Director of Public Health Annual Report 2019: Alcohol and us
What works to reduce alcohol harms
Action to reduce alcohol consumption and its related harm needs national and local action. The greatest chance of improvement is when policies complement and reinforce each other because they create a ‘critical mass’ effect and change what is considered socially normal drinking to help reduce alcohol-related harm.
Changes to national policy
According to an extensive review of the international evidence conducted by Public Health England, one of the most effective ways to reduce the harms of alcohol is through national policy.
Taxation and alcohol sales
Changing national policy on alcohol tax and sales are some of the most effective and cost effective ways to prevent alcohol consumption, and reduce alcohol-related harm.
Studies suggest a 10% increase in the price of alcohol would lead to a 5% decrease in its consumption and that doubling tax rates would decrease alcohol-related mortality by an average of 34.7%. For the same increase in taxation, traffic-crash deaths would decrease by 11.2%, sexually transmitted infections by 5.5%, and violence and crime episodes by 2.2% and 1.4% respectively. However, for taxation to be effective the price increase must be passed to the consumer.
Minimum pricing is a direct price control set by government aimed at preventing the sale of alcohol below a certain price. This often affects the high-strength, cheap products sold in supermarkets, off licences and grocery stores. Minimum prices effectively reduce health and other harms, and these benefits affect the heaviest drinkers who experience the greatest harm. For example, studies in Canada have showed a 10% increase in minimum prices of alcohol reduced: consumption of all beverages by 8.4%; wholly alcohol-related deaths within nine months by 32%; acute alcohol-related hospital admissions by 9%; and chronic alcohol-related hospital admissions by 9% two to three years after the policy was implemented. In addition, alcohol-related road traffic violations were reduced by 18.8% and crimes against persons reduced by 9.4%.
National policy on marketing
Regulating how companies promote alcohol can reduce drinking among young people. There is a strong body of research which says that exposure to alcohol marketing increases the risk that children will start to drink alcohol, or if they already drink, will consume greater quantities. This is also the case for digital marketing.
National policy on hours of alcohol sales
Policies that reduce the hours during which alcohol is available for sale, particularly late night in pubs and clubs, can substantially reduce alcohol- related harm in the night-time economy. This is especially so when they are enforced and are targeted at the most densely populated areas.
National policies to reduce drink driving
Enforcing drink driving legislation reduces road traffic crashes, casualties and fatalities due to alcohol. This includes policies which specify lower legal alcohol limits for young drivers. These are effective at reducing casualties and fatalities in this group so they have the potential to reduce inequalities given that the vast majority of harm on the road is experienced by young drivers.
What works at a local level
Increasing public awareness of the harms of alcohol, increasing knowledge of units, managing the drinking environment and supporting young people to make informed choices about drinking alcohol can help reduce the harms from alcohol.
Public information and awareness
Increasing knowledge and awareness about the harms of alcohol is important, and it increases public support for changes which have a greater impact on decreasing the harms of alcohol.
Education in schools
The evidence of what works for school based alcohol education is emerging. The best available evidence suggests that to be effective school-based drugs and alcohol education should teach a wide range of skills, such as problem solving, decision making, self-control, coping, and general social communication and assertiveness skills. In addition, strategies to recognise and resist family influences, peer pressure and media pressure and prevent the ‘normalisation’ of drinking alcohol. These should be part of wider programmes that target multiple risk behaviours, help build self-esteem and life skills.
There is considerably more and more robust evidence that shows what is ineffective in preventing alcohol and drug use amongst young people.
This includes providing information on its own and without reference to a wider context, fear arousal approaches; and using police officers in uniform. Teachers were found to be better able to manage the interactive model of learning which is more effective.
Managing the drinking environment
Research on managing the drinking environment in the UK is still emerging. This aims to reduce alcohol-related harm and intoxication, rather than long term health effects. Research suggests that programmes to manage the drinking environment should have many components and be implemented by multi-agency partnerships.
Treatment and brief interventions
Identifying people who are already drinking and are at risk, and providing brief advice is effective in reducing alcohol consumption and harm. This is also the case for providing specialist treatment for those with harmful drinking patterns and dependence.
Training the workforce
The earlier alcohol misuse is identified, the better. Some interventions that have been shown to help reduce alcohol misuse before it becomes an embedded problem are as follows:
Identification and Brief Advice
Identifying people early and giving them brief advice on how to reduce their alcohol drinking has been shown to provide a return on investment. Alcohol identification and brief advice (IBA) aims to find and support people who are at risk from harm due to their alcohol consumption.
Healthcare professionals can provide IBA as a short conversation, for example, while undertaking routine care in primary and community care or hospital.
IBA is best when it helps find and support the people who are not dependent on alcohol but they are drinking too much. IBA can reduce the amount a person drinks each week by 12% on average.
