010): Can stand-alone computer-based interventions reduce alcohol consumption?
A systematic review. Addiction, 106, 267–282
83. Kaner EFS, Dickinson HO, Beyer F, Pienaar E, Campbell F, Schlesinger C, Heather N, Saunders J, Burnand B (2007): Effectiveness of
brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004148.
30
Case Study 3: Kingston ‘Down Your
Drink’ (DYD)
In Kingston, a web-based treatment ‘Down Your
Drink’ is used to help risky drinkers to reduce
their alcohol consumption. The website provides
help with decision making, cognitive behavioural
therapy and tools to help monitor and measure
drinking. This service takes the place of a faceto-face brief intervention.
Referral into this service is predominantly by
general practice, and thus patients must be
identified as needing this assistance by
screening (AUDIT-C) by either a GP or
practice nurse.
The service begins with an initial assessment
with an Alcohol Project Worker (APW). This is
conducted using a computer and comprises a
selection of alcohol assessment tests, including
AUDIT, to determine level of drinking and
dependence on alcohol. The APW is present to
introduce the patient to the programme and to
assist with use of the computer, but does not need
to be medically qualified.
•
Phase 1 uses motivation interviewing
techniques to help the user come to a high
quality decision about their wish to change
their drinking behaviour.
•
Phase 2 provides advice on behavioural selfcontrol and cognitive behavioural therapy as
well as tools such as a drink diary with
feedback on alcohol content, calories
consumed and spending.
•
Phase 3 is about sticking to the changes, and
relapse prevention.
An evaluation of the service, due to be published
shortly, followed patients referred during the first
12 months of the programme. Initial referral rates
into the programme were low, although it is
thought that these would increase as the GPs
become more used to referring into the programme,
and see the benefits to their patients. Patients
were followed-up 3 months after they had entered
the programme. Although patient numbers were
low, there was an average reduction in alcohol
consumption of over 50%.
Having done the baseline assessment the patient
is introduced to the website, shown how to use it,
and given information on how to access the site.
This service is cheap to run and can be easily
scaled. With a service such as this available to
which patients can be referred, GPs may become
more willing to screen for alcohol problems. Each
patient used 2.5hrs of the Alcohol Project Worker’s
time, however since the assessment is protocoldriven a specialist alcohol nurse is not needed.
This service is now being extended by Kingston
PCT so that referrals can come from a wider
range of services, including housing, probation,
social services, A&E and hospitals. Further
Alcohol Project Workers are being trained to
facilitate the web-based service.
The patient is then free to work through the
website in their own time, and receives follow-up
phone calls at 2 week intervals, to check that they
are not having any technical difficulties.
The Kingston ‘Down Your Drink’ website guides
the user through 3 phases of treatment, a
decision phase, a change phase, and a ‘keeping
on track’ phase.
http://www.dyd.kingston.nhs.uk/
31
From one to many: The risks of frequent excessive drinking
7 Future changes to
the health service
The future direction for health and social care services will
be laid out in 3 outcomes frameworks, the NHS
Outcomes framework, the Social Care Outcomes
Framework and the Public Health Outcomes Framework.
Alcohol features in both the NHS Outcomes framework
and the proposals for the Public Health Outcomes
framework. These outcomes frameworks will then drive
the development of quality standards which set the
standard for high quality care in a particular area. The
quality standard for alcohol dependence and harmful
alcohol use is currently in draft form and is due to be
published this summer.
3. Movement of public health from PCT to local authority
The movement of public health into the local
authority will enable Directors of Public Health to
work more closely with those responsible for the safety
and prosperity of the region. Public health will
be responsible for the commissioning of alcohol
services across all levels of need. This will include
the commissioning of low-level community services
for alcohol, for example alcohol specialist nurses
working within GP practices for the provision of
brief interventions.
There are various practical changes which may affect the
way in which alcohol services are commissioned and
delivered:
Recommendation
Public health should use the JSNA to commission
alcohol services according to need.
This would include a service for the delivery
of Brief Interventions with measurable outcomes.
1. The NHS Commissioning Board will be responsible
for GP contracts.
The move to a national GP contract with the national
commissioning board will open the possibility for a
more uniform contract and may lead to a move to
national mandatory alcohol screening.
Recommendation
Public Health should take responsibility for
education of the local population on alcohol,
to ensure that all understand the harms of
risky drinking.
2. The establishment of Health and Wellbeing Boards
which will produce Joint Strategic Needs
Assessments (JSNAs) and a Joint Health and
Wellbeing Strategy.
4. The abolition of PCTs and development of
‘Clinical Commissioning Groups’ to commission
local services.
The health and wellbeing board will bring together
leaders from the council and the commissioning
groups to establish the health and wellbeing needs of
the population and develop a strategy for action. It is
important that all public health themes are included
in the JSNA, including alcohol. JSNAs should make
use of the data already available, such as the Local
Health Profiles which include regional information
on alcohol related hospital admissions and numbers
of increasing and higher-risk drinkers.
Clinical Commissioning Groups (CCGs) will need to
work closely with public health to ensure that a
complete spectrum of alcohol assistance and care is
provided. CCGs will be responsible for commissioning
the acute care of those who have developed alcoholrelated conditions and will need to work with public
health to try to keep the number of referrals down
through secondary prevention services.
5. Many community services previously managed by
the PCT are now provided by acute trusts.
The movement of the community alcohol team into
acute trusts may bring benefits by reducing the
disconnect between acute and community alcohol
services. Those with alcohol problems often move
between primary and acute care, and there needs to
be continuity in the assistance they are given to deal
with their drinking.
32
One model that may become appropriate in this situation
is that of the Alcohol Care Team which has been
developed as a QIPP Evidence Case Study.84 Alcohol
Care Teams would reside in the acute trust but work
across primary and secondary care, coordinating care
across acute departments, providing access to Brief
Interventions and working in the community via an
“Assertive Outreach Alcohol Service”.
Local Authorities
• Commission primary care
alcohol services across all
tiers in line with local needs
• Provide population-wide
education
• Commission NHS Health
Check for those aged 40-74
Health and Wellbeing Board
Provide evidence on local
needs (JSNA) and strategic
direction and planning (Health
and Wellbeing Strategy)
Commissioning
National Commissioning
Board
• Commission online or
email-based alcohol
screening at age 30
Community alcohol services
Provision of Brief Interventions
within GP practices by health
trainers or alcohol specialist
nurses
Commissioning
Referral
GP practices
• Screen new patients
and those presenting
with alcohol-related
conditions
• Refer patients screening
positive to the
appropriate services.
• Provide Brief
Interventions within
the practice where
necessary
Referral
Local Clinical
Commissioning Group
• Work with public
health to ensure that
a complete pathway
of provision for alcohol
misuse services is
available
Referral
Commissioning
Other local services
• Dentistry • Maternity
services
• Pharmacy
• Probation • Sexual health
services
• Social care
• Housing
Figure 7: Commissioning and provision of alcohol services after the NHS reorganisation.
84. NICE (2011): Quality and Productivity Case Study: Alcohol Care Teams. NICE. London. Available at:
http://arms.evidence.nhs.uk/resources/qipp/29420/attachment. Accessed 22/06/11.
