1. AGL – AUTONOMOUS GROUP LEARNING Learning in Small Groups with an Organizer AGL 51 - ALCOHOL CONTROL FOR YOUNG PEOPLE Easily adapted and simplified for age, education, local language, culture etc. with school support. Dr Bob Boland & Team MD, MPH (Johns Hopkins), ITP (Harvard) ex UN VERSION NO. 5 FOR ADAPTION & TESTING January 2015

2. ESSENTIAL INDIVIDUAL PRE-LEARNING BEFORE THE PROGRAM This is brief training to help young people with alcohol control. It is dedicated to those who try so hard to help others to avoid alcohol abuse. ¨Don’t be afraid to say No. Connect with your friends, and avoid negative peer pressure because you don't have to go along … to get along!¨ Alcohol may be good for health and morale, but alcohol abuse with uncontrolled drinking, can produce very serious damage: Neglecting Responsibilities at home, work, or school. For example: neglect of children, performing poorly at work, poor or failing grades in school, skipping out of commitments etc. Drinking Alcohol in Dangerous Situations. For example: operating machinery, driving, frequenting bad neighborhoods, mixing alcohol with medications etc.. Getting into Legal Problems. For example: legal arrest, fights, drunk, disorderly conduct, domestic disputes etc. Continual Relationship Problems. For example: with teachers, partners, friends and family etc.

3. ESSENTIAL INDIVIDUAL PRE-LEARNING BEFORE THE PROGRAM The program works well for a MG - Main Group of 24 persons, in 6 SG - small groups (4 persons), with an Organizer, and no need for an Instructor. It tries to be an amusing program, because we learn better when we can laugh. Perhaps check up on the key resource data for the program? It is an excellent free website: ICAP International Center for Alcoholic Policies: http://www.icap.org/LinkClick.aspx?fileticket=COm6IgHSbq4%3d&tabid=124#pag e11 The key measurement of alcohol control is BAC – Blood Alcohol Content. BAC under 0.020% is acceptable. BAC of 0.020% is 20mg per 100ml of blood). BAC up to 0.080% is with risk. BAC at 0.080% is intoxication. BAC at higher levels is with high risk. BAC above 0.30% can lead to death. Some useful alternatives to alcohol are listed in Appendix D (coming later). Question: Are you ready for the program?

4. INDEX POWERPOINT AUDIO VISUAL SLIDES Item Minutes Group PART I ‑ EARLY MORNING Sect. 1 – Introduction 10 MG Sect. 2 – Review 30 SG Sect 3 ‑ Study – Community & Body 20 MG/SG Sect. 4 ‑ Study – Drinking Measures 20 MG/SG Sect. 5 ‑ Review 20 SG Minimum minutes 120 Maximum 180

5. PART II ‑ LATE MORNING Sect. 6 ‑ Study – Promotion & Dangers 20 MG/SG Sect. 7 ‑ Case Studies 20 SG Sect. 8 ‑ Study – Lifestyle 20 MG/SG Sect. 9 – Review 30 SG Sect. 10 ‑ Learning Maintenance 10 MG Minimum minutes 120 Maximum 180 APPENDICES: A – Glossary B – Quiz & Answer Sheets C - Exercise D – Advice on Attitudes E - Further study & Powerpoint

6. PART 1 1. INTRODUCTION 1.1 Objectives The program is SG training for young people directly or indirectly involved in the motivation of alcohol control in a specific community. The specific learning objectives are: a. To become familiar with the language, customs and concepts of alcohol control in a community. b. To develop skills to help young people for both the prevention and management of alcohol control. c. To motivate young people to manage the risk of alcohol abuse in terms of: health, family, education, relationships, cultural impacts, health care etc. d. To motivate further study in the future..

7. Need to find ways to motivate young people to believe, that they can really achieve their very personal objectives, with mental and physical health, and without the harm caused by alcohol abuse, violence or damage to family and the community. 1.2 Syllabus Alcohol problems in the community. Alcohol problems in the body. Strength of alcohol drinks. Measures. Drinking and danger. Sobering up. Alcohol and life style. Binge drinking. Intoxication. The good news

8. 1.2 Guide to the Learning The AGL autonomous group learning system, creates a continually active learning environment, with lectures in MG Main Group, but mainly based upon learning in SG (4), with text and cases, assisted by an organizer. The two parts of the program can be completed in a morning or on separately. Each part involves a main group lecture and small group discussion of text and cases. Pre-learning with a 30 minute audio tape introduces the concepts and makes the learning easier. A quiz at the start and end of the program measures the progress. Review of the Glossary and other appendices and the KLP.s, reinforces the learning. Powerpoint audio visual for whole program.

