ALCOHOL: THE BURDEN OF HARM
Although Scotland’s cultural heritage is linked to the production and consumption of alcohol, excess alcohol consumption is widespread and contributes to illness, injury and loss of life, as well as social consequences of family breakdown, crime and disorder and lost productivity.(82)
Industry sales show that “enough alcohol was sold in Scotland in each of the last three years to enable every man and woman over 16 years of age to exceed the sensible weekly guideline on each and every week.” It is estimated that alcohol misuse costs £2.25billion every year.(82)
Guidance regarding alcohol consumption is given as “units” of alcohol. One unit of alcohol contains 10ml or 8g of pure alcohol. This allows comparison of different alcoholic drinks with each other. Table 1 illustrates in summary the guidance for sensible drinking and definitions for alcohol consumption.
Alcohol Consumption Guidance
Hazardous drinking includes any drinking pattern exceeding the daily or weekly recommended limits without current harm. Harmful drinking is consumption of alcohol at a level which causes ill health frequently seen at consumption levels of more than 50 units of alcohol for men and 35 units for women.(83)
“I think the perception is that there are alcohol problems in the West of Scotland. I think it’s an area that you need to address as a society as a whole. I don’t think there is a quick fix to it but I think it is something that we need to be out in the open and deal with openly.”(20)
LOCAL SURVEY OF ALCOHOL CONSUMPTION
The Health and Wellbeing Survey of the NHSGGC population carried out in 2008 identified that among those who completed the survey (8,278 respondents), 35% never drink and 65% drank at least sometimes. Among those who do drink, 36% drink once or more a week and three percent drink 6-7 days a week.
Sixty one percent of respondents in the 15% most deprived areas drank at least sometimes, compared to 66% from other areas. Twenty eight percent of respondents from the 15% most deprived areas had a drink at least once in the past week, compared with 40% from other areas.
Detailed analysis of the drinking patterns of the local population is based on the responses of 60% of the sample who had a drink in the last seven days.
Consumption data from the local survey is based on revised assumptions about standard measures of alcohol in licensed premises and at home which have been used routinely by Alcohol Statistics Scotland 2009.
Thirty seven percent of the local sample of drinkers exceeded the weekly recommended drinking limits in the past week, ranging from 43% in males to 29% in females. There was little difference between residents living in the 15% most deprived areas compared with those living in other areas for both males and females; 44% of males living in the 15% most deprived areas compared to 42% of males living in other areas; 32% of females living in 15% most deprived areas compared to 29% of females living in others areas.
Figure 1 shows the percentage split of men and women by CH(C)P area that exceeded the recommended weekly alcohol limits compared to respondents who did not consume any alcohol the previous week.
% Exceeding Recommended Weekly Alcohol Limits by Gender Respondents Who Have
Had A Drink in the Past Week
A higher proportion of the population in younger age groups exceeded recommended drinking limits for both males and females, 47% males and 36% females under 45 years of age, compared with 26% males and 16% females aged over 65 years.
A comparison of alcohol consumption with Scottish figures obtained in 2007 is shown in Table 2.
NHSGGC and Scottish Alcohol Consumption Patterns (17,84)
Fifty nine percent of all drinkers had “binged” in the past week, 65% males, and 51% females. The definition of “binge drinking” is a man drinking more than eight units on a single day, or a woman drinking more than six units a day. Among males the overall proportion who binge drink did not vary between the 15% most deprived areas (59%) and the other areas (59%).
There was little difference in binge drinking between females living in the 15% most deprived areas and those living in other areas (50% compared to 49% respectively). There was little difference in the proportion of males who binge drink between the two areas, 66% in 15% most deprived areas, 65% in other areas. The binge drinking pattern was particularly common in young males, 75% under 45 years; 36% over 65 years; females 61% under 45 years; 24% over 65 years.
“Kids … they come up to you and say: “Can you buy me a drink?” You just look at the size of them… 10, 11 years old. I think it is a big problem around here.”(20)
There is particular concern about young people’s alcohol consumption. The results from surveys of secondary school children conducted in Glasgow city, Renfrewshire and West Dunbartonshire carried out in 2008 is compared with the summary of drinking behaviour of Scottish school children and is illustrated in Table 3. The data has been analysed and reported differently, therefore the summary table has been adapted to accommodate a range of measures, not all of which are similar.