33
Hospitals
• Screening of all
admitted patients
• Referral to community
alcohol services
From one to many: The risks of frequent excessive drinking
7 Future changes to
the health service
The current changes to the commissioning structures
within the NHS, together with a reinvigoration of public
health, will lead to a greater focus on preventative
measures which help people to lead healthy lives and
reduce their risk of developing chronic conditions.
We suggest that public health should commission the
provision of Brief Interventions by alcohol workers in the
community, preferably working within GP surgeries. This
provides GPs with an easy referral mechanism, and thus
will encourage patient screening.
As can be seen from Figure 7, public health, general
practice and hospitals all have a responsibility for
screening and the provision of Brief Interventions. GPs
should provide screening as part of the new patient checkup and where relevant during normal consultations,
hospitals should screen all newly-admitted patients and
those working in other services such as dentistry or
probation may also be able to screen patients. All those
providing screening would benefit from somewhere to
refer risky drinkers if a Brief Intervention cannot be
provided during the initial consultation.
Clearly, alcohol services will need to work both in the
community and in acute care and there will be many
different access points. The movement of public health
into the local council will enable those working in public
health to have a broader insight and understanding of the
wider issues around alcohol through their connection with
other areas of the council. This will be an area on which
the health and wellbeing board should take a lead,
bringing all interested parties together to work together to
ensure that there is provision across the spectrum of need.
34
From one to many: The risks of frequent excessive drinking
8 The causes of
risky drinking
Whilst those working in the health service would prefer to
reduce drinking levels due to the increased cost of
treatment for alcohol-related health conditions, people
making individual choices about whether and how much
to drink will be weighing up the benefits and costs to
themselves. Whilst the choice of how much to drink given
the risk to health is a personal one, it is important that
people have all the information necessary to make this
decision. We believe that those choosing whether to drink
alcohol and how much alcohol to drink should be able to
make an informed choice, understanding the costs and
benefits of their decision. If people are not aware of the
harms related to drinking they cannot make a valid choice
about their own life.
Whilst there is much scope for an improvement in
identification and intervention with risky drinkers by the
health service, the person with the most responsibility for
their own drinking is the individual.
Drinking moderately is about a balance between the
enjoyment of alcohol and the harms which may be caused
by excessive drinking. Several studies have done research
looking at the reasons for high drinking levels. A study by
the NWPHO identified the top reasons for drinking as:
•
alcohol goes well with food
•
alcohol makes socialising more fun.85
Other reasons for drinking include participation in the
pub culture, relaxation or escaping from problems.86
Reasons to drink
A part of socialising
Enjoy the taste
Awareness of alcohol-related health harm
Public understanding around the risks of alcohol harm is
low. A YouGov poll conducted in January 2010 showed
that 55% of English adults believe that alcohol only
damages your health if you binge drink or get drunk. The
poll showed that 83% of those who regularly drink more
than the recommended limits don’t think their drinking is
putting their long-term health at risk. In another survey,
46% of the population did not know the sensible drinking
guidelines.87 There is a widespread ignorance of the harms
associated with risky drinking. While 86% of drinkers
surveyed knew that drinking alcohol is related to liver
disease, many were unaware of the links with cancer, stroke
or heart disease. One of the difficulties in making sound
behavioural choices is the time gap between the drinking
behaviour and the health consequences. Chronic diseases
such as liver disease and cancers may not manifest until
the damaging drinking behaviour has continued for many
years. This makes education about the risks and future
consequences of this behaviour essential.
Reasons
Reasonsnot
notto
todrink
drink
Harm to health
(often not understood)
Relaxation,
reducing stress
Cost of alcohol
(affordability has
increased over time)
Pub culture
Risk of harm to
others – family, friends
Peer pressure
Boredom
To forget problems
Habit
Table 4: The balance of motivations for drinking vs. not drinking.
85. Morleo M, Carlin H, Spalding J, Cook PA, Burrows M, Tocque K, Perkins C, Bellis MA (2010):
Attitudes towards alcohol: segmentation series report 1. NWPHO. Liverpool.
86. Rolfe A et al. (2009) op. cit.
87. Wilkins D, Payne S, Granville G, Branney P (2008):The Gender and Access to Health Services Study. Department of Health. London.
35
From one to many: The risks of frequent excessive drinking
8 The causes of
risky drinking
A report published by Alcohol Concern, “Off Measure”89
highlights the difference between what we think we drink
and actual alcohol sales, showing that the difference
between alcohol surveys calculating consumption and
alcohol sold is the equivalent of a bottle of wine per
drinker per week! Although understanding of units is
growing, further education may be necessary.
Even amongst those that know the harms related to
drinking and the recommended maximum number of units
for low-risk drinking, there is wide misunderstanding
around how many units constitutes a drink. With
increasing alcohol content and glass sizes there are now
more units in a glass than in previous years. Wine in
particular, which used to come in a standard 125ml glass,
is now more often sold as glasses of 175ml or 250ml and
the alcohol content is increasing. The average alcohol
content of a bottle of wine in 1992 was 12.7%, but this
average rose to 13.7% in 2005 and alcohol content may
be up to 15% in some wines.88 This makes it easy for us to
consume more alcohol than we think we are. There has
been a move towards the display of units of alcohol on
bottles and cans which we hope will become further
widespread through the Public Health Responsibility Deal.
Noting the alcohol content and number of units in a drink
on drinks menus would be useful to allow people to make
more informed choices when drinking outside the home.
Recommendation
Units should be displayed clearly on the front of
all bottles or cans of alcoholic drinks, in a minimum font size.
Figure 8: Variations in the strength of alcoholic drinks will affect the number of units consumed.
88. Alston JM, Fuller KB, Lapsley JT, Soleas G, and Tumber KP (2011): Splendide Mendax: False Label Claims about High and Rising Alcohol
Content of Wine. Available at: http://purl.umn.edu/103845
89. Bellis MA, Hughes K, Cook PA, Morleo M (2009): Off Measure: How we underestimate the amount we drink. Alcohol Concern. London.
36
Education about drugs and alcohol should begin at
school, and is part of personal, social, health and
economic (PSHE) education. An Ofsted report from 2010
found that a better understanding was needed in many
schools of the social and physical effects of alcohol.90 In
15 of 73 secondary schools visited between September
2006 and July 2009, it was found that students’ factual
knowledge about drugs, including alcohol and tobacco,
was inadequate.
Recommendation
A national public health education campaign is
needed to ensure that the population are made
aware of the harms related to risky drinking.
The campaign needs to advise people of the risks
of different conditions associated with drinking,
and the harms of drinking every day.
In particular the campaign should highlight risks
such as the risk of specific cancers of which
many are not aware.
Recommendation
In order to further investigate the causes of risky drinking
and the different approaches that can be taken by the
government, public health and health professionals on this
issue we have compared the approach in this country with
that in other parts of Europe. We have tried to identify
the factors which lead to different levels of alcohol
consumption as well as the variation in cultural attitudes
around drinking.
Alcohol education should be an annual component
of PHSE through secondary school education.
This should include information on the long-term
risks of drinking at different levels.
There is a widespread belief amongst the population that
drinking a little every day is good for your health, due to
widely publicised evidence of cardiovascular benefits of
alcohol. However even at this low level of drinking there
is still an increased risk of other diseases, and drinking
every day should never be encouraged. Getting into a
habit of daily drinking can often lead to an increase in
consumption and a corresponding increase in health
harms. Drinking even one glass of wine in the evening, if
drunk every day, will reach the limits of what is considered
‘low risk’ drinking by the Department of Health.