9. 2. REVIEW (SG) – 30 minutes 2.1 First do the quiz (Appendix B) 2.1 Then briefly review the KLP - Key Learning Points

10. 3.0 STUDY - COMMUNITY & BODY (MG/SG) – 20 minutes 3.1 Impacts on the Community Common Signs and Symptoms of Alcohol Abuse include: a pattern of drinking that results in harm to health, interpersonal relationships and ability to work. Poverty is a significant factor in many countries leading to uncontrolled non-commercial, possibly toxic, alcohol markets. Producers and sellers of such alcohol are very active in the trade, because there is a huge demand for the product and they need some income. Consumers with very low income and choose local non-commercial alcohol drinks which may be toxic, because they cannot afford controlled commercial drinks.

11. 3.2 Risk They face many physical and mental health risks including: liver cirrhosis, cardiac failure, abdominal inflammation, pancreatitis, depression etc. Non-commercial alcohol drinks, are often produced in unsanitary conditions, using other toxic substances. In many countries one in six young people begin alcohol drinking by age 15, mainly non-commercial alcoholic drinks. For example: In Kenya consumption of muratina (karubu) is the most common, followed by many alternatives such as: changaa, busaa and miti ni dawa. Despite the government’s efforts to control, legalize and license improved commercial alcohol, many producers will not spend the time and money to obtain a license for proper production. Thus consumers continue to be at risk.

12. 3.3 Impacts in the Body As people who drink more alcohol, they become a louder, over- confident, lose their inhibitions, start to slur their words and finally to become unsteady on their feet, with difficulty in judging distances. The key measure of impact on the body is BAC. Blood Alcohol Content. It is the amount of alcohol in the blood and is determined by many factors: age, weight, sex, quantity and type of alcohol consumed, speed of drinking, on the amount of food in the stomach and past drinking history. BAC of 0.020% is 20mg per 100ml of blood. BAC under 0.020 is excellent. BAC up to 0.080 is with risk. BAC at 0.080 is intoxication. BAC at higher levels is with high risk. BAC above 0.300 can lead to death.

13. 3.4 Circulation of alcohol Alcohol is small molecules, absorbed into the blood. Alcohol not yet swallowed is absorbed rapidly directly into the blood through the lining of the mouth. Alcohol swallowed goes down to the stomach, which breaks it down in food and drink before passing it on to the small intestine, and then to the blood. All body cell membranes are highly activated by alcohol in the blood, which can move rapidly into nearly every tissue of the body. Excess alcohol can damage many different organs in the body. If there is no food in the stomach, then them alcohol passes rapidly and is absorbed into the blood, to circulate around the body and reach the brain, in about 5 minutes. This depresses the brain functions of behaviour and judgment. Alcohol reaches the liver in about 20 minutes, which processes and breaks it down, and removes it from the body in the urine, at the rate of 8 grams of alcohol per hour. Less than 10% alcohol is eliminated from the body in urine, breath and sweat. The rest is oxidized - this means, like food, it combines with oxygen in the blood to release heat, energy or calories.

14. 3.5 Effects The immediate effects of drinking, depends upon the amount of alcohol in the bloodstream (measured by Blood Alcohol Concentration - BAC). It varies with the speed of drinking, sex, weight and body composition etc. BAC affects of drinking the same amount of alcohol are: women more affected than men, a small person more affected than a big person, a person who has empty stomach more affected, than one who has eaten, a person who drinks rarely more affected than one who drinks regularly See the glossary for calculating number of grams of alcohol in any alcoholic drink. BAC of 0.020% is 20mg per 100ml of blood.). Women have a higher BAC than men after drinking the same amount, because they have less body fluid to dilute the alcohol. Many people still ask, “How much can I safely drink and still drive?” Answer, it all depends upon your BAC and the law. Small group (SG) discussion on issues arising.

