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Adults and Alcohol

This chapter  will focus on Adults and Alcohol – there is a chapter on Alcohol and Young People in the Developing Well section.

Alcohol misuse, or problem drinking, occurs when a person drinks above the recommended medical guidelines, which currently state that:

  • Men should not drink more than 3 to 4 units of alcohol a day on a regular basis.
  • Women should not drink more than 2 to 3 units of alcohol a day on a regular basis.
  • Pregnant women, or women trying for a baby, should avoid alcohol altogether during the first 3 months of pregnancy as there is an increased risk of miscarriage.  Thereafter, they should drink no more than 1-2 units, once or twice a week.

(NICE, 2012)

The majority of people enjoy a drink without causing trouble for those around them, but there is a significant minority who do not.  Too many high streets and town centres have become ‘no-go’ areas on a Friday and Saturday night because of alcohol-fuelled violent crime and antisocial behaviour.  It is responsible drinkers, businesses and the wider community who pay the price in terms of crime and disorder on streets, and blocked accident and emergency departments due to alcohol related injuries (Home Office, 2012).

The current estimated cost to the UK economy of alcohol misuse is as follows:

  • NHS in England – £3.5 billion per year (at 2009/10 costs)
  • Crime in England – £11 billion per year (at 2010/11 costs)
  • Lost productivity in the UK – £7.3 billion per year (at 2009/10 costs)
  • Across the UK, up to 14 million working days are lost annually through absences caused by drinking
  • Over 200,000 people go to work with a hangover every day.

The total cost of alcohol misuse to society is estimated to be approximately £21 billion per year and this does not include the impact of alcohol misuse on families and communities.

(NICE, 2012)

From 2013, local authorities are responsible for commissioning public health services, including alcohol misuse treatment and prevention services.  The Public Health Outcomes Framework sets out the desired outcomes for public health and supporting indicators to measure progress.  In Bedford Borough the following high level indicators are used to measure progress in relation to health and alcohol misuse.

  • Reduction in alcohol-related admissions to hospital
  • Reduction in mortality from liver disease
  • Increased take up of the Health Check 1 programme by those eligible – this will include screening for alcohol misuse from April 2013.

In order to build a more detailed picture of alcohol related harm in Bedford, the additional local health indicators to measure progress have also been identified:

  • Persons under 18 admitted to hospital due to alcohol specific conditions
  • Alcohol specific hospital admissions
  • Alcohol related A&E attendances

It is likely that, from April 2013, the following key performance indicators from the substance misuse performance framework will also be included2:

Increase the number of clients in effective treatment:

  • Number of community alcohol users in structured treatment
  • Number of clients receiving alcohol brief interventions
  • Number and percentage of new receptions in prison identified as having an alcohol issue and commencing alcohol treatment
  • Number and percentage of those prisoners identified as having a drug / alcohol problem declining substance misuse treatment

Reduction in harmful substance misuse:

  • Units of alcohol consumed per month recorded for all clients in contact with treatment in the year to date (National Treatment Agency)

Alcohol misuse is the third greatest overall contributor to ill health after smoking and raised blood pressure, and almost 7 million adults are estimated to be drinking at levels that increase the risk of harming their health.

Excess drinking

Binge drinking3 in the UK accounts for approximately half of all alcohol consumed.  The problem of excess drinking has primarily developed for the following reasons:

  • Cheap alcohol is readily available which has led to a change in behaviour, with increasing numbers of people drinking excessively at home.  This includes people drinking before they go on a night out i.e. ‘pre-loading.4         There has not been enough challenge to the individuals that drink and cause harm to others, or to businesses that tolerate excess drinking and, in some instances, encourage this behaviour. (HM Government, 2012)
 

Home consumption

In 2010, purchases of alcohol for consumption in the home had increased by 45% compared with 1992 (Harker, 2012).  The rise in home consumption could be linked to the decline of the pub, the ban on smoking and the increased affordability and availability of alcohol from supermarkets.  More alcohol is now consumed in the home than in licensed premises (IAS, 2009).