The new social marketing strategy for public health91
states that there will be no more central single-issue
campaigns but that marketing will concentrate around
larger campaigns such as ‘change4life’. From April 2013,
responsibility for public health marketing will move to
local authorities. However, given the low public
understanding of drinking harms we believe that there is
a real need for universal health information on this topic
with clear messages. These could be targeted to different
age groups, since there are different risks associated with
getting drunk, regular daily drinking, or for older people,
drinking in conjunction with medication.
90. Ofsted (2010): Personal, social, health and economic education in schools. Ofsted. Manchester.
91. DH (2011) Changing Behaviour, Improving Outcomes.
37
From one to many: The risks of frequent excessive drinking
9 International
comparisons
rate for liver disease has doubled over the last two decades
and liver disease is now accountable for 11.4 deaths per
100,000.97 With this rising rate it is pertinent to explore
how other European countries differ from the UK in the
way they approach alcohol to determine if there are
lessons we can learn. In doing so a number of key areas
have been reviewed:
The European picture
Europe is the heaviest drinking region in the world.92,93
Countries classified by the WHO as EUR-A; encompassing Western Europe, are the greatest consumers
of alcohol, with beer and wine constituting the largest
consumption and spirits to a lesser extent. Europe drinks
two and a half times the rest of the world’s average.94
Economically alcohol is a valuable commodity; in 2006
the EU was identified as producing over a quarter of the
world’s alcohol and over half of the world’s wine. The
WHO has identified that 70% of alcohol exports in the
world and almost 50% of the world’s imports derive from
the EU, although much of this was traded between the
European countries. Excise duty provides a source of
income to all European countries and in 2003 it was
estimated that three quarters of a million people were
employed in drinks production alone, with considerably
more employed in marketing and sales. It is therefore
economically valuable.
•
Culture
•
Regulation and policy
•
Taxation of alcohol
•
Marketing
•
Education and Intervention programmes
Culture of drinking in Europe
Alcohol is a well-established part of European culture.
The UK in the past was considered to be a moderate
drinking country with countries in Southern Europe
drinking more than the UK. The Northern countries of
Europe have traditionally been perceived to be binge
drinkers and alcohol has played a more significant role in
causing violence and accidents. Southern European
drinkers have tended to be seen as users of alcohol as a
part of daily life. Alcohol in France and Italy has more
traditionally been used at meal times and in celebration,
with drinking at meal times estimated to account for 80%
of Southern Europe’s drinking compared to 50% within
the UK. In the UK the pattern of drinking is as an after
work activity defining the end of the working day or being
used for celebration. These cultural differences are
starting to change as closer integration between countries
occurs.
Set against this is the impact on health. The Anderson
and Baumberg report95 identified that the estimated
tangible cost of alcohol misuse in the EU in 2003 was
125bn Euros with intangible costs likely to have been as
high as 270bn Euros. All European countries are trying
to grapple with the problems associated with alcohol. The
WHO and EU have produced a number of reviews on
the current trends in drinking and issued guidance on the
advertising of alcohol, development of national strategies
and education and protection of young people. It should
be noted that none of these are enforceable and each
nation must develop its own approach. The sale, use,
regulation and advertising of alcohol are covered by
numerous laws in individual European countries.
The strongest link between alcohol and any chronic health
condition is that between alcohol and liver disease. Thus
the level of liver disease can be used as an indicator of the
effect alcohol is having on the health of the population.
The UK has experienced a rapid rise in the rate of liver
disease96 compared to other counties in Western Europe.
For example France, Italy and Norway have seen a
significant reduction in liver death rates and other related
alcohol diseases over the last decade. In contrast, the UK
92. Anderson P and Baumberg B (2006): Alcohol in Europe: A Public Health Perspective. Institute of Alcohol Studies. London.
93. WHO (2010) European status report on alcohol and health 2010. World Health Organization. Geneva.
94. Anderson P and Baumberg B (2006) op. Cit.
95. Anderson P and Baumberg B (2006) op. Cit.
96. WHO (2004): Global Status Report on Alcohol 2004. World Health Organization. Geneva.
97. Mathers C, Boerma T, Ma Fat D (2008): The global burden of disease, 2004 update. World Health Organisation. Geneva.
38
At various times in history the UK government has
attempted to restrict alcohol consumption, specifically
with the Gin Act98 and the Defence of the Realm Act99
which restricted licensing hours, and these were perceived
to have been largely successful. In general within the UK
there is an ambivalent attitude towards government’s
responsibility to intervene on alcohol restriction as
compared to other parts of Northern Europe e.g. Finland
and Germany where there is some antipathy and France
and Italy where there is stronger support.
Regulation and policy
Within the EU there is very little actual regulation at
regional level on alcohol other than that pertaining to the
enablement of a free market. Almost all regulation with
regard to the sale, pricing and advertising of alcohol is
carried out at national level, the exception being the EU
Audiovisual Media Directive (2007). Countries within the
EU are free to set their own taxation rates, advertising laws
and legal limits for driving.
There are in existence a number of frameworks and
policies developed by both the EU and the WHO. The
UK is signed up to these through the EU but they are in
UK law non-statutory. These include the WHO
Framework for Alcohol Policy in the European Region,
EU charter on Alcohol 1995 and WHO European
Charter on Alcohol Sales to Young People.
The major changes within the UK recently have been the
relaxation of licensing laws and the availability of cheaper
alcohol. Given the inherent nature of Northern
Europeans to binge drink and the resultant impact on
societal behaviour it could be said that both these changes
are counter-intuitive.
Country
Excise duty on
wine Jan 2010
(EUR per litre
100% alcohol)
Excise duty on
beer Jan 2010
(EUR per litre
100% alcohol)
Alcohol
affordability
index
Maximum legal
blood alcohol
concentration
whilst driving
(mg %)
Austria
0
5.2
3.62
50
16
Cz Republic
0
3.15
4.14
0
18
Denmark
7.5
6.84
3.77
50
16
Finland
25.73
26
2.83
50
18
France
0.32
2.64
3.45
50
16
Germany
0
1.97
3.64
50
16
Hungary
0
5.32
4.07
0
18
Ireland
23.84
15.71
2.31
80
18
Italy
0
5.88
2.73
50
0
Netherlands
6.23
5.02
3.65
50
16
Poland
3.38
4.04
2.98
20
18
Sweden
19.25
16.29
2.35
20
20
UK
21.36
18.08
2.38
80
18
Age limit for
alcohol sale
in shops
Table 5: Comparison of UK with other European countries on alcohol regulation and policy. Data taken from Österberg E L (2011) ,
Bennetts R (2008) and the WHO Alcohol control database .102
98.
99.
100.
101.
102.
Gin Acts 1729 -1751
Defence of the Realm Act (DoRA 1914)
Österberg E L (2011): Alcohol tax changes and the use of alcohol in Europe. Drug and Alcohol Review, 30: 124–129.
Bennetts R (2008): Trends in the Affordability of Alcohol in Europe. Institute of Alcohol Studies.