15. 4.1 STUDY – DRINKING MEASUREMENT (MG/SG) – 20 minutes 4.1 Strength of Drinks BAC 0.02% can be expressed as 20mg per 100ml of blood. The legal limit is 0.08%!! The strength of alcohol drinks varies considerably with the same drink. For example, beer may have 2% to 9% alcohol by volume (BAC). Many alcoholic drinks are mixed with soft drinks or water, to make the alcohol strength and measurement, meet the agreed convention for a standard drink, in grams of pure alcohol (ethanol). In practice a “standard” drink will always has a given amount of pure alcohol, regardless of whether it is beer, wine or distilled spirits. Some countries have different standards, ranging from 8g to 14g per litre. Some countries have no “standard drink”.

16. In US one "standard" drink contains roughly 14 grams of pure alcohol, which is found in: 13.0 ounces - of regular beer, which is usually about 5% alcohol 5.0 ounces of wine, which is typically about 12% alcohol 1.5 ounces of distilled spirits, which is about 40% alcohol An understanding of the strength, risks and benefits of alcohol consumption is important for preventing harm.

17. 4.2 Guidelines Strength Guidelines provide people with a sound basis for making decisions about their drinking and may motivate them to change. Official guidelines on alcohol consumption are generally produced by relevant government departments (ministry of health or other department responsible for alcohol issues) and other guidelines come from medical associations. Some countries have set rules to define standard drinks- In the UK alcohol producers specify the number of UK units (8 grams of alcohol per litre) in a beverage.

18. 4.3 Measures It is useful for consumers to be able to assess “low-risk levels of consumption. However, different countries have different standard drink measures, generally ranging: from: 5g to 10g Some countries have standard measures for pouring drinks.in the law. UK requires a sign to be displayed stating the size of the unit measure for beer, wine and the spirits (vodka, gin, whisky and rum) being served. Consumers can assess “low-risk levels of consumption” of their drinks, if they take the trouble.

19. Some countries don’t have any rules to define a “standard drink”. See Glossary Exhibit 2 for quick computation of BAC based on weight and number of standard drinks. Simple practice: What is the BAC weight 120 pounds and for two drinks? Answer: 0.027 A reference to a more precise BAC computation for men and women with several factors (sex, drinking time, food input etc.) on the internet reference given in Exhibit 2. Small group (SG) discussion on issues arising.

20. 5.1 Case studies – SG discussion Brief cases for discussion, plus sharing personal group experiences and decision making: 5.2 KLP’s Briefly review again section 1.2 and resolve outstanding issues. Any changes?

21. PART 2 – LATE MORNING 6. STUDY – PROMOTION & DANGERS (MG/SG) – 20 minutes 6.1 Promotion Some countries may have laws governing allowed promotions for alcoholic drinks. Most countries attempt to dis-courage people to drink a lot of alcohol in a short space of time, since this creates intoxication, drunken behavior, crime, social disorder and associated health problems. Need to assess the effectiveness of alcohol laws and practices, which relate to promotion of alcohol in the community.

22. 6,2 Dangers The body begins to be adversely affected upwards from 0.02% BAC, which can be expressed as 20mg per 100ml of blood. Some countries regard 0.053 as impaired driving level. Generally 0.08% is the accepted final limit. – Intoxication! Most countries have laws about drinking and driving. In those that do, this varies from 0.00% BAC (“zero tolerance”), in Hungary and the Czech Republic, to 0.02%, in Norway and Sweden, and to the high 0.08%, as in Canada, New Zealand, the UK and the USA. With set legal limit, intoxication checking, with breathalyzers and blood samples can be used by police to calculate the alcohol concentration (BAC). Sometimes physical tests are also used to assess the intoxication level. For example: “walking in a straight line”.,

23. Many people ask, “How much can I safely drink and still drive?” Answer: depends on your BAC and the legal limits of the country inn which you are driving. They vary. (above). It is impossible to forecast accurately that a certain number of grams of alcohol or a certain number of drinks. will keep you below a government limit (0.80%) to allow safe driving, because BAC varies by each person’s characteristics: age, sex, size

24. Alcohol Server Liability Server liability may arise In a bar, by continuing to serve an nice intoxicated customer with more alcohol. Servers some countries (e.g. USA) may face legal action for any car accident by the drunken customer they continued to serve-.. So servers need to inform and control customer drivers against intoxication. They must check the facts and offer alcohol-free or low-alcohol alternatives. Servers also display details of local taxi services or bus timetables, to encourage the customer not to drive away.

