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8. Alcohol

8. Alcohol is an increasing problem

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Alcohol consumption and its damaging effects have increased sharply in the Health Board area since the early 1990s.  Alcohol problems are worse in Greater Glasgow and Clyde than in the rest of Scotland, the UK or Western Europe.  The area has the worst four Local Authority areas in the UK for male deaths from alcohol and two of the four worst areas for women.

The main reasons for the worsening trend in alcohol problems are a mixture of increased affordability and social acceptability of drinking to excess.  The alcohol problem is therefore – like obesity - partly a result of greater affluence and choice.  At the same time, people in more deprived circumstances suffer the worst damage from alcohol for reasons that are not fully understood, but it is not just that they consume more alcohol. 

Improving the alcohol problems of NHS Greater Glasgow and Clyde area will require large scale measures to reduce the availability of alcohol and the acceptability of excessive drinking; improve detection and treatment of alcohol problems; and gain a better understanding of why deprivation makes alcohol so much more damaging. 

The public health challenge and the scale of the problem

Benefits and harms of alcohol to health and society

Moderate consumption of alcohol can be an enjoyable part of a healthy life.  But in Greater Glasgow and Clyde, the problem is one of increasing excessive consumption that leads to mental and physical illness, and premature death.  There is also a strong association between excessive alcohol intake and violent crime, lost working days, and socio-economic deprivation.  Reducing excessive consumption of alcohol is therefore a public health priority. 
Excessive consumption of alcohol increases the risk of a range of diseases including coronary heart disease, stroke, some cancers, as well as liver cirrhosis and psychiatric disorders.  The analyses reported in this chapter are restricted to illnesses that are directly caused by alcohol because it is not possible to accurately estimate the contribution of alcohol to other conditions using routinely-available data.  The full impacts of alcohol on health are therefore much greater than reported here.

Consumption patterns

Alcohol consumption has increased in the United Kingdom over at least 25 years as it has become more affordable.  At the same time, the strengths of the two most popular alcoholic drinks - table wine and beer - have increased.   

True alcohol consumption is generally under-reported.  Current recommendations are that men and women should not consistently drink more than 3-4 and 2-3 Units (8 grams/10 mls alcohol) daily respectively.  Binge drinking is defined as consumption in a single day of eight Units or more in men and six Units or more in women.  A maximum weekly total consumption of 21 Units is advised for men and 14 Units for women.

Seventy-two per cent of men and 58% of women in Scotland drink regularly (63).  Among them, 63% of men and 57% of women exceeded the recommended maximum daily amount at some point in the week, although a smaller number exceeded the maximum weekly recommended total consumption.  Men’s consumption of alcohol has fallen slightly over time, while women’s continues to rise.  Three quarters of men and women drink at home rather than in pubs, clubs, or restaurants. 

Sixteen-to-24-year-olds drink most heavily compared with other adults.  In Scotland, amongst 13-year-olds, 56% of boys and 59% of girls have drunk alcohol at some point in their lives. Seven per cent of 13-year-olds and 18% of 15-year-olds reported having been drunk more than 10 times. 

Socio-economic deprivation is associated with increasing alcohol consumption, but the harm it causes people in more deprived circumstances cannot be attributed solely to the quantity of alcohol consumed.  There is little evidence to explain why alcohol and deprivation make such a damaging combination, but it is likely to be due to a mixture of individual risks (such as poor diet or drug use) and environmental risks (such as drinking on the street).

Deaths from alcohol

Alcohol-related liver cirrhosis is the largest directly-attributable cause of death from alcohol.  It is a useful measure of how alcohol problems in Glasgow have changed over time and compare to other areas. Figure 8.1 shows that cirrhosis deaths have been higher in the Greater Glasgow and Clyde area compared to Scotland since at least 1981.  Death rates began to increase sharply in the early 1990s, with Greater Glasgow and Clyde death rates increasing twice as fast as the rest of the country.  There has been little further increase since 2004.  Scotland currently has the highest cirrhosis death rates in Western Europe and Greater Glasgow and Clyde cirrhosis deaths are over twice as high again.

Figure 8.1

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One explanation for Greater Glasgow and Clyde’s high cirrhosis death rates is the association between socio-economic deprivation and cirrhosis.  Figure 8.2 shows that people who live in the most deprived 15% of the population have four times greater risks of cirrhosis death than the rest of the Health Board area.