This level of reduction in drinking alcohol also saves £27 per person each year for four years due to fewer admissions to hospital related to their drinking. By delivering IBA in the NHS Health Check, it is estimated that over the last five years there were almost 1900 fewer deaths attributable to alcohol in England.
Recovery
The majority of people who suffer from an alcohol misuse disorder can recover with the right care and support, but it can take time for full recovery.
People who have misused alcohol report that recovery is a very personal concept and for many the goal is being ‘totally alcohol free’ and for things to be ‘less chaotic’. Many studies in the USA and the UK have shown that the following things help achieve these goals: developing supportive relationships with peers, family and friends; getting a job; having somewhere to live; being able to manage income and domestic arrangements; taking part in meaningful activities; caring for ones-self; having overall good health; and taking part in one’s community. By doing these things the studies show that people are more likely to function better, remain abstinent from alcohol, have better quality of life and lower stress. Studies stress the importance of a range of different organisations working together towards recovery such as substance misuse services, employment services, employers, housing providers and groups like Alcoholics Anonymous.
The view from Buckinghamshire’s alcohol services
Mark Prescott, the Clinical Lead at One Recovery Bucks, describes what recovery is and how One Recovery Bucks supports clients to recover from alcohol misuse.
"There is a common belief that ‘detoxing’ from alcohol is a quick fix, where someone can press the reset button and get on with their lives. Often people come to us wanting us to rescue them. In reality recovering from alcohol misuse is so much more than detox, which is a relatively short intervention, and it involves people making their own choices and decisions based on being given good, evidence-based information, treatment and support services.
Recovery is individual to that person. Recovery starts with someone accepting that their life is affected by alcohol, wanting and feeling ready to change. If someone wants to recover they may need support from a wide range of people in their community and family and friends. If they have lost the support of people around them there is work needed to repair those relationships and build new ones. Recovery may involve getting support for employment, housing, benefits, finance management and other aspects of life, whatever the goals of the individual may be.
When people come to us and they are ready to change, we start with a full health assessment, looking not just at their use of alcohol, but all the aspects of their life that surround this such as their emotions, their thoughts and behaviours, what they eat, how they sleep, their positive and negative coping skills, relationships, finance, and employment. We work with them to identify what life could look like for them without alcohol and how they may sustain this when they are abstinent.
When people are ready we support them with detox. This can be a risky procedure so it is carefully managed and monitored. Some people, who have good support at home and no other related health problems, may be able to detox at home. They can only do this if there is someone with them 24 hours a day who can dispense them their medication and call us if help is needed. For many people detox at home isn’t an option and they need hospital based detox. We have to make very complex decisions about people’s care, and my wish would be to be able to offer detox to more people that is appropriate to their need.
Alcohol services have changed over the last ten years and although we have clinicians like me, we also have a huge range of specialist staff that supports our service users with all aspects of recovery. When people can be aware of and work on all aspects of their life (not only the action of drinking alcohol) it allows them to build support and learn skills in all areas, increasing the likelihood of them achieving their recovery."
Alcoholics Anonymous also supports residents in Buckinghamshire.
"People use alcohol as an anaesthetic to life. Often AA is the last resort. It’s usually when life has reached crisis and people are really desperate that they find us. Regrettably, alcoholism is a disease that tells you that you don’t have it. The delusion is really strong, so for many people realising they have a problem and asking for help is not easy at all.
AA has 30 meetings in Buckinghamshire that take place on all days of the week and across the county. Probably about 600-700 people come to our meetings and the only requirement for membership is a desire to stop drinking. The disease is indiscriminate and people of all ethnicity, age, gender, and profession join our meetings. I’ve been part of AA for six years, and during that time I’ve seen an increase in the number of people attending. When I first started going to the Aylesbury meeting about 10 to 15 people came, now the number is about 20-30. Some meetings even have up to 50 or 60 people, although others often in rural areas are smaller with sometimes about five people. We are also seeing more and more people being referred from commissioned substance misuse services.
AA has a very good understanding of alcohol dependency, seeing it as having a physical aspect, such as cravings; a mental obsession whereby, between drinks, a person will frequently think about their next drink and obsessively think about all the reasons a drink is needed in a ‘washing machine head’ type way; and spiritual malady where people lack a meaningful, spiritual connection to life. Our 12 step programme helps people overcome all these three challenges, and many people stay connected to AA for years as it helps them through the challenges of life. Sadly, we can see people who leave us start drinking again months or years later with terrible consequences, though many do come back and find recovery.
The good thing about our recent growth is that as groups become bigger they have the potential to support people more effectively. When there are more people, new people find the wealth of experience, strength and hope in the meeting attractive and keep coming back. There are more people at different levels of their sobriety journey to help others and a lively atmosphere of smiling and laughing that is refreshing and enjoyable."