WHO (2011) Alcohol Control Database. Available at: http://data.euro.who.int/alcohol/ Accessed 02.08.11
39
From one to many: The risks of frequent excessive drinking
9 International
comparisons
As shown in Table 5, there are considerable variations in
alcohol policy and regulation between the different
European countries. The UK has high taxation and hence
a low affordability of alcohol, however is perceived to be
low on policy and regulation in comparison to France and
Italy where taxation is low and regulation is high. Norway
and Finland, in common with the UK, have high taxation,
but have greater statutory regulation. Therefore one
might draw the conclusion that taxation is not the key to
reducing alcohol consumption but that regulation of the
sale and marketing of alcohol has a greater part to play
in assisting in the reduction of consumption.
Recommendation
There is an urgent need for a government review
of alcohol policy in line with the international
evidence base.
Pricing and taxation
The UK has one of the highest rates of alcohol taxation
in Europe, alongside the Nordic countries. However this
is set against low cost alcohol which has flooded the
market. Taxation through VAT on alcohol has persistently
risen within the UK to increase the cost, but demand has
been able to withstand these rises. Despite increasing
taxation, the affordability of alcohol in the UK has been
steadily increasing and in 2010, alcohol was found to be
45% more affordable on average than in 1980.103
Policy controls on sale of alcohol to those under 18 is almost
universal within Northern Europe and some countries such
as Sweden and Norway restrict sales of spirits to those
under 20. Regulation in Southern Europe is least restrictive
with sales restricted to 16 years in Italy. However in Italy
there is a move to greater regulation on legal age limits for
sales of off licence and restaurant/bar sales.
An association between taxation and alcohol consumption
has been shown. Barber et al in 2003104 identified that
where the price of alcohol was raised the incidence of
road deaths, violent crime associated with alcohol and
incidence of cirrhosis fell. When Finland reduced taxation
in 2004 to stem the flood of cheap imports, the country
experienced a 17% rise in alcohol associated mortality.105
However in countries such as France and Italy there is less
taxation and alcohol can be purchased cheaply. In France,
the quality of the product has been given a higher focus
and improving quality of wine and setting these products
at a higher price has resulted in a reduction in the
purchase of cheaper wines.
While the UK has many regulations relating to the
taxation and production of alcohol, it is one of only two
countries in Europe where there is no statutory regulation
with regard to the advertising and marketing of alcohol,
a system of co-regulation and non-statutory guidance
being in place. The other country with limited regulation
is the Netherlands, which incidentally has also seen a rise
in the incidence of cirrhosis. After removing taxation from
the policy and regulatory equation, the UK reduces in
regulation from one of the highest ranking in Europe to
a country with a medium policy and regulation score.
While the UK has an alcohol strategy in line with WHO
and EU recommendation, the strength in any policy is the
leadership and commitment shown by national
government. The regulation, monitoring and education
must be sufficient to ensure any strategy’s success.
Furthermore, there must be a willingness by government
and others to use the powers they have to take measures
against producers, sellers and advertisers who breach
regulation. Within the UK there has been insufficient
leadership from government to tackle these issues.
It is often quoted that alcohol has inelastic demand but
recent studies are beginning to suggest that there is some
elasticity. Beer, considered to be the traditional alcoholic
drink for the UK, has increased in price at a faster rate
than other drinks and there has been a corresponding fall
in demand. Alongside this, it has been observed that
where income falls there is less consumption. Therefore it
could be assumed that taxation and pricing policies can
contribute to a reduction in consumption. The links
between consumption, tax and price are considered to be
subject to a number of variables that make it difficult to
assess the impact of any change.
103. The NHS Information Centre (2011): Statistics on Alcohol, England 2011. The NHS Information Centre. Leeds.
104. Babor T, Caetano R, Casswell S et al. (2003): Alcohol: No ordinary commodity: Research and public health. Oxford University Press/World
Health Organisation. Oxford.
105. Koski A, Sirén R, Vuori E, Poikolainen K (2007): Alcohol tax cut and the increase in alcohol- positive sudden deaths: a time series analysis.
Addiction. 2007 Mar;102(3):362-8.
40
It has been proposed that there should be a minimum
price per unit of alcohol, in order to stop supermarkets
selling alcohol as a loss leader. NICE public health
guidance has suggested a minimum price of 40p per unit.
The WHO reported that a price increase and minimum
pricing per unit were more likely to reduce drinking in
those who drank at harmful levels than those who
consumed less and even a small shift in price can reduce
consumption.106 Modelling suggests that a minimum price
of 40p per unit would lead to a 2.4% reduction in
consumption, and a saving of £80.3million to the NHS
together with savings of £6.8million in crime and
£13.2million in employee absenteeism.107
Marketing
Throughout Europe there are significant variations in
individual state’s legislation regarding the advertising of
alcohol, from Norway’s complete ban through to the
adoption of the WHO guidelines as a voluntary code.
The EU Audiovisual Media Directive (2007) is enforced
throughout all EU member states. There is a wealth of
contradictory evidence regarding the impact of
advertising on drinking habits in the population at large
and young people in specific. However, ELSA108
concluded that
‘Alcohol advertisements are related to positive attitudes and beliefs
about alcohol amongst young people, and increase the likelihood of
young people starting to drink, the amount they drink, and the amount
they drink on any one occasion.’
If we assume that there is limited appetite to raise taxation
as a method for controlling consumption then pricing of
alcohol to stem consumption is an alternative method.
The debate over minimum pricing per unit is very much
alive in the UK, but the UK government has up until now
rejected this proposal. We very much support the NICE
recommendation of introducing a minimum price of 40p
per unit.
This view is strongly supported by the WHO.
The UK operates a voluntary, self-regulatory code with
no legal limitations in force.109 This contrasts with a
number of countries in Europe where self-regulation is
supported by legislation. In comparison with these
selected countries the UK is the only country with no
statutes in relation to the prohibition of the marketing of
alcohol. The UK does operate a system of penalties for
violation of advertising and marketing codes, but the
rigorousness of how these are pursued is open to debate
and sanctions are less stringent than other countries.
Recommendation
A minimum price of 40p per unit should be
introduced for all alcohol sales.
A further problem with alcohol pricing is that it is often
cheaper to buy alcohol in larger quantities. For instance,
standard sized bottles of wine in the supermarket are
much cheaper than the small bottles designed for one
person, and when eating out it is often cheaper to buy the
whole bottle than several glasses.
Recommendation
Wine should be made available in both shops and
restaurants in sizes that can be drunk by two people whilst remaining within the low-risk limits.
We suggest that half bottles be encouraged.
106.
107.
108.
109.
NICE (2010): Alcohol-use disorders: preventing the development of hazardous and harmful drinking (PH24). NICE. London.
NICE (2010): Implementing NICE guidance: Costing Report, Alcohol-use disorders: preventing harmful drinking. NICE. London.
STAP (2007): Alcohol marketing in Europe: strengthening regulation to protect young people. Utrecht: National Foundation for Alcohol Prevention.
