1. South East Regional Public Health Group Information Series 1 Alcohol, Health and Wider Social Impact Why is Alcohol Important? Individual and Social Well-Being:  Harmful drinking is among the foremost underlying causes of disease, injury, violence – especially domestic violence against women and children – disability, social problems and premature deaths;  It is associated with an increased risk of a wide range of health and social problems, including brain damage, alcohol poisoning, breast cancer, skeletal muscle damage and accidents, violence and criminal behaviour;  It is also associated with mental ill-health, has a serious impact on individual well-being and that of families, communities and society as a whole, and contributes to social and health inequalities. Between 780,000 and 1.3m children are affected by parental alcohol problems. This makes them 4 times more likely to suffer from a psychiatric disorder by the age of 15 than the national average and increases the risk of aggressive behaviour, delinquency, hyperactivity and other forms of conduct disorder;  The risk of harm associated with alcohol consumption is also particularly relevant for driving, in the workplace and during pregnancy. Economy:  The economic loss to society resulting from harmful alcohol consumption is also worrying. In England this amounts to £6.4 billion a year in lost productivity through increased absenteeism, unemployment and premature death;  A recent EU report[1] estimates that using taxation to raise the price of alcohol by just 10% within the EU’s 15 wealthiest member states would save 9,000 lives within one year, as well as generating €13bn (roughly £8.9[1] billion) in excise duty. Crime and Disorder:  Alcohol related violence not only represents a significant public health challenge it also a major contributor to social exclusion and the fear of crime. Alcohol related violence and other antisocial behaviour represent significant public health challenges;  Alcohol related crime and disorder are thought to cost up to £7.3 billion a year with alcohol treatment costing the NHS £1.7 billion a year. It is also responsible for about ⅓ of A&E attendances, rising to 70% during the night and about 150,000 hospital admissions per annum. Alcohol and Young People:  Binge drinking has been recognised as especially harmful behaviour. The UK also has some of the highest levels of drunkenness among young people in Europe. 76% of 15-16 year olds report to having been drunk at least once and 29% attest to having been drunk 20 or more times;  The UK is one of the top binge drinking nations in western Europe, binge-drinking 28 times per year on average – about once every 13 days. Adolescents are also the third-worst binge-drinkers in the EU, with more than a quarter 15-16 olds binge-drinking 3-or-more times in the last month[1].[1] [1] Ibid. [1] Alcohol in Europe: A public health perspective. June 2006 Institute of Alcohol Studies. http://ec.europa.eu/health-eu/news_alcoholineurope_en.htm[1] http://ec.europa.eu/health-eu/news_alcoholineurope_en.htm Vision Promoting sensible drinking and reducing the harmful consequences of alcohol. PROTOTYPE – AUGUST 2006 This information series has been compiled by the Regional Public Health Group based in the Government Office of the South East. They aim to summarise key public health issues based upon evidence, in order to facilitate good practice and improve health at local and regional levels. They are NOT policy documents.

2. Current Situation (Health profile of South East population) Alcohol consumption in the South East remains stable but does exhibit an increasing gradient among women – see Figure 1. Figure 1: Drinking patterns over time. (Trends in age standardised mean alcohol consumption in units per week among men and women, South East England, 1994-6 to 2000-2). Source: Department of Health. Health Surveys for England 1994 to 2002. Drinking Patterns. Figure 1 illustrates the increasing trend in alcohol consumption among men and women in the South East compared to the England average. While Box 1 demonstrates the gap that exists between need and required provision to tackle some of the problems arising from consumption. Box 1: The gap between need and provision. The Alcohol Needs Assessment Research Project (ANARP) 2004 identified that the South East had:  184,000 dependent drinkers  22,000 dependent drinkers were referred to treatment services  9,000 were assessed by treatment services  This is about 5% of the dependent drinkers (in other words 1 in 20 people who required a service got a service) If the South East were to provide a minimal level of access (10%) they would serve 18,000 dependent drinkers good level of access (20%) they would serve 36,000 dependent drinkers

