TACKLING ALCOHOL TOGETHER

Alcohol is our favourite drug. Within the United Kingdom and in many other countries throughout the world, alcohol is used to facilitate social interactions and change the way we feel. Nevertheless, most of us also recognise that alcohol can result in a wide range of harmful consequences. This summary of the book "Tackling Alcohol Together" will provide policy makers and commissioners with information on the extent of the harm as well as an evidence base for each of the following topics.

• Levels of consumption and harm for diverse groups
• Intoxication in social and environmental contexts
• Harm to the individual and the population
• The influence of price on consumption
• Mass media and school based alcohol education
• Regulations relating to alcohol
• Generalist treatments and specialist treatments
• Training professionals

Finally an evidence based policy mix will be outlined which could form the basis of an alcohol strategy.

Why do we need to tackle alcohol?

The excessive or inappropriate consumption of alcohol is a massive social and public health problem. The following statements, which are evidence-based and incontrovertible, should make it clear why we need a national alcohol policy.

The misuse of alcohol has a high prevalence in the UK

35% of male and 21 % of female single persons drink in excess of sensible limits - corresponding figures for married men and women are 24% and 13%. Consumption is rising in women across all age groups and in young men. Six per cent of men and 2% of women drink at harmful levels.

On a typical day, some 10,000 individuals seek help for their own or someone else's drinking problem.

 The misuse of alcohol leads to a wide variety of very distressing consequences

It has been estimated that 60% of para-suicides, 30% of divorces, 40% of domestic violence and 20% of child abuse cases are associated with alcohol misuse. About one third of all domestic accidents are alcohol related.

In the UK up to 40,000 deaths per year are alcohol related.

There are cost effective prevention and treatment policies which could ameliorate the harm caused by alcohol without seriously reducing the social benefits.

Alcohol-related problems must be addressed at the broad population and community level. Policies which focus only upon the heaviest drinkers are unlikely to succeed.

Alcohol-related harm is responsive to price and availability, legal sanctions, interventions at the primary care level as well as specialist treatments.

The policy makers dilemma

All policy making has to balance the benefits and the costs involved when seeking to change the behaviour of individuals, organisations and communities.

There are a range of diverse conflicting values, beliefs and vested interests, which make the policy maker's task a difficult one. Policy-making must be evidence-based if it is to be persuasive.

Why a national policy?

Prior to the Green Paper on Our Healthier Nation no UK government had deemed it necessary to propose a national alcohol policy whereas, and in sharp contrast, the need for a national drugs strategy has long been accepted. Tackling Drugs Together has been welcomed mainly because this policy clarifies the roles of different organisations and agencies. It sets out a framework for shared agendas with collaborative action and clear objectives. In the interest of the public good this is exactly what is needed to deal with the harmful effects of alcohol on our society.

A national policy should take account of conflicting vested interests but emphasise the following rights as enshrined in the European Charter on Alcohol published in 1995:

• All people have the right to a family, community and working life protected from accidents, violence and other negative consequences of alcohol consumption.

• All people have the right to valid impartial information and education, starting early in life, on the consequences of alcohol consumption on health, the family and society.

• All children and adolescents have the right to grow up in an environment protected from the negative consequences of alcohol consumption and, to the greatest extent possible, from the promotion of alcoholic beverages.

• All people with hazardous or harmful alcohol consumption and members of their families have the right to accessible treatment and care.

Influencing communities

Policy-making, in this area, is a balancing act with the public good as its guiding principle. Balancing risks and benefits is a task for the whole community.

The prevention paradox

The amount of alcohol related harm within a society, associated with a particular level of consumption, is a product of both the risk and the number of people drinking at that level. Paradoxically this means that moderate levels of risk can result in greater harm because more people are drinking at these levels. An analogy might help. Formula one racing is much more dangerous than driving along the local high street, but, in terms of total number of deaths within the UK the high streets are more deadly simply because more traffic is involved.

This paradox has important policy implications. The aim is not simply to reduce the number of heavy drinkers within the UK, but to reduce levels in the very large number of people who would be called moderate drinkers.

A broad community focus

Alcohol related problems in a community can be viewed from the following main perspectives:

• Levels and patterns of consumption vary across age, gender and subcultures. An evidence-based policy can ameliorate excessive drinking across these different groups.

• Sales and production refers to marketing strategies as well as the number of outlets such as public houses, off licences, supermarkets, corner shops and includes home production as well as illicit supplies of alcohol.

