Alcohol misuse – Briefing on the BMA's 2008 report
March 2008
Background
Recent years have seen increasing interest in the levels of alcohol misuse in the UK, and in particular the pattern of binge drinking and heavy drinking.
Alcohol consumption is causally associated with a wide range of medical conditions and is a significant cause of morbidity and premature death worldwide. It contributes to a range of acute and chronic health consequences, from alcohol poisoning and injuries resulting from traffic crashes to cancer and cardiovascular disease. The more an individual consumes, the greater the risk of harm. Alcohol misuse is associated with crime, violence and anti-social behaviour, and can impact significantly on family and community life. . It causes family breakdowns, is a major factor in domestic violence, and ruins job prospects.
The cost of alcohol misuse in the UK is substantial, both in terms of direct costs (eg costs to hospital services and the criminal justice service) and indirect costs (eg loss of productivity and the impact on family and social networks). The NHS spends millions every year on treating and dealing with alcohol problems and the criminal justice system also spends similarly large amounts dealing with alcohol-related and drink-driving offences.
The BMA is very worried about alcohol consumption among young people, particularly young girls. It is shocking that in Europe, the UK’s teenagers are most likely to be heavy drinkers. It is a tragedy that doctors are starting to see serious liver disease in young people because of alcohol. Young people must be made aware that having fun does not have to mean getting drunk three or four times a week. Unhealthy patterns of drinking by adolescents may lead to an increased level of addiction and dependence on alcohol in adulthood.
The government approach has led to increased consumption levels and alcohol-related problems and demonstrates a failure in the political drive to improve public health and order.
The control of alcohol at a national and international level is therefore essential. This requires the implementation of strategies that are effective at reducing overall alcohol consumption levels in a population, as well as targeted interventions aimed at specific populations such as young people or individuals who are dependant on alcohol. Tackling alcohol misuse also requires greater personal responsibility from individuals who consume alcohol in a manner that is harmful to themselves and those around them.
The BMA report ‘Alcohol misuse: tackling the UK epidemic’ (February 2008) Reference 1 considers the problematic levels of alcohol misuse in the UK and is not aimed at those who enjoy consuming alcohol in moderation. It examines the patterns and trends of alcohol consumption and goes on to review the range of adverse effects both on the individual and society that are associated with its misuse. The report concludes by considering the evidence for effective alcohol control policies and discusses the current approaches in the UK. The recommendations are for action by the UK Government and are evidence-based policies that need to be adopted in order to tackle alcohol misuse and its associated harms.
BMA reports on alcohol
Doctors see first hand how alcohol misuse destroys lives. The BMA has developed comprehensive policy addressing the issues surrounding alcohol use and the problems which can arise from its misuse, in terms of the effect on the individual and society in general.
The BMA’s 'Guide to Alcohol and Accidents' (1989) provided information on alcohol as a cause of accidents and gave practical advice on ascertaining alcohol consumption by individuals attending casualty departments, diagnosing long-term alcohol abuse and managing the ‘at risk’ drinker. 'Living with risk' (1990) reviewed the risks and trends of drinking alcohol. 'Alcohol: guidelines on sensible drinking' (1995) was based upon the BMA’s submission to the Government Review of the Sensible Drinking Message. It reviewed existing evidence and called for a comprehensive sensible drinking message that provided the public with guidelines on limits, along with concise statements about the evidence of benefits.
'The Drinking Driver' (1988) examined the scientific and epidemiological evidence relating to drink driving. It proposed a range of countermeasures aimed at persistent offenders who are likely to have an underlying drink problem and at social drinkers who offend. 'Driving impairment through alcohol and other drugs' (1996) reviewed the existing drink driving legislation. It suggested a reduction in the permitted blood alcohol concentration for driving and called for European harmonisation of drink driving regulations and broad legislation in terms of prevention, enforcement and rehabilitation.
