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Alcohol

Health and Social Behaviour: The Effects on Health of Alcohol and Combating the Issue

Definition

Alcohol is important to some people for social reasons but drinking above sensible drinking levels is associated with ill-health, crime and disorder.

There are 3 types of drinking:

  1. Sensible drinking
  2. Harmful drinking
  3. Binge drinking

1. Sensible drinking – drinking in a way that is unlikely to cause yourself or others significant risk or harm. Table 1 outlines the current government recommendations for sensible drinking.

Table 1: Government recommendations for sensible drinking levels

Adult Women Should not regularly drink more than 2-3 units of alcohol a day
Adult men Should not regularly drink more than 4-5 units of alcohol a day
Pregnant women or women trying to conceive Should avoid drinking alcohol. If they do choose to drink they should not drink more than 1-2 units of alcohol once or twice a week and should not get drunk.

Sensible drinking also involves a personal assessment of the risks and responsibilities of drinking at the time. For example, it is illegal to drink over a certain limit when driving and alcohol should be avoided when taking certain medications.

2. Harmful drinking – drinking at levels that lead to significant harm to physical and mental health and at levels that may cause substantial harm to others.

Table 2: Government guidelines for harmful drinking levels

Adult Women Regularly drink over 6 units a day (or over 35 units a week)
Adult men Regularly drink over 8 units a day (or over 50 units a week)
Pregnant women or women trying to conceive Women who drink heavily during pregnancy put their babies at risk of developing fetal alcohol syndrome or fetal alcohol disorder.

3. Binge drinking – drinking too much alcohol over short period of time e.g. over the course of an evening, and it is typically drinking that leads to drunkenness. It has immediate and short-term risks to the drinker and
to those around them. For example, people who are drunk are more likely to be involved in an accident or assault, be charged with a criminal offence, contract sexually transmitted disease and are more likely to have an unplanned pregnancy (women).

Table 3: Government guidelines on identifying binge drinking levels

Adult Women Drinking over 6 units a day
Adult men Drinking over 8 units a day

Many binge drinkers consume substantially more than 6 or 8 units a day, or drink this amount over a short space of time. The government recommends that after a heavy drinking episode, a person should refrain from drinking for 48 hours to allow the
body to recover.

A UK unit is 10ml or 8g of pure alcohol. The number of units in a drink depends on what you are drinking (how strong it is and how much there is of it). Half a pint of 3.5% beer/lager/cider is one unit, one small glass (125ml) of wine at 9% is one
unit. Few people are able to estimate accurately how many units they drink.  For example, wine often has a greater percentage of alcohol than 9% and a serving is often greater than 125ml.

Epidemiology

  • There are conflicting data on consumption and trends in alcohol consumption.
  • Drinking trends from the General Household Survey (GHS) have shown that alcohol consumption increased between 1960 and 1980 and then stabilised. The consumption of alcohol increased significantly in women and children in the 1990s.
  • In comparison, HM Revenue and Customs (HMRC) excise data for the UK domestic market shows a longer and continuing rise in overall consumption until 2004 followed by a fall in 2005 and 2006.
  • The discrepancy in the two data sources is likely to be due to the fact that the GHS data is based on reported number of drinks people remember having in the past week (i.e. people are likely to underestimate) and HMRC data includes all drinks
    sold that may not actually be drunk (i.e. drinks not finished or out of date).
  • Although best sets of data demonstrate a decline in alcohol consumption nationally, it is still too early to be sure that this is a ‘real’ decrease.
  • The incidence of alcohol-related deaths and disease has increased.
  • More alcohol is being bought from off-licenses and consumed at home rather than in public houses.
  • Drinking over the sensible drinking guidelines is more common in:
    • men than women
    • young people aged 16-24 than people in other age groups
    • areas of high deprivation than people living in areas of low deprivation

Effects on Health of Alcohol

Regular drinking at levels greater than sensible drinking is associated with health risks:

Alcohol related hospital admissions

Hospital admissions for alcohol-related injury or illness where alcohol was the primary or secondary diagnosis include: alcoholic liver disease, mental and behavioural disorders due to alcohol, and toxic effects of alcohol.

Health-related harm

Alcohol misuse is directly linked to deaths from certain types of disease, such as liver cirrhosis. It may also be associated with other causes of death such as hypertension, stroke, coronary heart disease, and pancreatitis. Men who regularly
drink more than 8 units and women who regularly drink more than 6 units a day raise their risk of having various diseases (see table 4 below)

Table 4: Increased risks of ill health to harmful drinkers

Condition Men (increased risk) Women (increased risk)
Hypertension 4 times 2 times
Stroke 2 times 4 times
Coronary Heart Disease 1.4 times 1.3 times
Pancreatitis 3 times 2 times
Liver Disease 13 times 13 times

Alcohol-related deaths

Alcohol related deaths include alcoholic liver disease (cirrhosis and fibrosis) and alcohol cardiomyopathy.