• Formal controls covers national legislation along with bye laws and the degree to which these are enforced within a community - in other words constraints upon the availability of alcohol.

• Social norms refer to the influence of a culture or sub-culture that is either supportive of drinking or antagonistic.

• Legal sanctions cover the laws that proscribe the use of alcohol in specific situations, for example, legislation against drinking and driving, public drunkenness, childcare and so on.

• Social, economic and health consequences must be assessed in order to monitor the impact of alcohol and the well-being of a community

Policy makers need a clear picture of how these perspectives interact and how the whole system can be influenced. An understanding of the dynamic nature of a community, whether at a national or local level, leads to a broad collaboration between government departments, and between diverse organisations and agencies.

Alcohol consumption in diverse sub-groups

The consumption of alcohol is, for the majority of people, a normal and unremarkable part of their lives. Over 90% of men and 85% of women drink alcohol and many will experience no serious problems as a result.

The sensible limits recommended by the Royal Colleges of Physicians, Psychiatrists and General Practitioners are:

• 14 units of alcohol per week for women and 21 units for men.
• 1 unit = 1 glass of wine or 1 single spirits or half pint of beer.
• Drinking above these levels is hazardous.

Alcohol consumption in the general population

Records from Customs & Excise provide fairly good estimates of alcohol consumption for the last 300 years. When records began, drinking per head of population was far in excess of today's levels. In recent years there has been a steady increase in consumption from 1960 but this trend upward has now reached a plateau.

Data from the General Household Surveys indicate that:

• Since 1984 the proportion of men aged 18-24 who were exceedingm 21 units has fluctated but the most recent figures (1996) show the highest level at 41 %.

• In recent years the number of women drinking more than recommended sensible limits has increased The largest increase was among the youngest women (see Figure 1).

• Highest consumers are men in the North & NW of England as well as in Wales

Figure 1:  Per cent of women aged 18-24 drinking more than recommended sensible limit

Young people

Recent research has identified a changing pattern of consumption with young people now drinking considerably more alcohol on any one occasion.

Between 5 and 10% of both boys and girls aged 14-15 are drinking more than the recommended levels for adults.

Under-age consumption of alcohol is a precursor to smoking and the use of illicit drugs. The risk of smoking and drug use is particularly high in adolescents who report high levels of drunkenness.

Students

Students are vulnerable to excessive drinking because college bars sell low price drinks, peer groups support excessive drinking and students face unfamiliar academic and social pressures.

In a recent study of second-year university students from 10 UK universities, 61 % of men and 48% of women were exceeding 21 units for men and 14 units per week for women.

Homeless people

The 1994 National Survey of psychiatric morbidity among homeless people in Britain found that 44% of people using night shelters were alcohol dependent, as were 51 % of rough sleepers, using day shelters. Homeless people are often excluded from health and social care services which are available to those with secure accommodation.

Older people

General household surveys show an increasing proportion of older people (age 65+) drinking more than the recommended limits.

Unfortunately, problem drinking is often overlooked in older people because it does not accord with prevailing stereotypes.

People with psychiatric disorders

People suffering from a mental health problem are more likely than the rest of the population to experience alcohol related problems. The mental health problem usually occurs before the alcohol problem.

A study of London Alcohol Treatment Services found that over a 12 year period a consistent 30-40% received a psychiatric diagnosis in addition to that of alcohol dependence.

It has been estimated that in a population of 500,000 there will be nearly 6,000 problem drinkers with severe mental health problems.

People at work

The costs to industry of excessive or inappropriate alcohol consumption includes accidents, absenteeism, lost revenue, disciplinary problems and the cost of rehabilitation.

An indication of some of these costs is given below:-

The social costs of alcohol misuse to industry (England and Wales, 1992)

People in prison

Research on alcohol use among prisoners shows that at least 30% would be labelled problem drinkers.  Also between 30 and 60% claim to have offended whilst under the influence of alcohol.

Conclusions

• The evidence shows that there is nothing fixed or unchanging about drinking habits.

• The young and older people have increased levels of consumption in recent years

• The evidence-base for planning prevention and service delivery depends upon having regular, consistent surveys of drinking habits and alcohol-related problems.

Intoxication in social and environmental context

Continuous, excessive drinking can cause a wide range of health and social problems but so can just one instance of intoxication. In certain social and family settings intoxication is associated with aggression, abuse and criminal behaviour as well as disinhibited sexual activities. Within certain environmental contexts such as using complex machinery or driving a car, even slight intoxication can result in injuries and fatalities.