There are vast differences in the price of alcohol between off and on licence sales and this correlates with individuals increasingly consuming alcohol at home.  Making alcohol less affordable is the most effective way of reducing alcohol-related harm.  International evidence suggests that making it less easy to buy alcohol by reducing the number of outlets selling it and the days and hours when it can be sold, is an effective way of reducing alcohol-related harm (NICE, 2010).

Pre-loading

Pre-loading, especially combined with on-premise drinking, is associated with heavier consumption and related adverse outcomes. Educational interventions as well as structural measures, for example reduction of late-night off-sale opening hours are needed to prevent high total consumption and related adverse consequences among young people (Labhart, 2012)

People who pre-load are four times more likely to consume over 20 units on a night out (Hughes, 2008).  Pre-loading can lead to people being drunk in residential areas prior to going out, and alcohol related problems on public transport.  It is more strongly associated with being involved in nightlife violence than the total amount of alcohol an individual consumed.  ‘Pre-loaders’ are two and a half times more likely to be involved in violence than other drinkers (Hughes, 2008).

Alcohol and the workplace

Research carried out by Drink Aware in 2010 (Garbatt, 2010) found that the average person goes to work suffering from the effects of alcohol three times a month.  Approximately 20% of employees questioned admitted to having struggled to work after a day of heavy drinking, with 1 in 10 having to leave work early feeling too ill to continue.

An analysis of studies reporting on the impact of workplace interventions relating to alcohol consumption and alcohol related behaviour has shown that they are effective in helping employees with alcohol problems.  One study, which included the training and education of staff, reported employees reducing their alcohol intake by 50%.

Facts, Figures, Trends

Nationally, 90% of the adult population drink alcohol, with over a quarter of the population estimated to be drinking at hazardous levels. 

Alcohol dependence

Harmful drinking represents the most hazardous use of alcohol at which damage to health is likely.  One possible outcome of harmful drinking is alcohol dependence where the person has a strong desire to consume alcohol and finds it difficult to control their drinking.

Nationally, the prevalence, or total number of people aged 18-64 years predicted to be alcohol dependent is 5.9% (8.7% of men, 3.3% of women).  For men, the highest levels of dependence were identified in those between the ages of 25 and 34 (16.8%), for women in those between the ages of 16 and 24 (9.8%).  Most recorded dependence was categorised as mild (5.4%), with relatively few adults reporting symptoms of moderate or severe dependence (0.4% and 0.1% respectively).  Alcohol dependence was more common in white men and women than in those from minority ethnic groups and there were no significant variations in the prevalence of dependence by region or income (PANSI, 2012).

Local context

In 2011/12 there were approximately 318 alcohol specific hospital admissions per 100,000 in Bedfordshire, 178 of which were from Bedford Borough.  Alcohol specific conditions are those wholly related to alcohol e.g. alcoholic liver disease or alcohol overdose.  During April to September 2012 there were 89 admissions from Bedford Borough, a decrease of 2 compared with the same period in 2011.

Graph 1:

Adult Alcohol 1 2013

Source: Public Health Intelligence, 2012

*Standardised rates take into account differences between the age structures of populations.

 

In 2011/12 there were approximately 3,107 alcohol related hospital admissions per 100,000 population in Bedfordshire, 1,613 of which were from Bedford Borough.  Alcohol related (or attributable) admissions are alcohol specific conditions plus conditions that are caused by alcohol in some, but not all, cases e.g. stomach cancer and unintentional injury.  During April to September 2012 there were 809 admissions from Bedford Borough, an increase of 13 compared with the same period in 2011 (see graph 2).

 

Graph 2:

 

Adult Alcohol 2 2013

Source: Public Health Intelligence, 2012

Alcohol dependence

The number of people in Bedford Borough who are alcohol dependent is expected to rise over the next 5 years, from 6,115 people in 2012 to 6,279 in 2016 (see table 1).