3. Figure 2: Proportion of males and females who drink over recommended limits. (Age standardised proportion of men drinking four or more units and women drinking three or more units of alcohol in the heaviest drinking day last week by Government Office Region, 2000-2 pooled.) Source: Department of Health. Health Surveys for England 1994 to 2002. Service Response:  There were low levels of identification, treatment and referral of patients with alcohol use disorders by GPs;  GPs tended to under-identify younger patients with alcohol use compared to older patients;  There were 43 per cent more agencies providing alcohol treatment services than previously identified. There are 696 treatment services in England;  Around £210m is spent each year on providing alcohol treatment in England;  There are 696 specialised alcohol treatment services in England. The majority of these are funded by the National Health Service (NHS) but run by voluntary organisations. Impact on Health:  £1.7bn is spent each year in England on dealing with alcohol-related illness;  There are over 30,000 hospital admissions annually for alcohol dependence syndrome;  There are up to 22,000 premature deaths per annum because of alcohol misuse.

4. Figure 3: Alcohol related hospital admissions. (Alcohol-attributable hospital admission rate by local authority, South East England, 1998-9 to 2002-3 pooled.) Source: Unit of Health Care Epidemiology, Oxford University. Linked Hospital Episode Statistics 1998-9 to 2002-3. Note: Figure shows spells-based hospital admission rates per 100,000 persons counting people each (and as many times as they were admitted) with any mention of alcohol as a contributory factor in the admission. What Works?  Cost Effectiveness of Treatment: evidence has demonstrated that alcohol treatments are highly cost effective in comparison with other health care interventions and there is a good economic case for investing in both brief interventions for hazardous drinkers and more intensive interventions for dependent drinkers;  Short and Long Term Savings: recent studies suggest that alcohol treatment has both short and long term savings and initial analysis from the UKATT Study suggests that for every £1 spent on treatment, the public sector saves £6;  Brief Interventions Reduce Alcohol Consumption: evidence shows that drinkers may reduce their consumption by as much as 20% as a result of a brief intervention and that heavy drinkers who receive an intervention are twice as likely to cut their alcohol consumption as heavy drinkers who receive no intervention;  As Cost Effective as Smoking Cessation: recent WHO study estimated that the cost effectiveness of alcohol brief interventions for hazardous and harmful drinking is approximately £1,300 per year of ill- health or premature death averted. This is nearly equivalent to the cost effectiveness of smoking cessations interventions which is about £1,200;  School-based Education Programmes: reviews of such approaches suggest a modest effect on alcohol consumption. Efforts to increase self esteem, mental health and general well-being of young people are more likely to have a greater impact on consumption and expressed problems.

5. Individual / Community:  Availability and price/strength of alcohol;  Alcohol exclusion zones;  Blood alcohol concentration laws can reduce alcohol related crash fatalities: The legal limit in the UK is 0.08% but reducing the limit reduces the crashes;  Sobriety checkpoints are effective;  Ignition interlock devices that immobilise the vehicles have evidence of effectiveness;  Server training programmes are also effective. A Summary of What Works: Alcohol screening is used to detect those individuals who are drinking above sensible levels. This is usually undertaken with a brief questionnaire. Brief intervention refers to advice and information that can be provided opportunely within a 5-10 minute interval but can also extend to a few sessions of on motivational interviewing or counselling. These interventions tend to be targeted at those drinking in a hazardous or potentially harmful fashion rather than dependent drinkers. By their very nature they are ideally suited to settings like primary care, A&E and a range of criminal justice venues making the most of opportunities with individuals who are in difficulty as a result of their alcohol consumption. Brief Interventions for a range of drink problems:  Brief interventions for heavy drinkers moderates drinking;  Multi contact brief interventions can reduce net weekly drinking;  Extended brief interventions in primary healthcare settings decreases alcohol intake in women;  Extended brief interventions in primary healthcare are effective for men and women for hazardous consumption;  Cognitive behaviour regarding interventions by nurse practitioners or brief advice reduces Consumption;  Brief interventions in opportunistic (non-treatment) settings and delivered by healthcare professionals;  Self help manuals are effective at reducing at-risk and harmful drinking especially with those seeking help and identified via screening;  Increase engagement by GPs in screening and giving advice for hazardous and harmful consumption. Treatment for heavy/hazardous drinking:  Community structured counselling and therapy;  Community detoxification via primary care;  Specialised residential services;  Self help groups.