A blood alcohol concentration of 40mg% results in some impairment and can be achieved by a man consuming just one pint of beer (2 units).

The risk associated with each successive drink increases exponentially as shown in the following relationships between BAC and increased risk of a drink driving fatality (compared to non-drinking drivers).

The effect of alcohol intake on level of intoxication is influenced by so many factors that it is difficult to predict. This variability of response makes alcohol such a potentially dangerous drug.

• 25% of all road accident fatalities have blood alcohol levels greater than 80mg%.

• Over 30% of pedestrians sustaining injuries have blood alcohol levels over 80mg%.

• Alcohol is a significant factor in over half of teenagers sustaining a facial injury.

• In young people one third of deaths from drowning are alcohol related.

Alcohol and risky behaviour

Alcohol intoxication impairs rational judgement and releases behavioural inhibitions. It increases the probability of indulging in risky activities which violate social norms.

Studies have shown that:

• Homosexual men who increased their alcohol consumption were more likely to maintain high-risk sexual practices than those who reduced their drinking.
• Teenagers who regularly consume more than 5 drinks in a day were three times less likely than non-drinkers to use condoms.
• Problem drinking is associated with self reported sexually transmitted disease.
• 15% of young women and 22% of young men said that they were less likely to use condoms after drinking.

Intoxication and aggression

Intoxication is associated with violence. The reasons for this association are complex.

For example:

• Many licensed premises are still male preserves where boisterous and aggressive behaviour is tolerated.

• People who drink heavily or behave badly are likely to seek out these settings.

• Crowded environments increase the probability of aggressive interactions.

• Intoxicated onlookers may be less likely to intervene.

In short, the drinker, the setting, the bystanders and alcohol combine to create aggression.

Intoxication and family disharmony

Domestic violence and other dysfunctional behaviour within the family context is a significant problem. Marital strain due to drinking is a commonly reported problem and domestic violence is related to the frequency and amount of drinking by partners. Alcohol abuse by either or both partners can also indirectly contribute to domestic violence by exacerbating financial problems, child care difficulties and other family stressors.

Child abuse includes physical, emotional and social abuse. All of these forms of child abuse are associated with heavy drinking parents.

Conclusions

• Family disharmony and long term consequences for children are strongly related to problem drinking.

• There are sporting, social and work activities that are incompatible with drinking. There is public support for separating drinking and certain high risk activities such as driving or flying - this culture needs to spread to lower risk activities.

• Even slight intoxication can result in injuries and fatalities.

Individual and population level risks

The individual level of analysis permits an investigation of the risks associated with increased consumption for individuals. The population level of analysis explores differences in consumption patterns and alcohol related problems across populations and cultures.

Individual drinking level and overall mortality

Heavy alcohol consumption is associated with increased levels of cancer, hypertension, haemorrhagic stroke, cardiovascular disease and liver cirrhosis. In most industrialised countries the overall relationship between alcohol consumption and mortality from all causes is J-shaped for both sexes. In other words both total abstinence and heavier drinking are more likely to be associated with premature death than is light drinking.

The data suggest that light drinking may have a protective influence especially against coronary heart disease (CHD). The Royal Colleges of Physicians, Psychiatrists and General Practitioners have noted that risk begins to outweigh benefit when consumption is around 3 units per day for men and 2 units for women.

There are no substantial reductions in absolute risk associated with light drinking for groups where CHD is not an important cause of death such as men under 35 and premenopausal women. Some of the apparent health benefit of drinking is a statistical artefact and unguarded claims that "alcohol is good for the heart" can be misleading.

Above: Cirrhosis mortality per 100,000 population

The relationship between level of alcohol consumption and liver cirrhosis is a strong one. In the UK alcohol accounts for approximately 80% of all cirrhosis deaths. Women develop liver disease after a shorter time and with less exposure to alcohol than men.

Individual drinking level and adverse social consequences

Starting at low levels of intake there is a steadily increasing risk of harmful social consequences, such as assaults or family distress, as level of alcohol consumption increases. Moderate levels of consumption can result in greater population harm because more people are drinking at these levels.

Above:  Experience of two or more adverse consequencesfrom drinking. Alcohol consumption (drinks per day) and per cent subjects reporting two or more adverse consequences (Canadian National Survey Data, Source: Room et al 1994)

There is a relationship between the mean level of consumption within a population and the proportion of heavy drinkers within the population. An individuals risk of becoming a heavy drinker depends, to some extent, upon the "wetness" of the drinking culture to which the person belongs. The drinking habits of a person living in an environment where drinking is cheap, freely available and where heavier drinking is the norm, will be different from those of a person living in a relatively dry environment.