 

Table 1: Number of people aged 18-64 years predicted to have alcohol dependence in Bedford Borough

 

2012

2013

2014

2015

2016

 

Rate

Number

Rate

Number

Rate

Number

Rate

Number

Rate

Number

Males

 

4,428

 

4,437

 

4,463

 

4,515

 

4,550

Crude rate of males

9.2%

 

9.2%

 

9.1%

 

9.1%

 

9.1%

 

Females

 

1,686

 

1,696

 

1,709

 

1,716

 

1,729

Crude rate of females

3.4%

 

3.4%

 

3.4%

 

3.4%

 

3.4%

 

Total

 

6,115

 

6,133

 

6,172

 

6,231

 

6,279

Crude Rate of Total

6.3%

 

6.2%

 

6.2%

 

6.2%

 

6.2%

 


 Source: table developed by the Public Health Intelligence Unit (PHIU) using PANSI, 2012 and Census 2011 Data Population Projections by Unitary Authority from ONS

The data in table 1 is based on a survey of the household population and is therefore likely to under-represent the number of dependent adults, as they are more likely to be homeless or in an institutional setting.  In addition, problem drinkers who do live in private households may be less available, able or willing to participate in surveys (PANSI, 2012).

 

Table 2:

 

Bedford Borough

East of England

People aged 16+, drinking at a level which increases the risk of damaging their health

 

21%

 

 

17%

Higher risk drinkers*

 

3%

(n = 3,389)

 

N/A

Increasing risk drinkers**

 

21%

(n = 22,353)

N/A

Lower Risk Drinkers***

 

76%

(n = 79,748)

N/A

Alcohol-related healthcare costs (2010/11)

£59 per adult

(£7.6m)

£62 per adult

Source: Alcohol Concern, 2012

*Drink at very heavy levels which significantly increases the risk of damaging health and may have already caused some harm to health

**Drink above the recommended levels which increases the risk of damaging health

***Drink within the recommended alcohol guidelines

 

Current Activity and Services

The lead commissioner for adult drug and alcohol services is B:DAAT (Bedfordshire Drug and Alcohol Action Team) which, as from 1st April 2013, sits within Public Health.  The team is responsible for coordinating and commissioning the drug, and more recently, alcohol related work across Bedfordshire.  It is the multi-agency, strategic body which develops, implements and delivers, substance misuse annual action plans, setting out the County's strategy and targets for the year.  B:DAAT responds to local issues and works in partnership with a range of stakeholders, including local communities.

CAN Partnership

In 2012 the CAN Partnership was awarded the contract to deliver the Bedfordshire integrated drug and alcohol service.  The new integrated service provides access to a full range of medical, psychological and social options from hubs in Dunstable and Bedford, and a satellite in Leighton Buzzard.  It supports service users throughout their treatment journey with an emphasis on the individuals’ recovery from alcohol misuse.

Community engagement, support and development run in tandem with traditional forms of treatment such as:

 

  • Open access
  • Harm reduction
  • Motivational enhancementStructured counselling
  • Low-threshold therapeutic groups programmes
  • Appropriate medical prescribing
  • Mental and physical health support

 

Medical and psychological services within HMP Bedford also form part of the integrated service within the community, by offering robust continuity of care for all clients in the criminal justice system.

http://can.org.uk/

 

Alcohol Identification and Brief Advice (IBA) training

Opportunistic case finding followed by the delivery of simple alcohol advice.

 

Making Every Contact Count (MECC)

Involves frontline staff systematically delivering timely, pertinent and consistent lifestyle messages during routine contacts.

 

Workplace Health

Alcohol awareness information and IBA training is incorporated within the support offered to local employers

 

Health Checks

The NHS Health Check programme is for adults in England aged between 40 and 74. At an NHS Health Check a series of routine tests are offered to help identify the risk of developing heart disease, stroke, kidney disease and type 2 diabetes.  Alcohol is now routinely included in Health Checks screening.

 

Community Alcohol Liaison Service (CALS)

CALS ensures individuals identified as experiencing alcohol related problems receive appropriate and timely support and, if required, referral to a specialist alcohol treatment service.

 

Local Views

The Bedford Borough Alcohol Strategy was developed in consultation with a wide group of professionals. The strategy was presented and emailed extensively. A countywide strategy group was set up and they were primarily responsible for the content and structure.  Some of the members invited to the group included:

 

Police/ Fire/ Probation/ Licensing/ Trading Standards/ Community Safety/ Hospital/ Victim Support/ Education/ Can Partnership/ Plan B/ Children’s Services/ B:DAAT/ Housing.