25. 6.5 Sobering Up After excess drinking, hw to sober up or get rid of the alcohol from the body. There will be many answers which are completely wrong. For example: Drink coffee? No!! - coffee contains caffeine (which is a stimulant) and mixing it with alcohol (which is a depressant) can have harmful side effects. Drink water?. No!! – although this rehydrates the body, drinking water has no effect on getting rid of the alcohol. Be sick /vomit? No!! – this will only get rid of the alcohol in the stomach, not the alcohol already quickly absorbed into the bloodstream. … and one answer that is always right … Stop drinking and wait? Yes - nothing to do but wait for your liver to process the alcohol out of your body. It is a long process and takes 20 minutes to start at a steady rate of around 8g per hour. So 80 g will need eight hours or more.

26. 6.6 The Best Way The best way to avoid drunkenness is for each individuals to “pace” himself based on good experience of how his body reacts. That is, to drink at a rate no faster than the body can break down the alcohol. The time to get rid of ALL the alcohol in your system, maybe later the same day or even the next day after drinking a significant amount. Be careful. Small group (SG) discussion on issues arising

27. 7. CASES (SG) – 20 minutes 7.1 Case studies Brief cases for discussion, plus personal group experiences shared for decision making: After a party your father is about to drive you home, but he seems to have had far too much to drink. Action?

28. 8. STUDY – LIFESTYLE (MG/SG) – 20 minutes 8.1 Culture Depending on the culture of the country, drinkers may be 90% of the adult population. Young people tend some very creative excuses to follow the culture. Drinking tends to be part of most cultures, associated with good times in parties, events and celebrations and often used as a “release”, at the end of a hard day or week at work. Alcohol consumed in moderation, at the right time and place, is compatible with a healthy lifestyle, but so many people, especially student in groups, drink regularly to excess.

29. 8.2 Risk In some cultures alcohol producers or distributors add certain chemicals to enhance the brew’s potency. This may be very dangerous. Some people have lost their sight or their lives after consuming these beverages or over-consuming, with greater risk of developing health and other problems. Despite hygiene and safety issues, some toxic drinks continue to be consumed because they are the only beverage alcohol that many people can afford.

30. 8.3 Binges Binge Drinking – is defined drinking too much in a single hilarious group session. In the US it is 5 or more drinks for a man and 4 or more drinks for a woman in a single session. Excessive Consumption – is defined as drinking too much over a period of time. Accepted sensible drinking guidelines vary enormously between different country cultures. The short term effects excessive drinking, include: alcohol poisoning, violence, high risk of an accident and crime.

31. 8.4 Long Term Effects The many long-term binge effects include poor health of liver, stomach, pancreas, heart, brain etc... With excess alcohol, liver damage may result in fatty deposits, inflammation or even cirrhosis, leaving permanent damage. Excess alcohol has a corrosive impact on stomach linings, with esophagitis, gastritis, ulcers and reflux and severe damage to the pancreas. Drinking more than 80g alcohol a time is sometimes linked with a significant rise in blood pressure, increased risk of heart attack or stroke. Thus binge alcohol can affect almost all parts of the body adversely.

32. 8.5 Intoxication Need to be aware of the early signs of customer intoxication. Need to determine how many grams of alcohol are in 3 or 4 of the most popular types of drinks, regularly served to customers, and to set the possible limits. Need to know the laws in the country on measuring and limiting drinks before excess is served to a customer. Where there are no limiting laws, then service manager, must sets the criteria that would require refusal to serve an intoxicated customer Need to avoid extensive intoxication, with the community problems of accidents, violence, crime etc.

33. 8.6 The Good News By contrast, there are many well researched health benefits associated with low to moderate levels of alcohol drinking which is limited to the guidance levels. Alcohol can be a protective factor for the heart, but only at these low levels, but only for people over the age of 40 years. In addition to having fewer heart attacks and strokes, moderate consumers of alcoholic beverages (beer, wine and distilled spirits or liquor) are generally less likely to suffer strokes, diabetes, arthritis, enlarged prostate, dementia (including Alzheimer's disease), and several major cancers. Overall, moderate drinkers tend to have better health and live longer than abstainers or heavy drinkers. Alcohol control by young people must become a high community priority. Small group (SG) discussion on issues arising.

34. 9. REVIEW (SG) – 30 minutes Study again KLP’s in section 1.2 Discuss the way to complete the exercise Appendix C Do again the quiz in Appendix B and check results

35. 10. LEARNING MAINTENANCE (MG) – 10 minutes Study Appendix E Final SG discussion to resolve issues and provide suggestions for program improvement APPENDICES A: Glossary B. Quiz C. Exercise D. Alcohol alternatives E. Further study