Populations with lower mean consumption levels tend to have lower proportions of heavy drinkers.

In the UK between 1979 and 1982 the mean consumption fell by 11% from 9.79 litres per year to 8.67 litres per year. This fall in consumption was followed by a 16% fall in drunkenness convictions, a 19% fall in. admissions to hospital for alcohol dependence, a 7% fall in drinking and driving convictions and a 4% fall in cirrhosis mortality.

This very general relationship between per capita consumption and alcohol related problems is of relevance when considering any national alcohol strategy because per capita consumption can be varied by measures available to government.

Conclusions

• Drinking increases the risk of accidents and social problems. Most of the evidence shows no definite threshold below which drinking is risk free.

• Per capita consumption is a measure of the "wetness" of a community or country. Government should monitor and seek to modify mean level of consumption when appropriate as a broad-brush approach to prevention.

• Most of the alcohol-related problems in a community are linked to the large numbers of people who drink moderately rather than the smaller numbers who are alcohol dependent.

The influence of price on consumption

The British people spend a considerable amount of money on alcohol each year: e.g. £28,006 million or £590 per adult - was spent in 1996. This corresponds to an expenditure of £77 million for every day of the year and £53,000 for every minute. Alcohol consumption accounts for 7.4% of total consumer expenditure. It is not surprising that trends in alcohol expenditure are influenced by its relative affordability.

Economic and other influences on consumption vary across beverages and therefore it is usual to disaggregate consumption into main beverage types.

Also the effects of price and income have different effects across different groups of the population. Drinking is a popular pastime among the young although income is often limited. Young adults are more price responsive than older groups and it has, therefore, been suggested that an increase in alcohol tax would have more impact on teenage drinking than raising the legal drinking age.

Price and income trends

The price of beverages relative to changes in income is usually presented as an affordability index. A fall in this index, which has occurred in the last 40 years, indicates that the price adjusted for income is falling, in other words alcohol is now more affordable. Wines, cider and perry as a group did become less affordable at the start of the period but are now more affordable than the average for all alcohol beverages. Spirits have changed the most significant falls, being 71 % more affordable in 1996 than in 1960. Beer has shown a variable pattern although still more affordable at the end of the period than at the beginning.

It may be easier to consider affordability in terms of the minutes required to earn the price of a typical product bearing in mind that thes figures will vary with group and gender income rates. Draft beer has become relatively less affordable since 1979 whereas whisky and wine are considerably more affordable.

Source: Centre for Health Economics Database

Taxation as a policy tool

There are two alternative views on how taxes should be set to control alcohol-related problems: to ensure that revenue covers the social costs of alcohol; or a more directional public health policy designed to minimise the harm of drinking both to the individual and the rest of society.

One way of comparing tax rates is to consider the tax in terms of alcohol content. The tax rates operational from January 1998 convert to the following sums per litre of pure alcohol:

• Beer (average strength) £11.14
• Table wine (11% alcohol) £13.15
• Wine (17% alcohol) £11.34
• Cider (4% alcohol) £6.1 2
• Cider (5% alcohol) £4.59
• Coolers (3%) £14.86
• Coolers (5%) £12.26
• Spirits £19.96

While the government is constrained by European law to treat beer and wine as like products the differential rates for other products is less clear cut. Average tax rates also hide considerable variation in the way different alcoholic beverages are treated. Beer and lager are taxed directly by alcohol content whereas wine, cider and coolers are subject to the same rate within quite a wide range of alcohol content.

Conclusions

• Alcohol behaves like any other commodity. As prices go up consumption comes down and vice versa.

• Heavy and alcohol-dependent drinkers are influenced as readily as light or moderate drinkers by price changes.

• Taxation is a policy tool that can reduce a large number of alcohol related problems across the board.

Mass media and school-based programmes

In a systematic content analysis of all evening programmes broadcast on British television over a 2-week period, references to alcohol occurred in approximately two-thirds of all prime time programmes. Furthermore, drinking was rarely associated with harmful effects. In another study drinking was mentioned or depicted, on average, every six and a half minutes.

The volume of references to drinking on television means that children are likely to witness several fictional representations of drinking each day. Moreover, alcohol advertising increases significantly during sports programmes and over holiday periods, like Christmas and New Year, when children are more likely to be watching. Young people are also more likely to watch popular music programmes where a high proportion of the videos shown depict band members consuming alcohol, usually in glamorous surroundings.