Alcohol and pregnancy

When pregnant women consume alcohol, the alcohol reaches the baby through the placenta. Babies process alcohol at slower rates than adults and are therefore exposed to greater amounts of alcohol and for a longer period of time. This can seriously
affect a baby’s development. DH recommends that pregnant women and those women trying to conceive should avoid drinking alcohol but if they choose to drink they should not drink more than 1-2 units of alcohol once or twice a week and should not get
drunk. In addition, NICE advises women to avoid alcohol in the first three months of pregnancy because of the increased risk of miscarriage.

See the ‘Know Your Limits’ website for further information of the health effects of alcohol during pregnancy. http://units.nhs.uk/pregnancy.html

Drinking and driving

There has been a huge reduction in the annual number of drink-driving deaths in Great Britain (1,600 at the end of the 1970s to 560 in 2005) but the rate of decline in the past 10 years has slowed significantly.

Crime and antisocial behaviour

  • Alcohol misuse may not only harm the drinker but others close to the drinker as well.  For example rowdy drunken behaviour can disrupt others and keep people awake at night.  Domestic violence, assault or neglect of children can also
    be linked to alcohol misuse.
  • British Crime Survey (BCS) includes measures of alcohol-related crime and disorder. The survey reports that alcohol-related violent offences have decreased every year since 1995 (except 2003/04).
  • Public perceptions of alcohol-related crime and disorder have increased with people thinking that being drunk or rowdy in a public place is a significant problem.

Young People Drinking

  • The UK now has among the highest incidences of youth drunkenness.
  • Underage drinking and drinking by young adults is perceived as a real problem by the public.
  • Young people drinking has shown links with increased:
    • injuries whilst under the influence of alcohol (binge drinking)
    • youth offending,
    • teenage pregnancy,
    • school failure, truancy and exclusion and
    • illegal drug misuse
    • deaths from liver cirrhosis

Combating Alcohol Ill-Health and Crime Using a Wide Range of Approaches

(including health service interventions and broader cultural interventions)

Government Policy and Recommendations

National Government recommendations have been introduced to reduce the alcohol related harms to health, violence and antisocial behaviour whilst ensuring that sensible drinkers are able to enjoy it as part of their social life.

The first cross-government strategy on alcohol, ‘Alcohol Reduction Strategy for England’, was published in 2004. The action plan included a number of key activities outlined in table 5.

Table 5: Activities in ‘Alcohol Reduction Strategy for England’

1. Better education and communication
  • ‘Know your limits’ (2006) binge drinking campaign to target 18-24 year old binge drinkers.

  • ‘THINK!’ drink driving campaign developed by the Department of Transport.
  • Restriction on alcohol advertising by Ofcom. In particular, rules around appeal to young people, sexual content and irresponsible or antisocial behaviour were strengthened.
  • Code of Practice by the Portman Group on the naming, packaging and promotion of alcoholic drinks. The code states that the drink’s name, packaging and promotion should not appeal specifically to under 18s, and should not
    encourage immoderate consumption, be associated with antisocial behaviour, illegal drugs or sexual success. Drinks found to be in breach of the code are not sold by retailers until they are re-branded to comply with it.
2. Improving health and treatment services
  • Trailblazer research projects to identify and advise people whose drinking habits are likely to lead to ill health in the future. The trailblazers use screening questionnaires to identify hazardous and harmful drinkers based on
    the Alcohol Use Disorder Identification Test (AUDIT) developed by the World Health Organisation. The patients identified as having an increased risk to their health because of their drinking are given a five-minute brief intervention.
  • National Alcohol Needs Assessment Research Project (ANARP) identifies services for those requiring treatment for alcohol disorders and relates this to need at regional and national levels.
  • ‘Alcohol Misuse Interventions: guidance on developing a local programme of improvement’ (2005) was published to assist local health organisations, local authorities and other organisations working with the NHS to tackle
    alcohol misuse.
  • ‘Models of Care for Alcohol Misuse’ (2006) was produced by DH and the National Treatment Agency to provide a framework for commissioning and providing interventions and treatment for adults affected by alcohol misuse.
  • The Review of the Effectiveness of Treatment for the Alcohol Problems (2006) by the National Treatment Agency provides a comprehensive review of the effectiveness and cost effectiveness of alcohol treatment.
3. Combating alcohol-related crime and disorder
  • New powers under the Licensing Act 2003 implemented in 2005 to regulate the sale of alcohol at the point of sale and robust powers to deal with irresponsible premises, to reinforce local alcohol retailers responsibility for
    alcohol-related crime and disorder, and to tackle the behaviour of individuals.
  • New powers under the Violent Crime Reduction Act 2006 to tackle irresponsible individual licensed premises, to reinforce local alcohol retailers’ collective responsibility for alcohol-related crime and disorder and to tackle
    the behaviour of individuals.
  • ‘Alcohol Misusing Offenders – A strategy for delivery’ (2006) by the National Probation Service provides a coherent framework for those tackling alcohol misuse in offenders. It is evidence-based and ensures consistency and
    coordination of delivery.
  • National Alcohol Misuse Enforcement Campaigns (AMECs) between 2004 and 2006 involved police and trading standards targeting irresponsible drinkers who were causing violence and disorder, and premises that were breaking the law by
    selling to under-18s.  Included a poster campaign warning the public of the new fines for disorder and the ‘Challenge 21’ policy adopted by most retailers.
  • Tackling Violent Crime Programme (TVCP) was launched in November 2004. It involved the Home Office working with practitioners in a small number of local areas with high levels of more serious violent crime. The good practice was
    then used to disseminate nationally.
  • The Children Act 2004 places responsibility on directors of children’s services to protect children and young people from harm (this includes parents with substance misuse problems who can place their children at risk).  ‘Working
    Together to Safeguard Children’ (2006)
    outlined ways in which individuals and organisations should work together to safeguard and promote the welfare of children.