As long ago as 1986 the BMA drew attention to the problem of young people and alcohol. In April 1999 the BMA published a second report ‘Alcohol and young people’ which included recommendations concerning the regulation of the drinks industry, tougher advertising controls, the need for a review of the licensing laws and health education. The BMA report 'Adolescent Health', Reference 2 launched in December 2003, examined evidence on alcohol consumption among young people.
The BMA’s web resource 'Binge drinking' Reference 3 was launched in 2005 and acts as a hub for information on the medical, personal and social effects of binge drinking. It considers the definition of binge drinking, summarises the recommended drinking guidelines and provides sources of further information.
'Fetal alcohol spectrum disorders – a guide for healthcare professionals' (June 2007) Reference 4 focussed on the adverse health impacts of alcohol consumption during pregnancy, and in particular the problem of FASD. This report is intended for healthcare professionals and relevant bodies with strategic or operational responsibility for public health and health promotion.
‘Alcohol misuse: tackling the UK epidemic’ (February 2008) calls on the government to show leadership and implement a full range of effective control policies that will reduce the burden of alcohol misuse.
Statistics
The Prime Minister’s Strategy Unit estimated that:
- 5.9 million people in Britain engage in binge drinking (8 or more units per day for men and 6 or more units per day for women)
- 2.9 million (7%) of the adult population in Britain are alcohol dependent.
The Alcohol Needs Assessment Research Project (ANARP) estimated that:
- 21 per cent of men and 9 per cent of women aged 16-64 in England are binge drinkers.
- 38 per cent of men and 16 per cent of women in England have an alcohol use disorder, corresponding to 26 per cent overall (8.2 million people)
The North West Public Health Observatory estimated that:
- 1.55 million people in England consume alcohol at harmful levels (over 50 units per week for men and over 35 units per week for women) and a further 6.3 million drink at hazardous levels (between 22 and 50 units per week for men and between 15 and 35 units per week for women).
The Information Centre estimated that:
- the number of NHS hospital admissions in England of adults aged 16 and over with a primary or secondary diagnosis specifically related to alcohol more than doubled from 89,280 in 1995/96 to 187,640 in 2005/06
- the number of NHS hospital admissions of children under 16 with a primary or secondary diagnosis specifically related to alcohol rose from 3,870 in 1995/96 to 5,280 in 2005/06
The National Social Marketing Centre estimated that the total annual societal cost of alcohol misuse in England to be £55.1 billion including:
- £21 billion cost to individuals and families/households (eg loss of income, informal care costs)
- £2.8 billion cost to public health services/care services
- £2.1 billion cost to other public services (eg criminal justice system costs, education and social services costs)
- £7.3 billion cost to employers (eg absenteeism)
- £21.9 billion in human costs (DALYs).101
Effective policies to reduce alcohol-related harm in the UK
Access to alcohol is an important determinant of alcohol use and misuse. This incorporates the implementation of policies that regulate the affordability of alcohol, as well as the introduction and enforcement of strict controls on the availability of alcohol to adults and young people. Recent governments have worked too closely with the alcohol industry and have pursued policies of deregulation and liberalisation regarding alcohol control.
- Controlling price
There is strong and consistent evidence that price increases result in reduced consumption. Reference 10 Our February 2008 report recommended that taxation on all alcoholic beverages should be increased at higher than inflation rates and this increase should be proportionate to the amount of alcohol in the product. The BMA is pleased that this recommendation has been adopted by the Chancellor of Exchequer in the 2008 budget. The evidence tells us that the cheaper and more accessible alcohol is the more people will drink. It has been estimated that a 10 per cent increase in alcohol prices in the UK would lead to a 10 per cent fall in consumption. Reference 11
Studies have also reported that price increases have the effect of reducing rates of alcohol problems including alcohol-related violence and crime, Reference 12 deaths from liver cirrhosis, Reference 13 and drink driving deaths.Reference 14 These tax increases may be unpopular with some members of the public but the BMA hope that they will look at the wider issue and recognise that the UK has a real problem on its hands regarding alcohol misuse.