Alcohol advertising and vulnerable groups

Considerable care goes into the design of alcohol advertising in an attempt to associate positive social images with alcohol products. There is a risk, therefore, that such advertising promotes alcohol use, reinforces underage drinking, recruits young people as new drinkers, or leads them to experiment earlier than they might. There is some evidence to support each of these propositions.

Mass media campaigns

Health Education Authorities have made the use of mass media campaigns an important component of their programmes. Such campaigns are believed to be cost-effective because of their 'reach', that is the percentage of the target audience receiving the message.

Mass media campaigns are most effective when they support community action rather than operate in isolation. Drink-driving campaigns, for example, increase public awareness of alcohol-related road traff ic deaths and maximise support for prevention policies, such as lower blood alcohol levels, random breath testing or stricter enforcement of the law. Also, media campaigns can heighten the perceived risk of detection when drinking and driving, and raise awareness of the penalties incurred if convicted.

Although those evaluating mass media campaigns have found it difficult to demonstrate effectiveness in the short term, it is possible that the campaigns have influence in the longer term, through the cumulative impact of news stories, advertising and other mass communications. Thus, the cumulative effect of drink driving publicity over the last thirty years has reduced the social acceptability of drinking and driving.

School based alcohol education programmes

The evolution of alcohol education has involved three phases. The first group of studies focused upon information-basedapproaches designed to provide factual information about the effects of alcohol use and misuse. Such an approach, which prevailed in the early 1960s to early 1970s turned out to be at best ineffective and at worst detrimental.

The second phase (early 1970s and 1980s) involved personal development and typically focused upon stress-management, decision-making and clarification of values. In the third phase (early 1980s) the social influence model has predominated. This social approach covers resistance skills training as well as more comprehensive approaches that usually include other social and communication skills as well as decision-making and problem solving skills.

Based upon available evidence there is no school-based approach that can be supported as a major plank of a prevention policy. In the studies that report positive effects this is limited to sub-groups and generally involves very trivial levels of alcohol use.

Conclusions

• The positive portrayal of drinking in the mass media may influence the behaviour of children and vulnerable adults. The overall effect on consumption is marginal.

• Encouraging news programmes and documentaries to focus on alcohol-related problems and policy issues is an effective way of generating support for alcohol control policies.

• Although school based approaches are popular there is no strong evidence to support widespread adoption of such interventions.

Regulations relating to alcohol

Number and type of outlets

Research from the US has shown a relationship between the number of outlets and specific alcohol-related problems such as road accidents and assaults. In the UK a relationship was demonstrated between number of outlets and consumption, especially for wine but not for spirits. Also in the UK the rise in the number of outlets selling alcohol has

been accompanied by a growth in alcohol consumption. The number of outlets rose from 129,367 to 201,148 between 1960 and 1995, an increase of 55 percent. Over the same period the number of off-licence outlets alone almost doubled. Meanwhile, average alcohol consumption rose from 5.7 litres of pure alcohol per year for every person aged 15 and over in 1960 to a peak of 9.8 litres by 1979. Since this time average consumption has only once (1982) dropped below 9 litres per head.

It is unwise to ignore the links between number of outlets with a license, levels of consumption and adverse consequences.

Restrictions on purchasing times

Evidence from other countries concerning the effects of altering the hours during which alcohol can be sold demonstrates a significant positive relationship, with longer hours leading to increased problems and shorter hours being followed by a reduction in such problems. In the UK, recent licensing reforms have extended permitted hours. Unfortunately other changes, such as a recession and unemployment, were occurring at the same time making the available evidence difficult to interpret. Nevertheless, the evidence from other countries indicates that it would be wise to assume that extending licensing hours will result in more problems rather than fewer.

Children and young persons

Age restrictions on consumption play an important role in the prevention of alcohol-related problems. An Australian study found that overall levels of male juvenile crime rose by between a fifth and a quarter after the lowering of the drinkin g age to 18 in some states during the 1970s. Similarly, in the USA, the reduction of the legal drinking age was associated with an increase in alcohol consumption and alcohol-related road accidents involving young people. Subsequently, when drinking ages in the USA were raised, the rate of traffic accidents among young people fell.

Conclusions

· One way of discouraging both under-age drinking on licensed premises and illegal purchase of alcohol from all types of licensed premises is to enforce the existing law more vigorously.

· Increasing the age limit for drinking in public places has been associated with reductions in alcohol-related problems.

· Legislation is an effective way to control the availability of alcohol. The distribution of outlets and their opening times will have an impact on public order and on consumption.