 

National and Local Strategies

The 2012 Government‘s Alcohol Strategy sets out proposals to clampdown on the 'binge drinking' culture; reduce alcohol fuelled violence and disorder and reduce the number of people drinking to damaging levels.  The strategy includes commitments to:

 

  • Introduce a minimum unit price for alcohol which will target the cheapest products and help reduce drinking in those who drink the most
  • Consult on a ban on the sale of multi-buy alcohol discounting
  • Introduce stronger powers for local areas to control the density of licensed premises, including making the impact on health a consideration for this
  • Pilot innovative sobriety schemes to challenge alcohol-related offending

 

The government has already legislated for a wide set of reforms to tackle binge drinking and the effect it has on individuals and communities, however additional work is required to tackle drink-fuelled, antisocial behaviour and crime.  In light of this, a national alcohol strategy consultation is currently taking place, seeking views on five key areas:

  • A ban on multi-buy promotions in shops and off-licences to reduce excessive alcohol consumption
  • A review of the mandatory licensing conditions, to ensure that they are sufficiently targeting problems such as irresponsible promotions in pubs and clubs
  • Health as a new alcohol licensing objective for cumulative impacts so that licensing authorities can consider alcohol-related health harms when managing the problems relating to the number of premises in their area
  • Cutting red tape for responsible businesses to reduce the burden of regulation while maintaining the integrity of the licensing system
  • Minimum unit pricing, ensuring for the first time that alcohol can only be sold at a sensible and appropriate price

 

In the event that new policy is released as a result of this consultation (the consultation period finishes in February 2013), local action plans will be updated accordingly.

 

The new Public Health Responsibility Deal collective pledge (Home Office, 2012), which was announced in conjunction with the Government’s Alcohol Strategy, is to take one billion units of alcohol out of the market by 2015.  This will be achieved through improving the choice available of lower strength products.  Companies have committed to helping their customers to drink within the guidelines by improving consumer choice by lowering the strength of existing brands, introducing new lower strength products and encouraging their customers to switch to lower unit drinks rather than similar drinks with a higher unit content.

 

Estimates suggest that in a decade, removing one billion units from sales would result in almost 1,000 fewer alcohol related deaths per year; thousands of fewer hospital admissions and alcohol related crimes, as well as substantial savings to health services and crime costs each year (Home Office, 2012).

 

National outcomes, as identified in the Government’s Alcohol Strategy, include:

  • Changes in attitudes so that people think it is not acceptable to drink in ways that could cause harm to themselves or others
  • Reduction in the amount of alcohol-fuelled crime, especially violent crime
  • Reduction in the number of adults drinking above the NHS guidelines
  • Reduction in the number of people binge drinking
  • Reduction in the number of alcohol related deaths
  • Sustained reduction in both the numbers of 11-15 year olds drinking alcohol and the amounts consumed

 

In October 2012, a local government public health briefing paper was published which summarises NICE (National Institute for Health and Clinical Excellence) recommendations for local authorities and their partner organisations, on how to reduce the harm caused by alcohol.  It suggests that local authorities:

  • Can influence where and when alcohol is consumed or sold
  • Can enforce laws on underage sales
  • Have an important role in ensuring licensed premises operate responsibly and collaborate to reduce alcohol related harm
  • Have a role in promoting and advising people about sensible drinking
  • Have responsibility for commissioning alcohol prevention and specialist treatment
  • Have responsibility for health checks which, from April 2013, will include an assessment of how much alcohol someone drinks.

 

What are the key inequalities?

Alcohol is strongly linked to health inequalities.  It has an inverse social gradient which means that consumption increases as income rises; the proportion of people exceeding the sensible drinking guidelines also rises in line with income. 

 

Children from higher income households in England appear to be at greater risk of some types of adolescent alcohol problems and these risks appear different in girls compared to boys.  Childhood social advantage may not generally be associated with healthier behaviour in adolescence (Melotti et al, 2012)

 

Among men and women aged 16-64 years, those in professional and managerial households are most likely to have drunk alcohol in the previous week; those in semi-routine and routine occupations are the least likely.  This is also true in the proportions drinking on 5 days or more in the previous week.  Similarly, those working are more likely to drink and binge drink than those who are unemployed and economically inactive (Harker, 2010).

