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.
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
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
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
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.
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
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
- 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
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 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.
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.
General household surveys show
an increasing proportion of older people (age 65+) drinking
more than the recommended limits.
||12% of men
||3% of women
||18% of men
||7% of women
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
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.
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
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).
|BAC of 50 to 90mg%
||risk increased by a factor
|BAC of 100 to 140mg%
||risk increased by a factor
|BAC above 150mg%
||risk increased by a factor
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
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
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.
- 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.
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
Child abuse includes physical,
emotional and social abuse. All of these forms of child abuse
are associated with heavy drinking parents.
Family disharmony and long
term consequences for children are strongly related to
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.
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
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
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
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
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
- 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
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
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
|Pint of draft
Source: Centre for Health Economics
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
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 behaves like any other
commodity. As prices go up consumption comes down and
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.
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
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
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.
The positive portrayal of drinking
in the mass media may influence the behaviour of children
and vulnerable adults. The overall effect on consumption
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.
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
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
· 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.
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
* 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
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.
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
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.
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
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 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
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, 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
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
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.
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
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
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
A training strategy would be
based upon the following principles:
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
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.
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.
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
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.
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
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
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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