- Availability
Licensing interventions are one of the most influential methods for controlling alcohol consumption and misuse through regulation of where, when and to whom alcohol can be sold. There is strong evidence that increased opening hours are associated with increased alcohol consumption and alcohol-related problems.Reference 15 Conversely, reductions in opening hours and the number of outlets are associated with reductions in alcohol use and related problems. Reductions in licensing hours in Norway, Finland and Sweden led to a decrease in the alcohol consumption of heavy drinkers.Reference 16
The Licensing Act 2003 now permits 24-hour opening in England and Wales. Of particular note, is the fact that public health was not considered as one of the licensing objectives in the 2003 Licensing Act. Reference 17 The proposed changes to licensing in Scotland and Northern Ireland will permit more modest extensions in opening hours. A high density of alcohol outlets is associated with increased alcohol sales, drunkenness, violence and other alcohol-related problems. Reference 18 Consumers are likely to be deterred from purchasing alcohol when there is a lower density of outlets due to the increased time and inconvenience involved in purchasing it.
The report recommends:
- The availability of alcoholic products should be regulated through a reduction in licensing hours for on- and off-licensed premises.
- Town planning and licensing authorities should ensure they consider the local density of on-licensed premises and the surrounding infrastructure when evaluating any planning or licensing application. Legislative changes should be introduced where necessary to ensure these factors are considered in planning or licensing applications for licensed premises.
- Enforcement of licensing laws
In addition to regulating licensing hours, legislation in the UK prohibits the sale of alcohol to intoxicated customers and people under the age of 18. The enforcement of licensing laws is a vital component of effective alcohol control that places the responsibility on licensees for the actions of their customers. This is an advantageous approach as it does not rely on compliance from the individual consumer and is likely therefore to be received as an acceptable alcohol control policy.
Active enforcement of laws regulating licensing hours and prohibiting the sale of alcohol to individuals who are intoxicated or those underage have been shown to be effective at increasing compliance with legislation.Reference 19. In the USA, enforcement has also been shown to increase public awareness, and when coupled with measures to encourage retailers and the public to comply with the law, to reduce alcohol-related problems such as road traffic fatalities and homicides.115, 157, 158 Reference 20 These benefits from increased enforcement of licensing laws have also been found to significantly exceed the costs.Reference 21
The report recommends:
- Licensing legislation in the UK should be strictly and rigorously enforced. This includes the use of penalties for breach of licence, suspension or removal of licences, the use of test purchases to monitor underage sales, and restrictions on individuals with a history of alcohol-related crime or disorder.
- Enforcement agencies should be adequately funded and resourced so that they can effectively carry out their duties. Consideration should be given to the establishment of a dedicated alcohol licensing and inspection service.
Irresponsible promotional activities are common in licensed premises and off-licences (including supermarkets and local convenience stores) throughout the UK, so it is essential that these forms of promotional activity are strictly regulated; thus prohibiting price promotions on alcoholic beverages, and by establishing minimum price levels. Research evidence suggests that repeated exposure to high-level alcohol promotion influences young people’s perceptions, encourages alcohol consumption and increases the likelihood of heavy drinking. Reference 22
Specific advertising strategies such as sponsorship of sporting and music events, as well as advertisements using celebrity endorsements all serve to reinforce the image of alcohol among young people and predispose them to drinking well below the legal age to purchase alcohol.Reference 23
The report recommends:
- Legislation should be introduced throughout the UK to:
- prohibit irresponsible promotional activities in licensed premises and by off-licences
- set minimum price levels for the sale of alcoholic beverages.