 

However, while people with lower socioeconomic status are more likely to abstain altogether, if they do consume alcohol they are likely to suffer greater harm from drinking than those from higher socioeconomic groups.  They are more likely to:

  • Have problematic drinking patterns and dependence
  • Die, in part, as a result of alcohol
  • Die of an alcohol specific cause
  • Be admitted to hospital due to an alcohol use disorder (Marmot 2010)

 

There is additional evidence to suggest that the following groups may be at higher risk of alcohol misuse:

  • People with mental health problems.
  • Lesbian, gay and bisexual people – a number of small studies in the UK suggest that there are higher levels of alcohol misuse among this group of people (BMA, 2008).
  • Transgender people – the Department of Health (2007) recognises that the experiences of transgender people, particularly the younger population, can place them at risk of alcohol abuse, as well as depression, self-harm and substance abuse.
  • Short term prisoners – Brooker et al (2009) found that 44.4% of short term prisoners were at risk of alcohol abuse; this is five times greater than the percentage of people misusing alcohol within the general population.

 

Ethnicity and alcohol

Most minority ethnic groups have higher rates of abstinence, and lower levels of frequent and heavy drinking compared to the British population as a whole, and to people from white backgrounds.  However over time, generational differences may emerge and there is some research to show that patterns of drinking in second generation minority ethnic groups may start to resemble the drinking habits of the general population.

 

Drinking patterns vary both between and within minority ethnic groups.  For example:

•      Abstinence is high amongst South Asians, particularly those from Pakistani, Bangladeshi and Muslim backgrounds.  However Pakistani and Muslim men who do drink, do so more heavily than other non-white minority ethnic and religious groups.

•      People from mixed ethnic backgrounds are less likely to abstain and more likely to drink heavily compared to other non-white minority ethnic groups.

•      People from Indian, Chinese, Irish and Pakistani backgrounds on higher incomes tend to drink above recommended limits.

•      Frequent and heavy drinking has increased for Indian women and Chinese men.

•      Drinking among Sikh girls has increased, whilst second generation Sikh men drink less than first generations.

 

The reasons for these variations in drinking patterns amongst minority ethnic groups are varied.  Although patterns among some first generation minority ethnic groups resemble those from their country of origin, stress associated with migration among first generations has also been linked with increases in drinking, particularly among white ethnic groups.  The experiences of moving to a new country can be affected by a number of factors including access to education and employment, changes to socio-economic status and peer influences and lifestyle choices.

 

In general, studies suggest that abstinence and low levels of drinking among non-white ethnic groups are associated with a strong ethnic identify, strong family and local community ties, continuing links with the host country and maintaining religious beliefs (Hurcome et al, 2010)

 

Alcohol and Older People

There has been a marked increase in alcohol consumption by the middle and older age groups, with approximately a third of older people developing alcohol problems for the first time later in life.  Although the exact reasons for this are unclear, there is likely to be a link with the ageing population and a greater number of people living alone with poor social support networks, leading to loneliness.  Other reasons include diminished mobility, multiple bereavements, chronic pain, poor physical health and poor economic and social support networks.

 

Alcohol problems are less likely to be detected in older people as they are more likely to try and hide the problems through shame and embarrassment.  It can also be difficult to distinguish the symptoms of alcohol problems in older people, from the symptoms caused by medical or psychiatric problems of ageing.

 

What are the unmet needs/service gaps?

 

The evidence suggests that minority ethnic groups are under-represented proportionately in seeking treatment and advice for drinking problems, although their rates of alcohol dependence are similar to those in the white population. 

 

A lack of awareness of what support and services are available is evident among some minority groups, particularly Muslim men and those on lower incomes.  There is also a reluctance to approach outside agencies across different minority ethnic communities which can lead to agencies underestimating need among different ethnic groups (Hurcombe et al, 2010).

 

Public Health are undertaking a mapping exercise around existing services and partners planned interventions around alcohol to inform a comprehensive Bedford Borough Action Plan.