CAP Code September 2010 - UK Committee of Advertising Practice
41
From one to many: The risks of frequent excessive drinking
9 International
comparisons
Comparison of European regulations on advertising
Advertising
to children
Location/
time
Media
channel
Sanctions
France
S
S
S
S
Italy
S
S
S
S
Norway
S
S
S
S
Finland
S
S
S
S
Germany
S
S
S
S
Spain
S
S
S
S
UK
NS
NS
NS
NS
Table 6: A comparison of European regulations on advertising. Data taken from STAP (2007).110
After Norway, France is considered to have the strictest
rules within the EU; the Loi Evin (1991)111 law places a
ban on advertising alcohol on TV and in cinemas and,
more interestingly in the light of UK law, places an
absolute ban on the drinks industry sponsoring sporting
or cultural events. Thus the Heineken Cup is called the
H Cup in France. In common with many European
countries there is a ban on advertising to children.
Significantly alcohol can only be advertised by product
with no associated lifestyle implications as is commonly
seen in the UK. The Loi Evin has successfully withstood
a number of challenges within Europe and has been
supported by the EU judiciary.
In Italy a voluntary code exits with regard to the content
of adverts but there are legal restrictions in place with
regard to certain forms of advertising112 such as a
restriction on advertising of alcohol between the hours of
4pm and 9pm, any form of media advertising to minors
in particular advertising within 15 minutes of children’s
programmes on TV. Bill boards advertising alcohol are
not permitted near schools. Recent debate in Italy appears
to be veering on the side of stricter rules and regulations,
but a strong drinks lobby retains some influence.
In general the UK is perceived as lax as with regard to
advertising when compared to other European countries
and has been criticised for ignoring other national media
rules when transmitting abroad.
In Finland the law specifically prohibits targeting minors
and restricts the content of adverts in much the same way
as the UK voluntary code. In addition, advertising must
not promote the idea that alcohol is refreshing. The
proposals to implement a ‘Loi Evin’ law in Finland have
not been pursued but stricter rules governing advertising
are likely to be imposed.
Recommendation
Statutory regulation on advertising should be
brought in line with other European countries,
following WHO recommendations.
110. STAP (2007): Regulation of Alcohol Marketing in Europe Utrecht: National Foundation for Alcohol Prevention.
111. Loi Evin no 91-32 du 10 Janvier 1991
112. Law/125 2001 Alcohol Act Alcohol Policies in EU member States and Norway 2001
42
subject and the content. Ofsted’s assessment of the
education in schools on the dangers of alcohol recognises
this as a gap within the UK’s educational system. The
danger is that there is a focus on binge drinking rather
than an informed approach towards drinking generally.
Education and intervention strategies
The WHO identifies that, as part of any successful
national strategy, education and public health information
are key components for success. Governments must have
access to high quality information on trends and outcomes
to inform the public of the hazards of excessive alcohol
consumption and actions and strategies that can reduce
intake.
National public health campaigns have been seen to be
successful in the past especially with regard to drink
driving, although national campaigns are thought to have
limited effect and more localised interventions are
recommended. The focus has been on developing
interventions for those who already have a problem and
throughout Europe the implementation of Brief
Interventions for those who are identified as harmful
drinkers is the direction of travel. Given the UK’s
propensity to drink there would appear to be the need for
improved education, coupled with a more hard hitting
national campaign to deliver the messages on the harmful
effects of alcohol.
Throughout Europe attitudes to drinking are largely
defined by parents and the informal education received
at home. While a number of countries advise against
children under 18 being given alcohol there is a belief that
a sensible introduction to alcohol reduces abuse. There is
no evidence that we know of to support this belief.
Some European countries such as Norway, Italy and
France include the impact of harmful alcohol
consumption within educational programmes for children
and adolescents. The UK has through PHSE a formal
mechanism for education in schools; however it is left to
individual head teachers to determine time spent on the
Figure 9: Number of units contained needs to be displayed clearly on all alcoholic drinks.
43
From one to many: The risks of frequent excessive drinking
10 Conclusion
There is widespread misunderstanding about the harm
caused by alcohol in our society. Many people do not
realise the harms of alcohol consumption or understand
the guidance given by the Department of Health. For too
long there has been a focus on binge drinking, drunkenness
and alcohol addiction allowing those who drink but do not
fit into these categories to continue drinking at high levels
without any understanding of the consequences.
A second area where changes should be made to influence
population-wide drinking are with regard to advertising.
Our regulation of alcohol advertising in this country is
very relaxed compared to the rest of Europe. This liberal
attitude should not be tolerated as alcohol-related disease
spirals upwards. We do not believe that this area can be
addressed by voluntary agreements, and urge further
statutory regulation.
There is an urgent need to simplify the messages with
respect to alcohol consumption. It needs to be understood
that when we are talking about liver disease, cancer, and
many other alcohol-related conditions the alcohol harm is
simply related to the quantity drunk – there is no safe limit!
In this report we have focussed on all those who are
drinking over the limits, but who are not binge drinkers or
alcohol addicted. There is an urgent need to communicate
the risks associated with this level of drinking, and the
message that daily drinking is not encouraged. Given the
high cost of health conditions associated with risky
drinking, this is both a health and economic problem and
to tackle it will save the NHS money.
At an individual level there is a need for better alcohol
screening by GPs and other professionals and provision
of assistance to reduce drinking. QOF indicators are
needed to encourage screening of newly registered
patients and targeted screening of those presenting with
alcohol-associated health conditions. In addition we have
suggested that a technology approach could greatly ease
the burden on GPs of patient identification. A universal
alcohol assessment should be carried out at age 30, via the
internet or email, in such a way that the result can be
imported directly into GP records. This universal alcohol
assessment, together with the incorporation of alcohol
screening in other NHS health checks would allow regular
screening of the entire registered population. This would
make it easy for the need for interventions to be identified,
and thus the provision of Brief Interventions in the
community.
In order to reduce drinking we need to try to shift the
incentives, from those which encourage drinking to those
which discourage drinking at high levels. The recent
House of Lords Science and Technology Select
Committee report on Behaviour Change,113 concludes that
there is a need for a range of approaches when trying to
change population behaviour, from education and nudges
to regulatory approaches. In this report we have looked at
the options for intervention across these different levels.
Through our research we have seen a variety of
mechanisms to try to increase the provision of Brief
Interventions in primary care. These appear to have been
most successful when a service is provided in the
community across the local area e.g. the web-based service
in Kingston, or health trainers in Bolton. This allows
individual GP practices to refer into these services and
thus lifts the burden of provision of Brief Interventions at
a practice level. Public health should continue to design
and promote these services, taking responsibility for
delivery of alcohol services across all levels of need.
Behaviour change can be focussed either at the population
level or the individual level. Here we have predominantly
focussed on individual behaviour change through Brief
Interventions but we have also considered a range of
population-wide measures. Two areas which stood out as
key areas of need were education and advertising. A large
proportion of the population do not understand the
harms caused by their level of drinking. There is
confusion about units and alcohol strength and a need for
much clearer public information to enable people to make
informed choices.
The current reorganisation of the NHS and Public
Health is an opportunity to renew the focus on services
for ‘risky drinkers’. As we move forward into the new
system and healthcare practitioners begin working
together in new ways it is important to ensure that there
is alignment of vision and focus on the services needed,
and a clear understanding of responsibility. This is an area
where the new health and wellbeing boards will be of
utmost importance, allowing joint working between local
council, public health and local clinicians to develop a
range of services in response to local needs.