Summary of Drinking Behaviour of Adolescents in GGC and Scotland (84-87)
While a significant number of secondary school children in NHSGGC and Scotland either do not drink alcohol or drink only occasionally, there appears to be significant proportion of young people, among those who drink, who drink to excess.
In Scotland, 33% of 13-year-olds and 54% of 15-year-olds who drink, reported drinking five or more drinks on the same occasion in the preceding 30 days.(84) The average amount consumed by Glasgow school children was not reported. However the 2008 survey indicated that 33% of those who drink, reported spending at least £6 a week on alcohol, 13% £11 or more a week, and three percent spending more than £20 a week on alcohol.(85)
A measure of the excess alcohol consumption can be estimated by the frequency of drunkenness. Scotland-wide, 73% of 15-year-olds and 53% of 13-year-olds who had drunk alcohol reported that they had been drunk at least once in their lives. For many this is not a one off event. 18% of 15-year-olds and seven percent of 13-year-olds reported having been drunk more than 10 times.(84)
Of those who drink in Glasgow schools, 42% report being drunk at least once a month, and for 27% of pupils that occurs on at least a weekly basis.(85)
Scottish figures indicate that alcohol was 69% more affordable in 2007 than in 1980. In 2007, people in Scotland spent an average of £5.97 per week on alcohol, five percent of their total expenditure.(84)
The total number of premises licensed to sell alcohol equates to a rate of 42 per 10,000 of the Scottish population over 18 years of age. However, there is considerable variation in the rate between council areas and NHSGGC council areas have below Scottish average rates.(84) Table 4 shows the number and rates of liquor licences per local authority area within the NHSGGC area.
Council Area Total Licences and Licences per 10,000 population(84)
NHSGGC has some areas close to the Scottish average, and some where the rates are lower. Total number of licences, however, is an imprecise measure as it gives no indication of the capacity of licensed premises, the volume of alcohol sold, or the hours of operation. While the rates of licensed premises per head of population for all our council areas appear lower than Scotland, this is not reflected in the levels of harm experienced by our communities or the adverse effects felt by many of our residents.
Alcohol related mortality has more than doubled in the last 15 years.(82) In 2007, of 55,986 deaths registered in Scotland, alcohol was the underlying cause in 1,399 (2%).(84) For NHSGGC in 2007, the standardised alcohol related death rate per 100,000 population was 56, compared to an alcohol related death rate of 35 per 100,000 population in Scotland for the same period.(84) In Scotland during 2007, 66% of alcohol related deaths occurred in the most deprived areas of Scotland. In contrast, only 19% of alcohol related deaths occurred in those areas classified as being the least deprived quintiles.(84) As NHSGGC contains 43% of datazones that make up the most deprived quintiles in Scotland and 31% of the NHSGGC population live in the 15% most deprived areas, it is not unexpected that it witnesses a disproportionate amount of alcohol
related ill health.
”I don’t think people understand. They think it’s just a drink but you don’t know what it can do to you. It can kill you in the end.”(20)
Children and Young People
NHS Quality Improvement Scotland analysed alcohol related attendances of children and young people to emergency departments in Scotland during a six week period in 2007. During this time 367 males and 302 females across Scotland attended accident and emergency departments as a result of alcohol use, two percent of all attendances by young people; 27% under 17 years of age. This included 132 males and 109 females aged eight to 17 years in NHSGGC. Forty eight percent presented as a result of trauma and 42% as a result of intoxication. Most attendances took place during evenings and weekends, peaking between 6.00pm to 8.00am on Saturday evenings to Sunday mornings. Presentations due to trauma increased with age, while presentations due to intoxication were more common in the younger age groups.(88)
Alcohol contributes to a significant amount of ill health. Only the more serious health problems are admitted to hospital and this represents the tip of the iceberg. There were 10,762 emergency admissions to acute hospitals in NHSGGC for adults aged over 16 with an alcohol related problem in 2007/08. An audit carried out by NHS Quality Improvement Scotland has revealed that four percent of emergency department attendances in Scotland are by patients with serious alcohol problems, mainly dependence (97%). The audit revealed that intravenous B vitamins, which can prevent the development of alcohol related brain damage were used in only 17% of these patients.