 

Recommendations
  • Ensure people drinking at increasing or higher-risk levels are identified and supported early (In particular Older People and BME communities)
  • Involve families in commissioning decisions, the design of health services and alcohol campaigns.
  • Use a range of media channels to convey consistent and relevant messages.
  • Reach out to the hard to reach, particularly those who do not access mainstream services
  •  Provide tailored support for patients regularly attending A&E and Primary Care for alcohol related issues:
  • Ensure specialist and timely alcohol treatment services / interventions are in place for adults:
  • Use multi agency data to inform future commissioning decisions and ensure resources are targeted more effectively:
  • Explore new approaches to raising awareness and discussing alcohol and related issues, within minority ethnic communities
  • Ensure mainstream alcohol services are culturally competent for both individuals and organisations

 

References

Alcohol Concern (2011) Making alcohol a health priority: Opportunities to reduce alcohol harms and rising costs London: Alcohol Concern

Alcohol Concern (2012) Alcohol-related healthcare costs.  Available at: http://www.alcoholconcern.org.uk/campaign/alcohol-harm-map

Department of Health (2007) Tackling health inequalities: 2007 status report on the Programme of Action. London: The Department.

Department of Health. & National Treatment Agency for Substance Misuse (2012) Statistics from the National Drug Treatment Monitoring System – Statistics relating to young people England, 1 April 2011 – 31 March 2012. Manchester: National Drug Evidence Centre.

Garbatt, A (2010) “Hung over at work? You're far from alone” The Guardian, 26 May 2010 (online).  Accessed at: http://www.guardian.co.uk/uk/2010/may/26/hangover-hung-over-work-drinkaware (accessed 26 June 2013)

Harker, R. (2012) Statistics on Alcohol. London: House of Commons Library.

HM Government (2012) The Government’s Alcohol Strategy. London: The Stationery Office.

Hughes, K. et al (2006) Youth violence and alcohol in North West Public Health Observatory. (2012) Protecting people Promoting health – A public health approach to violence prevention for England. Liverpool: The Centre for Public Health.

Hurcombe, R, et al (2010) Ethnicity and alcohol: a review of the UK literature. York: Joseph Rowntree Foundation.

nstitute of Alcohol Studies (2010) Adolescents and Alcohol – IAS Factsheet. Cambridge: IAS

LAPE (2012) Local Authority Profiles. Available at: http://www.lape.org.uk/

Labhart, F., Graham, K., Wells, S, & Kuntsche, E. (2013) ‘Drinking before going to licensed premises: An event-level analysis of predrinking, alcohol consumption, and adverse outcomes’ in journal Alcoholism: Clinical & Experimental Research, 37, 2, pp. 284-291

Ling, J., Smith, K., Wilson, G., Brierley-Jones, L., Crosland, A., Kaner, E., & Haighton, C. (2012) ‘The ‘other’ in patterns of drinking: A qualitative study of attitudes towards alcohol use among professional, managerial and clerical workers’ in journal BMC Public Health, 12, pp. 892 

Local Government Association (2013) Tackling drugs and alcohol. London: Local Government Association.

Marmot, M. (2010) Marmot Review – Fair Society, Healthy Lives: A Strategic review of Health Inequalities in England. Available at http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report

Melotti, R. Lewis, G., Hickman, M., Heron, J., Araya, R. and Macleod, J. (2012) ‘Early life socioeconomic position and later alcohol use: birth cohort study’ in journal Addiction

Moyer, A., Finney, J., Swearingen, C. and Vergun, P. (2002) ‘Brief Interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment -seeking and non-treatment seeking populations’, in journal Addiction, 97, pp. 279-292.

 

1. Everyone between the ages of 40 and 74, who has not already been diagnosed with one of the following conditions, is invited by their GP to have a check to assess their risk of heart disease, stroke, kidney disease and diabetes.  Local authorities become responsible for commissioning the NHS health check from April 2013.

2  In dicators to be confirmed by the National Treatment Agency.

3  Consuming more than double the recognised lower-risk daily limits over a short period of time.

4  Drinking at home before going out

 

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