Figure 8.2

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Further insights into alcohol-related deaths were gained from a study of patients who died as a direct result of alcohol in 2003 (64).  The study found that only a minority of patients had any record of being advised to stop drinking.  Less than half of patients attended specialist services for alcohol problems.  However, contact with statutory services was high.  For example, 37% of patients had been in police custody.  While it might be argued that failure to record details of advice given to people with alcohol problems does not prove that no advice was given, and that re-organisation of addictions services since 2003 should have improved the quality of care, the alcohol deaths study provides unique insights into the problems of people who suffer from the most severe alcohol problems in Glasgow city.
Alcohol-related hospitalisations

A&E survey of attendances by people who had drunk alcohol in the past eight hours

This survey was carried out at the five Greater Glasgow Accident and Emergency departments (65).  It found that:

  • 36% of all attendees for all three snapshots were ‘intoxicated’ (that is, they had consumed an alcoholic drink less than eight hours before interview in the A&E department).  85% of men were injured in fights/attacks.  A third of women self harmed and more than a quarter had accidents;
  • Around 70% of injured attendees who had drunk alcohol in the past eight hours were from the most deprived areas of Glasgow;
  • Of 172 interviewees who had been attacked, 65% thought that their assailant had been drinking alcohol;
  • More than a quarter of interviewees said they thought they had an alcohol problem and of them, about half said they had received help, usually from the NHS. 

Acute hospitalisations for alcohol-related conditions

Analyses of patterns of hospital admissions for alcohol-related conditions tend to show similar patterns to deaths, with rising rates over time and about a fourfold increased risk associated with living in the most deprived areas compared to the most affluent.  Figure 8.3 compares emergency admissions to general hospitals by residents in each of the 10 CH(C)P areas wholly within NHS Greater Glasgow and Clyde.  Results have been corrected to remove the effects of different sized populations or differences in the age and sex make-up of each area. 

Figure 8.3 shows how each CH(C)P area compares to the overall Health Board figure of 100.  The East Glasgow CHCP has the highest admission rate for alcohol-related emergencies (63% above average), while East Dunbartonshire CHP has only a third of the Health Board average.  These differences may be due to variations in the prevalence of alcohol problems or in the way that services – particularly preventive services – are provided.  It should be possible to implement best practice from the most effective preventive services across the CH(C)Ps and replicate this across the Health Board area.  This might lead to substantial reductions in hospital admissions.

Figure 8.3

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Effects on children and families

In 2005, it was estimated that there were 13,650 problem alcohol users in Glasgow City alone, about 20% of whom were women and 80% men (66).  A minimum of around 10,000 children have at least one parent who has an alcohol problem and about 3,800 (more than 3% of all children) live with a parent who has an alcohol problem.  For NHS Greater Glasgow and Clyde as a whole, the number of children who have a parent with an alcohol problem may be approximately twice as great.  The impacts of having a parent with alcohol problems are difficult to quantify precisely and many children do not live with the parent who has an alcohol problem.  However, alcohol will affect an adult’s ability to function as a parent, affect their employability, contribute to neglect of their children and is associated with emotional and physical abuse of partners. 

Alcohol and fire risks

One in five fatalities, casualties or rescues from domestic fires in Glasgow City had “being drunk or drugged” as the main contributory circumstance.  It is one of the commonest reasons for being a victim of fire.  Forty-three percent of all drink or drug-related fires also involved an unattended chip-pan, while one in ten involved someone falling asleep or being unconscious. 

How NHS Greater Glasgow and Clyde and its partners are currently responding

Current initiatives in Greater Glasgow and Clyde

A co-ordinated multi-agency effort is required to tackle alcohol problems.  In Glasgow City, NHS Greater Glasgow and Clyde, Strathclyde Police and Glasgow City Council work together in a strategic partnership, which is described in the Glasgow City Joint Alcohol Policy Statement.

Some current initiatives include:

Glasgow City Centre Initiatives - Includes the Community Prevention Trial, Glasgow Matters community television and Nite Zone.

Enforcement of existing laws - Includes fixed penalties for anti-social offences (introduced in September 2007), Custody Card initiative, and the Glasgow City Centre off-sales campaign.  The Licensing (Scotland) Act 2005 gave greater responsibilities to local Licensing Boards to control overprovision of licensed premises.

Advertising and promotion - Includes the Best Bar None Award scheme and Safer Licensed Premises scheme.

Education - Includes the Alcohol and Drug Education Service for Secondary Schools and Play Safe Campaign.