The recommended dose was administered to only 44% of cases. Overall, only 11% of eligible attendances were referred to specialist services, e.g. social work or alcohol liaison nurse.(89)
Excess alcohol consumption leads to a myriad of health effects, some occurring over a relatively short period, e.g. acute intoxication and others which develop gradually following long periods of heavy drinking. One example of the long term effects of excessive alcohol consumption is alcoholic liver disease, which is the main cause of death from liver cirrhosis in middle aged adults in Scotland. Analysis of death from alcoholic liver disease is shown in Figure 2.
Liver Cirrhosis. Age standardised mortality rates, males and females 15 to 74 years NHS Greater Glasgow & Clyde and the Rest of Scotland directly standardised to Western European population (Source: 1991 WHOSIS)
For both males and females the rate of deaths from alcoholic liver disease has witnessed a year on year increase in Scotland from 1981 until 2007, with males experiencing higher rates than females, as would be expected from their patterns of alcohol consumption. NHSGGC continues to have a higher age standardised death rate for both males and females than the rest of Scotland, the rate for males in NHSGGC being particularly high. The last three years, however, have witnessed a welcome decline in deaths due to alcoholic liver cirrhosis in males in our health board area. This trend is most apparent in our 15% most deprived areas among younger
men (20-29 year olds) and older men 60-74 year olds. Among females the opposite trend has occurred, with a year on year increase among young women (20-29 year olds), while the rate in other age groups is static or showing a modest decrease.
Mental Health Effects
Alcohol not only causes physical health effects. In 2006/2007 there were 4,053 alcohol related discharges from psychiatric hospitals in Scotland involving 3,257 patients.(84) The equivalent figure for NHSGGC was 1,073 discharges relating to 894 patients.(84) In Scotland in 2006/2007, alcohol misuse was responsible for 16% of all discharges from psychiatric hospitals.(84) Psychiatric admission was due to a range of problems, including harmful use of alcohol, alcohol dependence and alcoholic psychoses.
Alcohol related brain damage is one of the most disabling forms of psychiatric morbidity due to excess alcohol consumption. It may present with a mixed picture of dementia and specific memory impairment or it may resemble either a dementia-like illness or a specific memory impairment – Wernicke-Korsakoff Syndrome.
Early treatment may prevent or reverse this form of alcohol related brain damage by use of vitamin supplementation and management of alcohol withdrawal in dependent patients. However, a significant proportion of population who develop this condition will only improve partially, or not improve at all, and will require long-term care for the remainder of their lives. Examination of data for NHSGGC has revealed that a disproportionate number of these individuals reside in our most deprived communities (Figure 3). Many are of a comparatively young age and can be expected to live for many years if they cease alcohol consumption
(Figure 4). The majority of these patients are male, reflecting the excess alcohol consumption patterns witnessed in NHSGGC.
Alcohol Related Brain Damage Acute Hospital Admissions, persons aged 35 plus Age & Sex Standardised Ratios by SIMD Quintile, SMR01 2006/07 to 2007/08 NHS Greater Glasgow and Clyde (GG&C =100)
Alcohol Related Brain Damage Acute Hospital Admissions, persons aged 35 plus Age & Sex Specific Rates per 10,000 Population, SMR01 2006/07 to 2007/08 NHS Greater Glasgow and Clyde
The average length of stay in general hospitals for patients who have an emergency admission due to alcohol is 4.2 days. The average stay for patients who have an emergency admission and have alcohol related brain damage is 16.7 days. So, while this group of patients may be comparatively small compared to the majority of patients who consume excess amounts of alcohol, they require considerably more care prior to discharge from hospital and in the community once discharged.
COMMUNITY IMPACT OF ALCOHOL MISUSE
Research carried out in communities in Glasgow sought to examine the impact of alcohol on the lives of its residents. Consultation across all areas of the city identified that 99% felt alcohol affected their area to a least some degree, and 79% felt the effect to be medium to large.(90) The impact of alcohol on communities was negative for the majority of residents (95%), with only five percent of respondents providing any positive effects in their community.
Areas most affected included shopping areas/precincts, areas where alcohol could be purchased, parks, waste ground and surrounding streets. Children, young people and the elderly were most affected. Fears of abuse, violence, anti-social behaviour, litter, vandalism, violence and gang fighting were the most common negative experiences associated with alcohol use.(90)
The majority of respondents felt that the harm caused by alcohol in local communities could be addressed. Most people felt that a number of different actions had to be taken to make their communities safer places to live. Most of those interviewed felt that these changes, both planning and making the changes, needed a high level of community participation to ensure their effectiveness, and that these changes needed to be made urgently.(90)
MANAGING THE PROBLEM:
INTERVENTIONS TO REDUCE ALCOHOL RELATED HARM
A partnership multi-faceted approach across a range of services is essential if we are to succeed in addressing the range of physical and mental ill health effects and the social impacts on the lives of our families and communities. Some actions have begun already to address the issues.