6. Ways Forward Employment: The production and sale of alcohol make an important contribution to the economy by providing employment, export revenue for products and tax revenues in the order of £7 billion annually. However, this has to be set against the estimated cost of £7.3 billion associated with the health and crime and disorder outcome of alcohol itself. Workplace Policies: Many hazardous drinkers are employed and can be reached through workplace interventions by adopting alcohol policies. These set rules for alcohol consumption during and prior to working hours and include guidelines for advice on and management of hazardous drinking and alcohol problems. Licensing Committees: These have a unique role in reducing the impact of irresponsible licensees and promoting community safety through the management of alcohol retailing as it impacts on the night time economy. Figure 4: Model of interventions to reduce impact of alcohol.

7. National Drivers The Reform of the Licensing Laws 2003: In 2003, the UK Government announced a series of reforms to the Licensing Laws, which took effect in November 2005. These reforms give greater scope for:  Flexible opening hours;  Changes in the identity and accountability of the licensing authority;  Strengthened protection for children and young people under the age of 18. The Alcohol Harm Reduction Strategy for England: In 2004, the Government launched the ‘Alcohol Harm Reduction Strategy for England’, setting out a series of cross-agency measures designed to:  Tackle alcohol related disorder in town and city centres;  Improve treatment and support for people with alcohol related problems;  Clamp down on irresponsible drinks promotions by the industry;  Provide better information to consumers about the potential dangers of alcohol misuse. Choosing Health: Making Healthier Choices Easier: The Government’s White Paper, Choosing Health: Making Healthier Choices Easier was published in November 2004, setting out the following key aims:  Building on the commitments within the Alcohol Harm Reduction Strategy for England, investing in early intervention measures through the NHS;  Providing guidance and training to ensure all health professionals are able to identify alcohol related problems at an early stage;  Piloting approaches to targeted screening and brief intervention in both primary care and hospital settings;  Launching initiatives in partnership with the Criminal Justice System, to reduce re-offending, by ensuring that alcohol treatment needs are met alongside drug treatment needs;  Developing a programme to improve alcohol treatment services, based on the Models of Care Framework for alcohol treatment. The Alcohol Needs Assessment Research Project (ANARP): The Alcohol Needs Assessment Research Project (2005) gave the first detailed national picture of the need for treatment and the provision of alcohol services across the country. The key findings are as follows:  There is a high level of need for treatment across different categories of drinker. 38% of men and 16% of women aged 16-64 (approximately 8.2m people) have an alcohol use disorder in England;  The number of alcohol dependent individuals accessing treatment per annum is approximately 63,000, providing a ‘Prevalence Service Utilisation Ratio’ of 18. (i.e. 1 in 18 of the alcohol dependent population access treatment on a national basis). Alcohol Misuse Interventions: The Alcohol Misuse Interventions report was published by the Department of Health in 2005 and builds on the findings of the ANARP report, outlined in brief above. It presents powerful economic arguments for action to tackle alcohol misuse and provides guidance on developing and implementing programmes that can improve the care of hazardous, harmful and dependant drinkers.