Generalist treatment and minimal intervention

Generalist treatment involves a range of primary level workers who routinely encounter problem drinkers in their day-to-day work. Within the heath services, these include general medical practitioners, general psychiatrists, hospital physicians, and accident and emergency specialists. Professions allied to medicine, mainly nurses, are also involved.

Social workers, police, probation officers and prison officers can help to identify and change harmful drinking behaviour. Interventions for alcohol problems can also occur in the workplace.

The work of generalists in the alcohol area increasingly consists of formal or informal screening for alcohol problems and minimal intervention to modify drinking behaviour. This kind of activity is usefully called opportunistic: advantage is taken of opportunities that arise when people present to a facility or service for reasons unconnected with a possible alcohol problem. people drinking in hazardous or harmful ways are offered minimal interventions, usually aimed at reducing drinking to low-risk levels.

General medical practice and primary health care

By far the greatest amount of attention has been paid to general medical practitioners. This is for very good reasons. Over 98% of the population of the UK is registered with a general practitioner;

* there are over a million general practitioner consultations every day;

* two-thirds of a practice population visit their general practitioner within a one year period;

* 90% do so within a five year period;

* heavy drinkers visit their general practitioner roughly twice as often as light drinkers.

Several UK and international studies have clearly established that, among male excessive drinkers at least, a minimal intervention delivered at the primary care level and consisting of even just five minutes simple advice, is effective in reducing alcohol consumption and associated harm.

Cost benefits from minimal interventions

In addition to the benefits to the individual drinker one of the chief arguments in favour of the implementation of minimal interventions is that they can save money for the health care system in the longer run. Evidence to support this proposition is beginning to accumulate. For example, a Swedish study found that excessive drinkers who had received a minimal intervention showed an 80% reduction in sick absenteeism from work in the four years following the intervention. There was also a 60% reduction in days in hospital over five years and a 50% reduction in mortality from all causes over six years following intervention.

General hospital services

Just over a quarter of male in-patients on general medical wards, have a current or a previous alcohol problem. The rates for women are lower and more variable. There is also evidence that minimal interventions are effective in this setting. In one UK study patients receiving a minimal intervention showed improved outcome at the 12 month follow-up.

Screening and counselling hazardous and harmful drinkers on hospital wards is an important strategy for early intervention in alcohol problems and should be practised more widely in Britain.

Accident and emergency departments

Excessive drinkers are over-represented among attenders of Accident and Emergency departments. One study found that 40% of casualty patients had consumed alcohol before attending and 32% had a blood alcohol concentration over the legal limit for driving (80mg%).

A Finnish study has demonstrated substantial benefits from three counselling sessions given by a trained nurse in an A&E setting.

General psychiatry

Up to a fifth of admissions to psychiatric hospitals may be heavy drinkers and yet psychiatrists often fail to take a proper drinking history. This is particularly important since a large proportion of patients with the most severe mental health problems will also have an alcohol problem (32% in one UK study). The UKAlcohol Forum has recently produced guidelines for the management of alcohol problems in primary care and general psychiatry.

Social services and probation

Alcohol is a significant component in between 20% and 40% of all social work caseloads and is likely to exceed these estimates in child abuse cases. Studies have also shown that parental alcohol misuse is the most important factor that leads to the reception of children into local authority care.

The crucial relevance of problem drinking to probation work is shown by the fact that in 1994 probation off icers reported 30% of their caseloads as having severe problems with alcohol. For over seven in ten offenders in this category, an alcohol problem was directly related to the most recent offence.

Conclusions

• Specialist services are able to reach only a fraction of people whose lives are adversely affected by alcohol or whose excessive use of alcohol adversely affects others. The involvement of generalists across all sectors - health, social services, criminal justice and the workplace - in prevention and treatment is essential.

• Strong specialist services are required to treat the more severe cases of alcohol dependence, as well as to provide ongoing support, training and consultation to generalists in the field. A balance between specialist and generalist activity must be struck if treatment is to be widely effective.

• Across all sectors of generalist activity, there is a lack of training and scant use of basic skills in the recognition of an alcohol problem and the provision of minimal interventions.

Specialist treatment

Specialist treatment for major alcohol problems is better than no treatment. A rough estimate is that the rate of naturally occurring improvement is one-third, whereas two-thirds of individuals receiving treatment show some improvement.

American findings show that treatment for alcohol problems as a whole produces net gains for the health care system and is, therefore, a worthwhile and efficient use of financial resources. It has been estimated that for every US$10,000 invested, treatment saves about US$30,000 in medical spending for the managed care provider.