113. House of Lords Science and Technology Committee (2011): 2nd Report of Session 2010–12: Behaviour Change. House of Lords. London.-
44
From one to many: The risks of frequent excessive drinking
11 Bibliography
Alcohol IBA e-Learning course. Available at:
http://www.alcohollearningcentre.org.uk/eLearning/IB
A/. Accessed 21 June 2011.
Cabinet Office, Prime Ministers Strategy Unit (2004)
Alcohol Harm Reduction Strategy for England. Cabinet
Office. London.
Alston JM, Fuller KB, Lapsley JT, Soleas G, and Tumber
KP (2011): Splendide Mendax: False Label Claims about
High and Rising Alcohol Content of Wine. Available at:
http://purl.umn.edu/103845
Cheeta, S., Drummond, C., Oyefeso, A., et al. (2008) Low
identification of alcohol use disorders in general practice
in England. Addiction, 103, 766–773.
Chenery V (2011): Adult Dental Health Survey 2009 –
England Key Findings. The NHS Information Centre.
Leeds.
American Academy of Neurology (2008): Alzheimer’s
starts earlier for heavy drinkers, smokers. Press release, 16
April 2008. American Academy of Neurology. Chicago.
Corrao G, Bagnardi V, Zambon A, La Vecchia C. (2004):
A meta-analysis of alcohol consumption and the risk of
15 diseases. Prev Med. 38(5):613-9.
Anderson P and Baumberg B (2006): Alcohol in Europe:
A Public Health Perspective. Institute of Alcohol Studies.
London.
Deluca, P (2010) Survey finds only 15% of emergency
departments have formal alcohol intervention and
treatment policies for trauma patients Evidence Based
Nursing Vol.3 No.4
Association of Public Health Observatories (2011): Health
Profiles 2011. APHO. Available at: http://www.apho.
org.uk/default.aspx?RID=49802 Accessed 13th July.
DH (2010): Invisible patients: Report of the Working
Group on the health of health professionals. Department
of Health. London.
Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG
(2001): The Alcohol Use Disorders Identification Test
Guidelines for Use in Primary Care. Second Edition.
WHO. Geneva.
DH (2011): Changing Behaviour, Improving Outcomes:
A new social marketing strategy for public health.
Department of Health. London.
Babor T, Caetano R, Casswell S et al. (2003): Alcohol: No
ordinary commodity: Research and public health. Oxford
University Press/World Health Organisation. Oxford.
DH (2011): Dental Quality and Outcomes Framework.
Department of Health. London.
Bellis MA, Hughes K, Cook PA, Morleo M (2009): Off
Measure: How we underestimate the amount we drink.
Alcohol Concern. London.
DH (2011): The Primary Medical Services (Directed
Enhanced Services) (England) (Amendment) Directions
2011. Department of Health. London.
Bennetts R (2008): Trends in the Affordability of Alcohol
in Europe. Institute of Alcohol Studies.
DH/National Treatment Agency for Substance Misuse
(2006): Models of Care for Alcohol Misusers (MoCAM).
Department of Health. London.
Birch D, Ashton H, Kamali F (1998): Alcohol, drinking,
illicit drug use and stress in junior house officers in northeast England. Lancet 1998; 352: 785-6.
Dhital R, Whittlesea CM, Norman IJ, Milligan P.
Community pharmacy service users' views and
perceptions of alcohol screening and brief intervention.
Drug Alcohol Rev 2010;29;596–602
Brandish E, Sheron N (2010): Drinking patterns and the
risk of serious liver disease. Expert Rev Gastroenterol
Hepatol. 2010 Jun;4(3):249-52.
British Medical Association Board of Science (2008):
Alcohol misuse: tackling the UK epidemic. British
Medical Association. London.
Drummond et al. (2005): Alcohol Needs Assessment
Research Project (ANARP): The 2004 national alcohol
needs assessment for England. Department of Health.
London.
Cabinet Office (2003): Alcohol misuse: how much does it
cost?. Cabinet Office. London
45
From one to many: The risks of frequent excessive drinking
11 Bibliography
Dunstan S (2011): General Lifestyle Survey Overview: A
report on the 2009 General Lifestyle Survey. ONS.
Newport.
Lock C, Wilson G, Kaner E, Cassidy P, Christie MM,
Heather N (2010): A survey of GPs’ knowledge, attitudes
and practices on alcohol interventions. AERC. London.
Firth-Cozens J (1998): Individual and organisational
predictors of depression in general practitioners. British
Journal of General Practice 1998; 48: 1647-51.
Mathers C, Boerma T, Ma Fat D (2008): The global
burden of disease, 2004 update. World Health
Organisation. Geneva.
Gupta S & Warner J (2008): Alcohol-related dementia: a
21st century silent epidemic, British Journal Psychiatry,
193:351–353
McAuley A, Goodall CA, Ogden GR, Shepherd S and
Cruikshank K (2011): Delivering alcohol screening and
alcohol brief interventions within general dental practice:
rationale and overview of the evidence. British Dental
Journal 210, E15
Hatton, J, Burton, A, Nash, H, Munn, E, Burgoyne, L and
Sheron, N (2009): Drinking patterns, dependency and lifetime drinking history in alcohol-related liver disease.
Addiction, 104: 587–592.
McManus, S., Meltzer, H., Brugha, T., et al. (2009) Adult
Psychiatric Morbidity in England, 2007: Results of a
Household Survey. NHS Information Centre for Health
and Social Care. Leeds.
House of Lords Science and Technology Committee
(2011): 2nd Report of Session 2010–12: Behaviour
Change. House of Lords. London.
Morleo M, Carlin H, Spalding J, Cook PA, Burrows M,
Tocque K, Perkins C, Bellis MA (2010): Attitudes towards
alcohol: segmentation series report 1. NWPHO.
Liverpool.
Kaner EFS, Dickinson HO, Beyer F, Pienaar E, Campbell
F, Schlesinger C, Heather N, Saunders J, Burnand B
(2007): Effectiveness of brief alcohol interventions in
primary care populations. Cochrane Database of
Systematic Reviews 2007, Issue 2. Art. No.: CD004148.
Morleo M, Phillips-Howard P, Cook PA, Bellis MA
(2008):North West Alcohol Information Fact Sheet 1: Fact
Sheet 1: Tolerance and Perceptions of Drinking. LJMU.
Liverpool.
Key J, Hodgson S, Omar RZ, Jensen TK, Thompson SG,
Boobis AR, et al. (2006): Meta-analysis of studies of
alcohol and breast cancer with consideration of the
methodological issues. Cancer Causes Control 2006
Aug;17(6):759-70.
NAO (2008): Reducing Alcohol Harm: health services in
England for alcohol misuse. The Stationery Office.
London.
National Health and Medical Research Council (2009):
Australian Guidelines to reduce health risks from
Drinking Alcohol. NHMRC. Canberra.
Khadjesari Z, Murray E, Hewitt C, Hartley S, Godfrey
C (2010): Can stand-alone computer-based interventions
reduce alcohol consumption? A systematic review.
Addiction, 106, 267–282
NHS Choices. Available at: http://www.nhs.uk/
Livewell/alcohol/Pages/Effectsofalcohol.aspx Accessed
22/6/11.
King D, Mainous A, Geesey M (2008): Adopting
moderate alcohol consumption in middle age: subsequent
cardiovascular events. Am J Med. 121(3):201-6.