8. Children and Young People’s Block:  Increase the protective factors for high risk young people;  Reduce the number of young people drinking alcohol. Suggested areas to consider developing into an LAA:  Develop and extend parenting programmes that increase the protective factors for young people;  Develop a range of responses in A&E to young people attending/being admitted for severe alcohol intoxication;  Address underlying risk factors for alcohol use among young people. Substance misuse among young people can be driven by emotional distress, thus mental health promotion and violence prevention programmes are likely to be more appropriate at having an impact on behaviour. School-based mental health promotion prevention programmes are more likely to be a better investment than programmes which specifically target alcohol misuse. Safer and Stronger Communities Block:  Reduce the proportion of adult and young offenders, and prolific and other priority offenders who re-offend;  Reduce violent crime, including alcohol related violence, domestic violence, sexual offences, hate crime and the use of weapons;  Reduce recorded criminal damage (including damage not included in BCS comparator crime, such as that to commercial and public property);  Reduce the proportion of adults saying that they are in fear of being a victim of crime;  Reduce underage sales of alcohol. Suggested areas to consider developing into an LAA:  Establish data sharing protocols between A&E and the local CDRP to reduce alcohol-related assaults particularly associated with the night-time economy. Other issues like domestic violence and sexual assault should be addressed via a stronger partnership arrangements focused on victim services, e.g. screening for DV, use of SARCs and use of refuges with the VCS;  Scheme to identify volume offenders and provide brief interventions in CJS settings;  Provision of alcohol arrest schemes to reduce number of alcohol dependent drinkers in the CJS. Healthier Communities and Older People Block:  Alcohol-related hospital admissions, rate per 100,000 population per year;  Number of young people drinking alcohol;  Increase the number of offenders participating in alcohol treatment programmes. Suggested areas to consider developing into an LAA:  Identify at-risk patients via screening in primary care settings, including A&E, criminal justice settings and give brief intervention and structured advice;  Development and implementation of local Alcohol Harm Reduction Strategy. Economic Development Block:  Increase work productivity;  Reduce accidents associated with the workplace. Suggested areas to consider developing into an LAA:  Implementation of alcohol policy in workplace;  Implementation of Employee Assistance Programmes;  Presence of regular alcohol education programmes for staff. Local Area Agreements Indicators proposed in guidance and areas to consider

9. Indicators in the National Indicator Set that link to alcohol misuse Safer communities NI 15 Serious violent crime rate NI 17 Perceptions of anti-social behaviour NI 18 Adult re-offending rates for those under probation supervision NI 19 Rate of proven re-offending by young offenders NI 20 Assault with injury crime rate NI 32 Repeat incidents of domestic violence NI 38 Drug-related (Class A) offending rate NI 39 Alcohol-harm related hospital admission rates NI 40 Drug users in effective treatment NI 41 Perceptions of drunk or rowdy behaviour as a problem NI 47 People killed or seriously injured in road traffic accidents Children and young people NI 50 Emotional health of children NI 58 Emotional and behavioural health of children in care NI 65 Children becoming the subject of a Child Protection Plan for a second or subsequent time NI 70 Hospital admissions caused by unintentional and deliberate injuries to children and young people NI 72 Achievement of at least 78 points across the Early Years Foundation Stage with at least 6 in each of the scales in Personal Social and Emotional Development and Communication, Language and Literacy National indicators NI 87 Secondary school persistent absence rate National indicators NI 110 Young people’s participation in positive activities NI 111 First time entrants to the Youth Justice System aged 10 – 17 NI 112 Under-18 conception rate NI 113 Prevalence of Chlamydia in under 20 year olds NI 114 Rate of permanent exclusions from school N115 Substance misuse by young people Adult health and wellbeing NI 119 Self-reported measure of people’s overall health and wellbeing NI 120 All-age all cause mortality rate NI 121 Mortality rate from all circulatory diseases at ages under 75 NI 122 Mortality from all cancers at ages under 75 NI 134 The number of emergency bed days per head of weighted population NI 136 People supported to live independently through social services (all ages) NI 137 Healthy life expectancy at age 65 NI 138 Satisfaction of people over 65 with both home and neighbourhood Tackling exclusion and promoting equality NI 141 Number of vulnerable people achieving independent living NI 142 Number of vulnerable people who are supported to maintain independent living NI 143 Offenders under probation supervision living in settled and suitable accommodation at the end of their order or licence NI 144 Offenders under probation supervision in employment at the end of their order or licence NI 149 Adults in contact with secondary mental health services in settled accommodation NI 150 Adults in contact with secondary mental health services in employment Local Economy NI 152 Working age people on out of work benefits NI 153 Working age people claiming out of work benefits in the worst performing neighbourhoods NI 156 Number of households living in Temporary Accommodation NI 173 People falling out of work and on to incapacity benefits Environmental sustainability NI 195 Improved street and environmental cleanliness (levels of graffiti, litter, detritus and fly posting) (List provided by Alcohol Concern LAA Factsheet Dec 2007)