Acute Service: Addiction Action Plan
The Acute Addiction Action Plan aims to improve all aspects of the treatment and care provided in hospital to patients who have alcohol or drug problems. Good care results in better outcomes for patients and reduces the chances of acute and chronic illnesses as a result of addiction problems. One recent development has been the pilot project on Screening and Management of Alcohol Withdrawal aimed at the introduction of a standardised guidance for all general hospitals across NHSGGC. The pilot took place in the Royal Infirmary and the Western Infirmary from February to April 2009. Departments which participated were A&E, medical receiving wards and general medical wards. Evaluation of the project identified the most useful model for implementation in hospitals and result in:-
Appropriate management of this acute medical condition is vital if we are to prevent the form
of irreversible brain damage which is the root cause of Wernicke-Korsakoff syndrome. It also
enables acute staff to refer patients to alcohol liaison services to ensure they receive the help
they need to address their problem drinking. Further information can be obtained from the
Glasgow Acute Addiction Team, telephone 0141 276 6600.
Primary Care: Introduction of Alcohol Screening and Brief Interventions
There is evidence that one-to-one screening and brief interventions in primary care is effective in enabling people who drink alcohol to excess to reduce their consumption. For further information see SIGN guideline 74 on the management of harmful drinking and alcohol dependence in primary care. Targets set in 2007 by the Scottish Government (Better Health Better Care, Action Plan) require that health boards deliver an agreed number of alcohol based screen tests and offer brief interventions for people who are hazardous and harmful drinkers. This programme has incremental targets over a three year period up to 2011.
In 2008/09, the first year of operation of the programme, NHSGGC provided training and resources to enable primary care staff to help patients decrease their alcohol consumption. A total of 191 primary care staff in 186 practices across NHSGGC were trained by 31 March 2009 to deliver the programme.
NHSGGC was set a target of carrying out 4,902 brief interventions with patients who were consuming alcohol at hazardous or harmful levels. In the first year of this programme, NHSGGC exceeded its target and delivered brief interventions to 7,603 patients.
Alcohol Screening and Brief Interventions by CH(C)Ps
In year two of this programme, NHSGGC plans to consolidate training for primary care staff and extend the programme into antenatal care and accident and emergency departments. NHSGGC is also actively pursuing the possibility of providing screening and brief interventions access by a website.
During year three of the programme (2010/11), NHSGGC plans to extend training more widely across the acute care sector and develop the capacity of community planning partners in local authority settings to contribute to the delivery of this work.
Each of these steps will require considerable investment in training and resources to support the expansion of the programme.
As this work proceeds, it is anticipated that there will be more demands on specialist services, as people with more serious conditions are identified. NHSGGC is investing in these specialist services, including additional specialist alcohol nurses and counsellors.
The Health at Work team is responsible for improving health in workplace settings by working with employers within NHSGGC to assist with prevention and education initiatives to decrease alcohol misuse for the working age population. Companies who sign up to the Healthy Working Lives award scheme agree to put in place procedures which will improve the health of their workforce. Alcohol misuse may be addressed by adopting alcohol policies governing the use of alcohol by their workforce. Employers may provide one-to-one counselling for employees to address specific health issues including alcohol misuse.
NHSGGC has funded the training of occupational health staff in techniques of motivational interviewing for alcohol brief interventions to increase the skills of occupational health practitioners and promote the delivery of brief interventions in the work place, thus reducing hazardous drinking by employees. Training and support for occupational health staff engaged in this work will be provided by the Health at Work Team.
COMMUNITY INITIATIVES TO REDUCE ALCOHOL CONSUMPTION
Residents of most communities in Glasgow experience adverse consequences as a result of alcohol misuse. Therefore action to prevent the adverse consequences for communities is essential.