NICE (2010): Alcohol-use disorders: preventing the
development of hazardous and harmful drinking (PH24).
NICE. London.
Koski A, Sirén R, Vuori E, Poikolainen K (2007): Alcohol
tax cut and the increase in alcohol- positive sudden deaths:
a time series analysis. Addiction. 2007 Mar;102(3):362-8.
Lewis S (2011): Alcohol causes 7 per cent of hospital
admissions. HSJ 24 February, 2011.
NICE (2010): Implementing NICE guidance: Costing
Report, Alcohol-use disorders: preventing harmful
drinking. NICE. London.
Lister G (2007): Evaluating social marketing for healththe need for consensus. Proceedings of the National Social
Marketing Centre. London.
NICE (2011):Alcohol-use disorders: Diagnosis, assessment
and management of harmful drinking and alcohol
dependence (CG115). NICE. London.
46
NICE (2011): Quality and Productivity Case Study:
Alcohol Care Teams. NICE. London. Available at:
http://arms.evidence.nhs.uk/resources/qipp/29420/atta
chment. Accessed 22/06/11
Rolfe A, Orford J and Martin O. (2009): Birmingham
Untreated Heavy Drinkers Project Final Report.
Collaborative Group for the study of Alcohol, Drugs,
Gambling & Addiction in Clinical and Community
Settings, School of Psychology, University of Birmingham
& Birmingham & Solihull Mental Health NHS
Foundation Trust.
NICE (2011): Unconfirmed minutes of the 9th June 2011
QOF Indicator Advisory Committee. Available at:
http://www.nice.org.uk/aboutnice/qof/PrimaryCareQ
OFIndicatorAdvisoryCommittee.jsp Accessed 3.8.11.
Schütze M et al. (2011): Alcohol attributable burden of
incidence of cancer in eight European countries based on
results from prospective cohort study. BMJ. 2011 Apr
7;342:d1584.
Office for National Statistics website http://www.statistics.
gov.uk/CCI/nugget.asp?ID=8 Accessed 4 Aug 2011.
Ofsted (2010): Personal, social, health and economic
education in schools. Ofsted. Manchester.
Sheron N, Hawkey C, Gilmore I (2011): Projections of
alcohol deaths--a wake-up call. Lancet. 2011 Apr
16;377(9774):1297-9.
Österberg E L (2011): Alcohol tax changes and the use of
alcohol in Europe. Drug and Alcohol Review, 30: 124–129.
Smith DM, Atkinson RM (1995): Alcoholism and
dementia. Int J Addict 1995; 30: 1843–69.
Pastore L, Fiorella ML, Fiorella R, Lo Muzio L (2008)
Multiple Masses on the Tongue of a Patient with
Generalized Mucocutaneous Lesions. PLoS Med 5(11):
e212. doi:10.1371/journal.pmed.0050212
STAP (2007): Alcohol marketing in Europe: strengthening
regulation to protect young people. Utrecht: National
Foundation for Alcohol Prevention.
Prime Minister’s Strategy Unit (2003): Strategy Unit
Alcohol Harm Reduction Project: Interim Analytical
Report. Cabinet Office. London.
STAP (2007): Regulation of Alcohol Marketing in Europe
Utrecht: National Foundation for Alcohol Prevention.
The NHS Confederation (2010): Too much of the hard
stuff: what alcohol costs the NHS. The NHS
Confederation. London.
Proude E, Lopatko O, Lintzeris N, Haber P (2009): The
Treatment of Alcohol Problems A Review of the
Evidence. Australian Government Department of Health
and Ageing. Ch10.
The NHS Information Centre (2011): Statistics on
Alcohol, England 2011. The NHS Information Centre.
Leeds.
Purshouse R, Brennan A, Latimer N, Meng Y, Rafia R,
Jackson R, Meier P (2009): Modelling to assess the
effectiveness and cost-effectiveness of public health
related strategies and interventions to reduce alcohol
attributable harm in England using the Sheffield Alcohol
Policy Model version 2.0 Report to the NICE Public
Health Programme Development Group. University of
Sheffield. Sheffield.
Tramacere I, Negri E, Bagnardi V, Garavello W, Rota M,
Scotti L, Islami F, Corrao G, Boffetta P, La Vecchia C
(2010): A meta-analysis of alcohol drinking and oral and
pharyngeal cancers. Part 1: overall results and dose-risk
relation. Oral Oncol. 2010 Jul;46(7):497-503. Epub 2010
May 4.
Rehm J, Zatonksi W, Taylor B, Anderson P (2011):
Epidemiology and alcohol policy in Europe. Addiction,
106 (Suppl. 1), 11–19
Tully MP, Temple B (1999): The demographics of
pharmacy's clientele - A descriptive study of the British
general public. International Journal of Pharmacy
Practice 7 (3), 172-181.
Robinson S, Harris H (2011): Smoking and drinking
among adults, 2009: A report on the 2009 General
Lifestyle Survey. Office for National Statistics. Newport.
Watson M, Blenkinsopp A, Harrison A, Neilson E (2008)
Community pharmacy and alcohol-misuse services: a
review of policy and practice. Royal Pharmaceutical
Society of Great Britain. London.
47
From one to many: The risks of frequent excessive drinking
11 Bibliography
Wilkins D, Payne S, Granville G, Branney P (2008):The
Gender and Access to Health Services Study. Department
of Health. London.
World Health Organisation (1992) The ICD–10:
Classification of Mental and Behavioural Disorders:
Clinical Descriptions and Diagnostic Guidelines. WHO.
Geneva.
World Health Organisation (2004): WHO Global Status
Report on Alcohol 2004. WHO. Geneva.
World Health Organisation (2010) European status report
on alcohol and health 2010. World Health Organization.
Geneva.
World Health Organisation (2011) Alcohol Control
Database. Available at: http://data.euro.who.int/
alcohol/ Accessed 02.08.11
World Health Organisation: Lexicon of alcohol and drug
terms.http://www.who.int/substance_abuse/terminology
/who_lexicon/en/
48
From one to many: The risks of frequent excessive drinking
Appendix 1:
The AUDIT Test
The AUDIT questionnaire.114 A score of 8 or above indicates risky drinking.
114. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG (2001): The Alcohol Use Disorders Identification Test Guidelines for Use in Primary
Care. Second Edition. WHO. Geneva.
49
From one to many: The risks of frequent excessive drinking
Appendix 2:
Glossary
Brief Intervention
Higher risk drinking
A treatment strategy in which structured therapy of short
duration (typically 5-30 minutes) is offered with the aim
of assisting an individual to cease or reduce the use of a
psychoactive substance or (less commonly) to deal with
other life issues. It is designed in particular for general
practitioners and other primary health care workers. To
date, brief intervention-sometimes known as minimal
intervention-has been applied mainly to cessation of
smoking and as therapy for harmful use of alcohol.115
If you’re in this group, you’re at an even higher risk of
damaging your health compared to increasing risk
drinkers.