- A statutory code of practice on the marketing of alcoholic beverages should be introduced and rigorously enforced. This should include a ban on:
- broadcasting of alcohol advertising at any time that is likely to be viewed by young people, including specific provisions prohibiting advertising prior to 9pm and in cinemas before films with a certificate below age 18
- alcohol industry sponsorship of sporting, music and other entertainment events aimed mainly at young people
- marketing of alcoholic soft drinks to young people
Considerable reductions in the incidence of drink-drive road incidents and related deaths have occurred in the UK since 1980. The number of fatalities and serious injuries resulting from drink-drive road crashes, however, remains significantly high. In the UK, the BAC limit is 80mg/100ml which is among the highest in Europe, yet there is a marked deterioration in driving performance between a BAC of 50mg/100ml and 80mg/100ml. Drinking by drivers with a BAC between 50mg/100ml and 80mg/100ml is a significant but largely hidden cause of road traffic crashes and has been estimated to account for 80 road deaths a year in England. Reference 24
It is essential that further measures are implemented to build on progress achieved over recent years in reducing the levels of drink-driving in the UK. This includes a reduction in the legal BAC limit from 80mg/100ml to 50mg/100ml, and consideration for further reductions for all newly qualified drivers who are felt to be particularly at risk of alcohol-related road crashes as a result of their limited driving experience.
Enforcement of drink-drive legislation is essential for compliance. In the UK, this is operated through selective breath testing and high-profile media campaigns. Selective breath testing requires police to have judged that a motorist has consumed alcohol before implementing the test. This deterrence-based policy is insufficient as many offenders may be able to avoid detection. Random breath testing permits police to stop motorists who are not suspected of committing an offence or of being involved in an incident. This is an advantageous approach as motorists are unable to influence the likelihood of being tested. With the exception of Denmark and the UK, random breath testing is permitted throughout the EU.Reference 25
The report recommends:
- The legal limit for the level of alcohol permitted while driving, attempting to drive, or being in charge of a vehicle should be reduced from 80mg/100ml to 50mg/100ml throughout the UK.
- Legislation permitting the use of random roadside testing without the need for prior suspicion of intoxication should be introduced throughout the UK. This requires appropriate resourcing and public awareness campaigns.
- Education and health promotion
The use of public information and educational programmes is a common theme for alcohol control policies in the UK and internationally. Such approaches are politically attractive but have been found to be largely ineffective at reducing heavy drinking or alcohol-related problems in a population.Reference 27
In the UK, mass media campaigns, public service messages and school-based educational programmes are used as key alcohol control measures. While these may be effective at increasing knowledge and modifying attitudes, they have limited effect on drinking behaviour in the long term.Reference 28 It is essential that the disproportionate focus upon, and funding of, such measures is redressed.
The report recommends:
- There should be further qualitative research examining attitudes to alcohol misuse in the UK.
- Public and school-based alcohol educational programmes should only be used as part of a wider alcohol-related harm reduction strategy to support policies that have been shown to be effective at altering drinking behaviour, to raise awareness of the adverse effects of alcohol misuse, and to promote public support for comprehensive alcohol control measures.
Much of the strategy to reduce alcohol-related harm in the UK focuses on recommended drinking guidelines. While the majority of people are aware of the existence of these guidelines, few can accurately recall them, understand them, or appreciate the relationship between units and glass sizes and drink strengths4, 54, 201-203, 204 Reference 29
Labelling of alcoholic beverage containers would be a useful method for explaining recommended drinking guidelines and for supporting other alcohol control policies. In the UK, recent voluntary agreements with the alcohol industry have led to the inclusion of information on unit content on some alcoholic beverages. The recommended guidelines, however, may only be one of the sources that inform individual decision-making with respect to alcohol consumption. Other influences include intrapersonal factors such as prior drinking experiences and interpersonal reasons such as peer influence.
The report recommends:
It should be a legal requirement to prominently display a common standard label on all alcoholic products that clearly states:
- alcohol content in units
- recommended daily UK guidelines for alcohol consumption
- a warning message advising that exceeding these guidelines may cause the individual and others harm.