10. References and Resources Breakdown by Regions and Local Authority Area by range of indicators. NW Public Health Observatory Data  Alcohol Harm Reduction Strategy for England, 15 March 2004: http://www.strategy.gov.uk/output/page3669.asp Alcohol Harm Reduction Strategy for England, 15 March 2004: http://www.strategy.gov.uk/output/page3669.asp  Alcohol Needs Assessment Research Project, and Models of Care for Alcohol Misusers are available at: http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/AlcoholMisuse/fs/en Alcohol Needs Assessment Research Project, and Models of Care for Alcohol Misusers are available at: http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/AlcoholMisuse/fs/en  Choosing Health: Making healthier choices easier: http://www.dh.gov.uk/PublicationsAndStatistics/Publications%2fPublicationsPolicyAndGuidance%2fPub licationsPolicyAndGuidenceArticle%2ffs%fen?CONTENT ID=4094550&chk=N5Cor Choosing Health: Making healthier choices easier: http://www.dh.gov.uk/PublicationsAndStatistics/Publications%2fPublicationsPolicyAndGuidance%2fPub licationsPolicyAndGuidenceArticle%2ffs%fen?CONTENT ID=4094550&chk=N5Cor  Department of Health: alcohol misuse: http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/AlcoholMisuse%2ffs%2fen Department of Health: alcohol misuse: http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/AlcoholMisuse%2ffs%2fen  The Licensing Act 2003: http://www.hmso.gov.uk/acts/acts2003/20030017.htmLicensing Act 2003:http://www.hmso.gov.uk/acts/acts2003/20030017.htm  Prevention and reduction of alcohol misuse. Evidence briefing summary, March 2005, HDA http://www.publichealth.nice.org.uk/page.aspx?o503424  Prevention of alcohol misuse, HDA, October 2004 http://www.publichealth.nice.org.uk/page.aspx?o=502745  Binge drinking in the UK and on the continent (Choosing Health? Briefing), HDA, June 2004 http://www.publichealth.nice.org.uk/page.aspx?o=502777  Alcohol Needs Assessment Research Project (ANARP) 2004 http://www.nwph.net/nwpho/Lists/Alcohol/AllItems.aspx  Deehan, A – Alcohol and Crime: taking stock. Home Office Crime Reduction Series paper 3 1999. http://www.crimereduction.gov.uk/drugsalcohol8.htm http://www.crimereduction.gov.uk/drugsalcohol8.htm  Cheers? Understanding the relationship between alcohol and mental health. The Mental Health Foundation 2006. http://www.mentalhealth.org.uk/page.cfm?pagecode=PRAW#report  The British Crime Survey Sept. 2003 http://www.homeoffice.gov.uk/rds/bcs1.htmlhttp://www.homeoffice.gov.uk/rds/bcs1.html  Omnibus Survey: Nationally representative household survey among adults aged 16 and over in England & Wales which includes alcohol. http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/StatisticalCollection/DH_4100251 http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/StatisticalCollection/DH_4100251 Safe.Sensible.Social. The Next Steps in the National Alcohol Strategy, 2007; www.dh.gov.uk/publications www.dh.gov.uk/publications For further information please contact: david.sheehan@dh.gsi.gov.ukdavid.sheehan@dh.gsi.gov.uk For additional copies of the Information Series please visit http://www.sepho.org.uk/viewResource.aspx?id=10297 http://www.sepho.org.uk/viewResource.aspx?id=10297