Higher risk drinking is:
•
regularly drinking more than 8 units a day, or more
than 50 units a week if you're a man
•
regularly drinking more than 6 units a day, or more
than 35 units a week if you're a woman118
Dependence
A cluster of behavioural, cognitive, and physiological
phenomena that develop after repeated substance use and
that typically include a strong desire to take the drug,
difficulties in controlling its use, persisting in its use despite
harmful consequences, a higher priority given to drug use
than to other activities and obligations, increased
tolerance, and sometimes a physical withdrawal state.116
Increasing risk drinking
Drinking at this level increases the risk of damaging your
health. Alcohol affects all parts and systems of the body,
and it can play a role in numerous medical conditions.
Increasing-risk drinking is:
•
drinking more than 3-4 units a day on a regular
basis if you're a man
•
drinking more than 2-3 units a day on a regular
basis if you're a woman119
Harmful drinking
A pattern of psychoactive substance use that is causing
damage to health. The damage may be physical (e.g.
hepatitis) or mental (e.g. depressive episodes secondary to
heavy alcohol intake).117
Lower risk drinking
Hazardous drinking
Lower-risk drinking means that you have a low risk of
causing yourself future harm.
A pattern of drinking that increases the risk of harmful
consequences for the user. In contrast to harmful use,
hazardous use refers to patters of use that are of public
health significance despite the absence of any current
disorder in the individual user. The term is used currently
by WHO but is not a diagnostic term in ICD-I0.
However, drinking consistently within these limits is called
'lower-risk', rather than 'safe', because drinking alcohol is
never completely safe.
NHS recommendations for lower risk drinking state that:
•
men should not exceed 3-4 units a day
on a regular basis
•
women should not exceed 2-3 units a day
on a regular basis120
115. World Health Organisation: Lexicon of alcohol and drug terms. http://www.who.int/substance_abuse/terminology/who_lexicon/en/
116. World Health Organisation: Lexicon of alcohol and drug terms. http://www.who.int/substance_abuse/terminology/who_lexicon/en/
117. World Health Organisation (1992) The ICD–10: Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic
Guidelines. WHO. Geneva.
118. NHS Choices. Available at: http://www.nhs.uk/Livewell/alcohol/Pages/Effectsofalcohol.aspx Accessed 22/6/11.
119. NHS Choices. Ibid.
120. NHS Choices. Available at: http://www.nhs.uk/Livewell/alcohol/Pages/Effectsofalcohol.aspx Accessed 22/6/11.
50
From one to many: The risks of frequent excessive drinking
Appendix 3:
Project participants
Steering group members
Roundtable participants
Julia Manning
Simon Britten
Dr Jonathan Shapiro
Dr Carsten Grimm
Ranjita Dhital
Dr Lynn Owens
Dr Jamie Dalrymple
Chris Sorek
Gail Beer
Dr Eleanor Winpenny
Andy Hockey
Nisha Tailor
2020health (Chair)
Retired psychiatrist and dual
diagnosis specialist
Senior Lecturer,
University of Birmingham
RCGP Alcohol Lead
Specialist Pharmacist, King's
College London
Nurse Consultant, University
of Liverpool
GP and Chair of Primary Care
Society for Gastroenterology
Chief Executive, Drinkaware
2020health
2020health
Lundbeck
Munro & Forster
Fiona Bruce MP
Baroness Berridge
Lucy Batten
Martyn Penfold
Alison Rogers
Adrian Brown
Baroness Hayter
Tracey Crouch MP
Dr Michael Glynn
List of Interviewees
Dr Elizabeth Murray
Phil Ramsell
Jeff Fernandez
Prof Robin Touquet
Dr Kieran Moriarty
Professor Saman
Warnakulasuriya
Dr Roger Matthews
Dr Tom Smith
Prof Eileen Kaner
Prof Janet Krska
Dr Nick Sheron
Prof Jonathan Chick
Prof Woody Caan
Director, e-Health Unit,
University College London
Senior Health Promotion
Specialist, NHS Bolton
Alcohol Nurse Specialist,
Primary Care Drug and
Alcohol Service, NHS Islington
Consultant in A&E medicine,
Paddington
Consultant Gastroenterologist,
Royal Bolton Hospital
Professor of Oral Medicine
& Experimental
Oral Pathology
Chief Dental Officer, Denplan
Chief Executive, BSG
Director, Institute of Health
and Society, Liverpool
University
Reader in Medicines and
Health, UCLAN
Clinical Senior Lecturer,
University of Southampton
Consultant Psychiatrist,
Spire Murrayfield Hospital,
Edinburgh
Professor of Public Health,
Anglia Ruskin University
Andy Hockey
James Holloway
Julia Manning
Gail Beer
Dr Eleanor Winpenny
51
Congleton Constituency
House of Lords
Policy Officer, Royal College
of Physicians
Alcohol Strategy Coordinator,
NHS Wandsworth
Special Advisor,
British Liver Trust
Team Leader - Alcohol &
Drug Liaison, St George's
Healthcare NHS Trust
Chair, APPG on
Alcohol Misuse
Vice-Chair, APPG
on Alcohol Misuse
Consultant in
Gastroenterology,
Barts and The London
NHS Trust
Public Affairs Manager,
Lundbeck
Associate Director,
Munro & Forster
Chief Executive, 2020health
Consultant Director,
2020health
Researcher, 2020health
“ If the government was to heed this report which might almost be re-named "one too many"
- with its emphasis on education, statutory
regulation of advertising and increased
availability of Brief Interventions, we might see a
significant impact on the harm caused by
excessive drinking, thus benefitting both
individuals and the wider society. Please read it
Mr Lansley.”
Baroness Hayter,
Chair, All Party Parliamentary Group
on Alcohol Misuse
“As the incidence of oral cancer in the UK is
rising, this report highlights the significant role of
the general dental practitioner in assessing
alcohol misuse and screening for oral cancer.
It should be read by all members of the primary
dental care team.”
Russ Ladwa, Dean,
Faculty of General Dental Practice (UK)
“GPs are well aware of the problems alcohol
abuse can cause. We see the long term damage
to individuals and their families probably more
than any other group of healthcare professionals
in the UK. I hope this guidance will help GPs and
their patients make informed decisions that will
prevent serious ill health in the future.”
Dr Clare Gerada, Chair, RCGP
2020health.org
83 Victoria Street
London SW1H 0HW
Published October 2011 by
2020health.org
© 2011 2020health.org
T 020 3170 7702
E [email protected]
Price £10
“Alcohol Concern supports this report. There is
so much to be gained from achieving a healthier
relationship with alcohol, both for individual
health and the economy as a whole. Simple
measures such as smaller servings and lower
strength products would go a long way to
ensure those who enjoy a drink can do so
without suffering the adverse consequences of
unwittingly overdoing it. At a time of an economic
downturn we more than ever need a healthy
population and reduced costs to society.”
Don Shenker,
Chief Executive, Alcohol Concern
“This report is a helpful contribution on the issue
of brief interventions and alcohol risk.”
John Middleton,
Vice President, UK Faculty of Public Health
“ This report from 2020health provides an
excellent overview of the health harms
associated with alcohol consumption, which
affect the 20% of our adult population who are
risky drinkers. Individuals need to be aware of
the risks associated with their alcohol
consumption so that they can make informed
choices about their drinking levels. It is
important that NHS services are available to
support those drinking at high levels who wish
to reduce their drinking.”
Tracey Crouch MP, Vice-Chair,
All Party Parliamentary Group
on Alcohol Misuse
ISBN: 978-1-907635-16-8