To succeed, community initiatives aimed to prevent alcohol related harm must be:-
Successful programmes emphasise modifying drinking cultures through local policies, structures and systems, strengthening collaborative networks between professional and stakeholder groups and involving local communities to achieve maximum effect. In this type of work whole communities are the target rather than individuals within the community.(91)
A pilot community project was carried out in Govan from December 2007 to June 2008. The project aimed to reduce the accessibility of alcohol to under 18s through the promotion of responsible sales practices within off-licences and targeting of “agent purchasing” (the purchasing of alcohol by a person legally permitted to purchase alcohol in order to provide it to under 18-year-olds). The project included education and training for off-licensing staff, increased enforcement activity by the police and diversionary activities for under 18-year-olds.(92)
Results of the campaign included:-
There is anecdotal evidence that there was displacement of agent purchasing from off-licences that took part in the project to others near the project’s boundary. There is also anecdotal evidence that attendance at diversionary activities increased over the course of the project, though the extent to which this was due to the project is not clear.
Stakeholders and local residents did not observe a difference in antisocial behaviour over the course of the project. Police statistics, however, show that there has been a significant decrease (40%) in antisocial behaviour crimes charges, the number of reported incidents of antisocial behaviour decreased by 20%, and the number of antisocial behaviour incidents logged and reported on CCTV decreased by 31%.
Based on the results of this pilot project it was recommended that each CH(C)P should develop a community based intervention to run over a two-year period to establish interventions which work at community level.
Illustrations of successful community engagement with alcohol issues include the “Alcohol in my Life” campaign in the West of Glasgow. The aim of this programme is to take a partnership approach to prevention and education for alcohol misuse. It will give an opportunity for young people, parents, licensees and community members to address key alcohol related health topics and develop a local community alcohol action plan.
“Meeting the Shared Challenge” is being used by the East Glasgow CH(C)P to address health inequalities and enhance the level of control and influence that disadvantaged communities have over the factors that impact on their health and well-being. A series of community engagement events are planned to encourage agencies and communities to take ownership and responsibility for tackling alcohol problems in their community and develop a local alcohol action plan.
Glasgow City Centre Project
Glasgow city centre is unlike other NHSGGC areas in that it has a small resident population which is increased at weekends by 100,000 people drinking in the city centre at night, many of whom have come from much further afield. Most are young, 18-25 year olds and they frequent the 350 pubs which close at midnight and the 90 night clubs which close at 3.00am. These premises are all licensed to sell alcohol, in addition to licensed hotels, restaurants and off-licences.
“Play Safe in Glasgow” is a preventative and educational programme which targets 18-30 year olds and promotes safe, sensible drinking in Glasgow’s city centre. It has been running annually over the festive period since 2004. This programme is offered at work to employees of interested companies. In the winter of 2008/09, 28 workshops and six events were held in workplaces in Glasgow. Evaluation of the project revealed that 90% of staff found the Play Safe session to be useful and 37% indicated that they would change or modify their alcohol as a result of the session. For further information see the Health at Work Play Safe Report 2008-2009.
ADDITIONAL WORK TO IMPROVE THE SAFETY OF THE CITY CENTRE AT NIGHT
A further five-year city centre community prevention trial is currently underway in Glasgow looking at means to decrease incidents of violence in the city. It will analyse incidents of reported crimes, A&E admissions and police data to evaluate whether the level and seriousness of crime is decreasing.
Assessing overprovision of licensed premises
The new 2005 licensing legislation came into force in September 2009. Paragraph 7 of the Licensing (Scotland) Act 2005 places a range of responsibilities on local licensing boards. These include a responsibility to assess over-provision of licensed premises and licensed premises of a particular description. (Licensing Scotland (Act) 2005 Scottish Executive) The Act does not offer a definition of areas that should be used as localities or a definition of overprovision. Licensing boards are required to make these decisions in consultation with the chief constable and persons who represent local interests, including licence holders, residents and
One means of assessing this aspect of the licensing legislation is to assess the prevalence of alcohol associated crime in localities. Initial work carried out using police, licensing board and health board data has explored the level of violent crimes in communities. Pilot work revealed that the strongest predictor of violent crimes in a neighbourhood was the number of licensed premises in the area. This work was useful in identifying areas where high numbers of licensed premises were contributing to crime.
Further work is currently underway looking at the whole of NHSGGC using police, licensing board and health board data. On completion it will be useful to licensing boards in assessing new applications for premise licences in areas where high numbers of premises are already in existence, exploring the potential harm that may result from issuing further licenses.
PUBLIC HEALTH MESSAGES
PRIORITIES FOR ACTION