Benefits to the health care system in terms of cost-off sets are only one aspect of possible economic advantages that treatment might bring. It will also result in reduced criminal activity and criminal justice costs, reduced social care and housing demands, reduced accidents as well as productivity and training gains for employers. Added to these third party benefits are possible benefits to individual problem drinkers and their families in improved employment prospects and earnings, improvements in social functioning, reduced risk of arrests for drunkenness, drink driving etc., and reduced expenditure on alcohol, all of which can be considered economic gains.

Alcohol problems and psychiatric co-morbidity

Co-morbidity, or dual diagnosis, is important to a consideration of alcohol treatment services for two reasons. First, people who have an alcohol problem and one or more additional mental health problems have a less favourable prognosis than those people with an 'uncomplicated' drinking problem. Secondly, people with a co-morbid problem use many more health and social care resources.

Dual diagnosis patients are some of the most vulnerable and needy individuals in society, with homelessness, poor physical health and arrests for violence or other criminal behaviour adding to their adjustment problems. Yet the indications are that co-morbid individuals are more likely than others to be excluded from mainstream services, chiefly because of the lack of adequate service provision for this group.

Mutual aid for alcohol problems

A major source of specialist treatment for alcohol problems within the non-statutory sector is often omitted from discussions of treatment because it lies outside the formal planning and funding framework. This is the mutual help that problem drinkers offer to each other in the attempt to recover from their problems. By far the most prominent of these organisations is Alcoholics Anonymous which offers in the region of 2,900 meetings per week in England and Wales, an average of 15 meetings per week for each Health District. Data from Alcoholics Anonymous Headquarters in York indicates a membership in the UK of some 60,000 active members.

All the mutual-aid groups harness powerful psychological processes including the understanding and acceptance of a drinking problem by fellow sufferers, the group cohesion and social support for a new lifestyle, and the availability of help in a crisis.

The current state of alcohol treatment services

The absence of agreement on minimum purchasing and commissioning guidelines for specialist alcohol services have contributed to a highly variable patchwork of treatment provision across the UK. Treatment services are often poorly coordinated and afforded a low level of priority in planning.

Local funding of specialist alcohol services, particularly within the nonstatutory sector, has been resourced through ad hoc monies, gained from central initiatives and time-limited project funds such as joint finance schemes as well as voluntary donations and subventions from Social Work and Health budgets. This has led to local service developments being driven by the availability of specific project funds, rather than on the basis of objective needs assessment.

In the statutory sector, Regional Units have become smaller with a more local focus, have lost key functions such as training and research and development due to lack of a critical mass and, in some cases, have closed.

Conclusions

• Treatment gives value for money.

• Research indicates that treatment reduces the harmful impact of alcohol misuse at the population level, particularly with respect to more chronic alcohol problems.

• The expertise and role of specialist National Health Service alcohol units needs to be strengthened. Specialist services are required to support policy implementation at a local level, to support primary health care teams and alcohol counselling teams, and as a focus for training and research.

• Specialist services involving health, social work and voluntary agencies need to be developed to address the needs of those with psychiatric disorders, brain damage as well as for young people and the homeless

Training professionals

A training strategy would be based upon the following principles:

• Different professional groups have a different role to play in the prevention and treatment of alcohol problems. The enthusiasm for 'multidisciplinary' training can obscure this basic truth in the quest to break down barriers between the professions.

• Role legitimacy is conferred through the introduction of alcohol topics at an early stage in the professional training rather than as a 'bolt on extra' after the core, and by implication, essential subjects have been taught.
• Attitudes to treating problems of alcohol misuse will be determined to a large extent by the question of whether the professional is confident that he or she has the knowledge and skills to tackle the problem.

Specialists in the field should receive training which is provided by recognised education and training providers, validated by award making bodies, normally Universities. A standard set of core addiction competencies should be taught supplemented by higher level super specialist knowledge and skills.

The policy mix

It is clear and incontrovertible that alcohol related harm in our society is massive. It is also clear that government as well as national and local organisations can make a difference. The aim of any policy objective is, with public consent, to reduce the adverse consequences of alcohol without unacceptable diminution of the benefits and pleasures.

Major benefits will follow if the large number of people who drink more than recommended limits can be encouraged to drink less. The focus is on the population as a whole and not just on the heavy drinkers.

Not all alcohol policies are equally effective. Changes in price and affordability will have a more powerful influence than alcohol education in schools. Licensing authorities can have a greater impact on health and social distress than can sensible drinking guidelines.