4.     Working with the alcohol industry

  • Health information on bottles including the Government’s sensible drinking message and the alcohol unit content of containers and of standard glasses. Ongoing discussions with the industry regarding the inclusion of messages
    that encourage sensible drinking e.g. ‘Know Your Limits’.
  • Establishing the Drinkaware Trust (2007), an independent charity to promote sensible drinking. www.drinkaware.co.uk
  • Social Responsibility Standards for the Production and Sale of Alcohol Drinks in the UK (2005). The standards were compiled jointly by the Government and alcohol industry. They draw together existing codes, good practice and
    advice in a single cohesive set of standards.
  • Local partnership schemes e.g. Best Bar None. This is based on partnership working between police and local retailers to promote responsible management of on-license premises and to reduce incidents of alcohol-related crime and
    disorder.

Since the initial government strategy to reduce alcohol was introduced in 2004, there has been significant progress. For example, levels of alcohol consumption are no longer rising. There are, however, issues of increasing concern: public concern
about the harm caused by alcohol has risen, and the incidence of liver disease and deaths caused by excessive drinking has continued to increase. In addition, there is evidence that an English ‘drinking culture’ exists, in which binge drinking
and drinking to get drunk are normal behaviour.

The Government acknowledged that further work needed to be undertaken and in 2007 it launched a new strategy, ‘Safe. Sensible. Social’.  The strategy identifies 3 key areas:

  • Ensure the laws and licensing powers that have already been introduced are being used widely and effectively.
  • Focus attention on minority drinkers (e.g. young people under 18 who drink alcohol, 18-24-year-old binge drinkers, and harmful drinkers) who cause or experience the most harm to themselves, their communities and their families.
  • Develop an environment that promotes sensible drinking through better information and communication, and by working with those already involved with reducing alcohol related harm.

In addition, the Government highlighted a number of actions that need to be undertaken:

  1. A sharpened criminal justice system for those committing crime and antisocial behaviour when drunk. For example, offenders will receive facts about unsafe drinking, and offered advice, support and treatment. The Government proposes to introduce
    a method which will ensure that those offending will pay for these interventions.
  2. A review of NHS alcohol spending to improve both national spending and local investment in alcohol prevention and treatment services.
  3. More help for people who want to drink less, for example, telephone helplines, interactive websites and support groups.
  4. Toughened enforcements of underage sales by local authorities and police on premises selling alcohol.
  5. Trusted guidance for parents and young people to help young people and their parents make informed decisions about drinking.
  6. Public information campaign to promote a new sensible drinking culture. For example, the ‘Know Your Limits’ campaign is intended to expand by promoting sensible drinking and highlighting the physical and criminal harm related to alcohol
    misuse.
  7. Public consultation on alcohol pricing and promotion which will involve an independent review of the evidence on whether alcohol pricing and promotion cause people to drink more.
  8. Crime and Disorder Reduction Partnerships (CDRPs) will be required by law to have a strategy to tackle crime, disorder and substance misuse (including alcohol-related disorder and misuse) in their area by April 2008. CDRPs comprise the police,
    local authorities, police authorities, fire and rescue authorities and primary care trusts.

Interventions

Public Health interventions will involve a coordinated approach across a range of stakeholders, for example, a number of government departments, the NHS, local authorities, the police, voluntary organisations, the alcohol industry, the wider
business community, and the media will need to work together to implement the Department of Health and local alcohol strategies.

Other publications

The Alcohol Needs Assessment Research Project (ANARP) 2004

http://www.dh.gov.uk/en/Publicationsandstatistics

Alcohol Misuse Interventions: Guidance on developing a local programme for Improvement 2005

http://www.dh.gov.uk/en/Publicationsandstatistics

Models of Care for Alcohol Misusers (MoCAM) 2006

http://www.dh.gov.uk/en/Publicationsandstatistics

References

  • Department of Health (2007). Safe. Sensible. Social. The next steps in the National Alcohol Strategy.
  • Department of Health. Alcohol Misuse section. http://www.dh.gov.uk

© Hannah Pheasant 2008