- recommended daily UK guidelines for alcohol consumption
- a warning message advising that exceeding these guidelines may cause the individual and others harm.
- information on recommended daily UK guidelines for alcohol consumption
- a warning message advising that exceeding these guidelines may cause the individual and others harm.
Preventing alcohol-related harm requires the accurate identification of individuals who misuse alcohol, but there is currently no system for routine screening and management of alcohol misuse in primary or secondary care settings in the UK. The BMA is calling for a more comprehensive system to identify patients at risk of alcohol misuse – this could be done via screening questionnaires when individuals visit their GP, or attend for a general hospital appointment or when they go to A&E. The report is also calling for new ring-fenced funding for specialist alcohol treatment services so that patients can be seen as soon as possible.
The BMA believes it is necessary that more is done to help people with alcohol problems. Doctors need to identify patients who are misusing alcohol much earlier, but it doesn’t end there. There must be enough funding in place to refer patients who are at risk to specialist centres. It is disheartening to refer someone who has an alcohol problem for help but know that they’ll be waiting months to be seen by the appropriate specialised agency. In that time not only does their health worsen but the effects on their family and work life can be catastrophic.
The report recommends:
- The detection and management of alcohol misuse should be an adequately funded and resourced component of primary and secondary care in the UK to include:
- formal screening for alcohol misuse
- referral for brief interventions and specialist alcohol treatment services as appropriate
- follow-up care and assessment at regular intervals.
- A system for the detection and management of alcohol misuse in primary care should occur via the implementation of a direct enhanced service by the UK health departments. This must be adequately funded and resourced.
- Systems for the detection and management of alcohol misuse should be developed for A&E care and the general hospital setting throughout the UK. These must be adequately funded and resourced.
- Comprehensive training and guidance should be provided to all relevant healthcare professionals on the identification and management of alcohol misuse.
- Funding for specialist alcohol treatment services should be significantly increased and ringfenced to ensure all individuals who are identified as having severe alcohol problems or who are alcohol dependent are offered referral to specialised alcohol treatment services at the earliest possible stage.
- There should be continual assessment of the need for and provision of alcohol treatment services in the UK, building on the 2004 Alcohol Needs Assessment Research Project in England, and ensuring similar assessment is undertaken throughout the UK.
The BMA believes that international cooperation on alcohol control is essential for several reasons including the considerable global burden of alcohol, and trans-border factors such as global advertising and production, formal and informal trading and smuggling.
Reducing alcohol-related harm across the European Union (EU) has been facilitated by the 2000 World Health Organisation (WHO) European Alcohol Action Plan,Reference 30 the 2006 EU Alcohol Strategy, and the establishment of the EU Alcohol and Health Forum. It is vital that the UK Government strongly supports EU initiatives and policies aimed at reducing alcohol-related harm to individual and public health. While the introduction of agreements such as the WHO European Alcohol Action Plan and the EU Alcohol Strategy provide a useful platform for action, their effectiveness has been questioned due to the influence of the alcohol industry on their development. A further drawback of EU-level action and agreements is the fact that they are non-binding. Reference 31
An alternative approach would be to introduce a legally binding treaty similar to the WHO Framework Convention on Tobacco Control (FCTC). This would serve to support governments in developing and implementing effective alcohol control policies, foster collaboration between countries, counter the international trade agreements that currently restrict governments from introducing stricter alcohol control policies, and effectively engage non-governmental organisations.
The report recommends:
- There should be strong support for European Union, World Health Organisation and World Health Assembly initiatives and policies aimed at reducing alcohol-related harm to individual and public health.
- Lobby for, and support the World Health Organisation in developing and implementing a legally binding international treaty on alcohol control in the form of a Framework Convention on Alcohol Control.
Please contact the parliamentary unit:
E-mail: parliamentaryunit@bma.org.uk.
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