A national strategy should be constructed from a mix of evidence-based policies. The emphasis being on the mix and on the evidence. There is no masterstroke, such as education, which can transform the drinking habits of a nation or community. There are, however, many effective policy initiatives that need to be taken seriously. The following proposals are likely to be the main elements of any policy mix. They relate to six interacting domains.

Consumption

Tax charges have a key role to play in reducing consumption and making a difference to the health of the nation.

* Relating tax to the alcohol contents of drinks is a more specific recommendation.

* The UK government should seek partners in Europe to facilitate upward equalisation of tax rates across Europe.

* In most situations price increases will not reduce the alcohol taxation revenue to the government.

* Since consumption is linked to affordability this measure should be regularly monitored.

Sales and production

In granting licenses, licensing authorities need to return to a criterion of need as opposed to an emphasis on market forces.

Server training in responsible beverage sales has been shown to redlice the risks of alcohol-related road traffic crashes. Licensing authorities should specify server training as one criterion for the award of a license.

Formal controls

Opening hours should be seen as one method of influencing availability of alcohol. Any attempt to extend opening hours should be resisted unless the change is supported by very solid research evidence.

Age restrictions play an important role in the prevention of alcohol-related problems. Reducing the legal drinking age is linked with an increase in alcohol-related road accidents involving young people. When drinking ages are raised traffic accidents among young people fall.

One way of discouraging both under age drinking on licensed premises and illegal purchases of alcohol from all types of providers is to enforce the existing laws on under-age drinking more vigorously.

Licensing authorities should have access to more information on licensees who break the law and on licensed, premises that are associated with disorder. The police and A & E departments are beginning to collect information on those premises that are associated with disorder and injuries.

Social norms

The available evidence suggests that altering social norms through advertising restrictions, mass media campaigns, school-based education or publicising safe limits will probably have only a marginal effect unless accompanied by other initiatives. Media advocacy can pave the way for alcohol policy measures. For example, providing information on local or national problems such as under-age purchasing will help to increase public acceptance for policy measures designed to counteract the problem.

Legal sanctions

Drinking and driving is now considered to be a high risk activity. Impairment can occur after just one or two drinks and globally the tendency is to reduce the legal blood alcohol level for drivers. Random breath testing with a high profile publicity campaign has been shown to be one of the most effective methods of reducing this problem.

Other forms of transport such as boating and civil aviation are also recognised as having an alcohol-related risk.

A number of countries have prosecuted managers of retail establishments for serving alcohol to intoxicated persons who are then involved in an accident. Server liability is used as a policy to encourage safer beverage use.

Health and social services

The policy measures outlined above are directed towards the aim of reducing alcohol-related harm in our communities, particularly in contexts where drinking is hazardous. Interventions directed at individuals also have an impact on the overall level of adverse consequences.

Screening and minimal interventions within primary health care settings have been shown to be effective. Further work needs to be carried out on the barriers to the implementation of this approach. Similar interventions within A & E departments, social services and probation are likely to be as effective but further research is needed before widespread implementation.

Specialist treatment services increase recovery rates by one third and the treatment of people with drinking problems reduces the total health care costs associated with injury, chronic health problems and hospitalisation.

Services for the homeless and those with severe mental health problems should be given special emphasis since there is evidence that these groups are being excluded from appropriate services.

Workplace policies and employee assistance programmes can address alcohol-related problems at an early stage and with powerful psychological incentives. The workplace offers many opportunities for influencing patterns of alcohol consumption and reducing alcohol related problems. One study developed an intervention that resulted in 70% of employees improving their work performance. Furthermore, Employee Assistance Programmes have high levels of acceptability across the workforce.

A National Strategy

In "Our Healthier Nation" published by the Department of Health it was noted that: "The Government is preparing a new strategy on alcohol to set out a practical framework for a positive response."

The book "Tackling Alcohol Together", written by an expert group convened by the Society for the Study of Addiction, provides an evidence base for such a strategy and is intended to support the more detailed proposals that have been put together by Alcohol Concern.

There is sufficient evidence to support the particular mix of policies outlined above but there is also a need to inform and convince. It is important to have the will and consent of the people. The facts are clear. Lives can be saved. Injuries can be prevented. Quality of life can be improved while still enjoying sensible drinking.

A national strategy will balance the freedom of the individual with the rights of others. It will emphasise the responsible use of alcohol. Most importantly it will give due weight to health and social issues where other pressures tend to predominate.

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