Acute alcohol liaison service in Inverclyde and Renfrewshire

SSPC - School, social work, police and community pilot to reduce offending and behavioural problems in young people in East Renfrewshire.

Sensing change - pilot project for people with sensory impairment and alcohol problems in Renfrewshire.

Acute action plan implementation - The overall aim of the three-year Plan is to develop good practice guidelines and establish consistent approaches across all general hospitals in relation to screening and assessment for individuals with alcohol and drug problems, prescribing and withdrawal management, interventions, harm reduction, and education and training. The Greater Glasgow plan is likely to be extended to cover the entire NHS Greater Glasgow and Clyde area soon.

Community setting action plan implementation – This work is progressing in a similar format to the acute action plan with a focus on training and education, screening and assessment, interventions, health and safety, harm reduction and managing withdrawals.

Key public health messages and priorities for action

Alcohol is a major preventable cause of ill-health and premature death in the NHS Greater Glasgow and Clyde area.  Despite a range of local initiatives, alcohol problems are worsening at a faster rate than the rest of Scotland.  A mixture of approaches is needed to both target services at individuals with existing alcohol problems and at a population-level to reduce consumption of alcohol. 

If NHS Glasgow and Clyde Glasgow is to reverse the worsening problem of alcohol several things will need to happen:

Greater commitment to tackling alcohol problems will be needed from all public sector organisations in the NHS Greater Glasgow and Clyde area.  We need consistent and congruent approaches so that health education messages are not conflicting with other policies.  Examples of this approach include:

  • Having supportive workplace alcohol policies in public sector organisations and their major suppliers to reinforce cultural change away from harmful drinking;
  • Stopping sponsorship and advertising by alcohol manufacturers in public sector premises;
  • Reviewing our policies for consumption of alcohol in public sector premises.

People with alcohol problems will need to be better identified and managed.  There are many unexploited opportunities for identifying alcohol problems when individuals use statutory services such as primary care, social work and police custody.  Brief intervention approaches are effective in helping people who drink hazardously, but are not physically addicted to alcohol.  Examples of this approach include:

  • Implementation of standardised alcohol screening across primary care and community health and social care settings using clear guidelines on diagnosis and referral, and providing properly resourced follow-up services that use evidence-based interventions;
  • The Quality and Outcomes Framework, which remunerates GPs for targeted work, could include screening for alcohol problems;
  • Increased education, training and support of staff in a variety of non-NHS services is needed to more effectively identify and manage individuals with alcohol problems;
  • Arrest Referral for alcohol problems both increases alcohol problem service uptake and reduces reoffending.  There is potential to extend its use.

National legislation on alcohol pricing, advertising and availability will be required.  There is good evidence that these have been effective in reducing alcohol-related harm in Western Europe.  As society experiences the effects of worsening alcohol problems, there will be greater public support for national legislation.  Examples of contributing to this approach include:

  • The provision of high quality information on how alcohol is harming our population and the benefits that might be achieved through legislation;
  • Development of a comprehensive approach to influence national policies to reduce alcohol-related harm.  These include pricing, labelling, advertising and relationships with the alcohol industry.

Persistent and widespread measures will be needed to make excessive alcohol consumption socially abnormal.  Examples of this approach include:

  • Continuing to enforce new and existing laws on public drunkenness, including enforcing current drink driving laws and reducing the Scottish national legal blood alcohol limit from 80 to 50 mg/dl in line with most western European and north American countries;
  • Looking for alternative approaches to changing attitudes to drunkenness in general in society, acknowledging that most alcohol is consumed at home;
  • Support effective implementation of the Licensing (Scotland) Act 2005, particularly those measures which have been shown to reduce alcohol-related harm, including addressing overprovision and mandatory server training;
  • Development of actions to ensure the enforcement of the restrictions in the Bill aimed at days and hours of sale and underage sales using evidence of good practice from other parts of the UK (such as the Bottlewatch scheme).

The multiplicative effects of socio-economic deprivation on alcohol need to be better understood.  Reducing alcohol consumption alone will not reduce the large inequalities that exist in alcohol related harm between affluent and deprived area.  Examples of further work required in this area include:

  • Knowledge of additional approaches in nutrition, psycho-social interventions, road safety and other fields.

Initiatives to reduce alcohol harms will need to be evaluated.  Ineffective interventions should be discontinued and good practice extended throughout the Health Board area.  NHS Greater Glasgow and Clyde should contribute to, and learn from, the Scottish Alcohol Research Framework.

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