Health warnings on bottles and new advice on alcohol and pregnancy

‘Sensible drinking‘ messages on bottles by the end of 2008 and new advice to avoid alcohol when pregnant or seeking to become pregnant are two key components of the new Alcohol Strategy. Both ideas immediately ran into controversy, the Government being accused of either going too far or not far enough. Interestingly, one accusation that might have been made but was not was that the Government has in effect now raised the ‘sensible drinking‘ limits. Despite this, and for entirely different reasons, some drinks companies were reported as threatening not to co-operate with the new labelling initiative.

There was also criticism of the new advice on pregnancy for going beyond the scientific evidence. However, the British Medical Association (BMA) supported the Government‘s new message. The BMA said that while it was true that there is currently no conclusive evidence that drinking one or two units of alcohol per week is harmful to the developing child in the womb, evidence is continuing to emerge of possible risks of prenatal alcohol exposure at low to moderate levels. The BMA agreed, therefore, that “Given the current uncertainty regarding the level of risk to the developing foetus, and the lack of clear guidelines, the only safe sensible drinking message is not to drink any alcohol during pregnancy.”

Sensible drinking message on labels On ‘sensible drinking‘ the Department of Health said that by the end of 2008 it expected all alcoholic drinks labels to include alcohol unit information, following what it described as a ground breaking agreement between Government and the drinks industry.

It stated that labels will include:

• The drink‘s unit content and the recommended Government ‘safe drinking’ guidelines.

• UK Health Departments recommend men do not regularly exceed 3-4 units daily and women 2-3 units daily.

The label may also refer the consumer to the alcohol-industry funded charity ‘Drinkaware’ for further advice.

In addition, the Government is also encouraging the alcohol industry to include ‘sensible drinking’ information for pregnant women on labels.Avoid alcohol if pregnant or trying to conceive is the shortened form of the Government advice announced on 25 May 2007.

Public Health Minister Caroline Flint said; “This landmark, voluntary agreement will help people calculate, at a glance, how much they are drinking and whether they are staying within sensible drinking guidelines.We want to make it as simple as possible for people to keep an eye on how much they are drinking and help them take the responsibility for lessening the impact excess alcohol can have on their health. Although most spirits and beer labels for sale in the UK market and many supermarkets’ own brands of beers, wines and spirits, do carry some information on unit content people can miscalculate and lose track of how much they are drinking. Unit information combined with sensible drinking guidelines on the new labels will make it simpler for people to calculate how many units they are drinking and make it easier for them to stick to the recommended limits.”

But have the limits been raised? Until 1995, the recommended ‘sensible limits’ of regular consumption were no more than 21 units of alcohol per week for men and no more than 14 units per week for women. There was also guidance on hazardous and definitely harmful levels of consumption.

In December 1995, following a Government review of the ‘sensible drinking’ message, the guidance was changed from weekly to daily limits – no more than 3-4 units per day for men, and no more than 2-3 units per day for women, but with the qualification that consistently drinking 4 units a day for men and 3 units for women was not recommended on health grounds. There was also advice to have two alcohol-free days following an ‘excessive drinking episode’.

While the advice to have two alcohol free days after a heavy drinking episode is retained in the small print of the Government’s revised Alcohol Strategy, it appears to be omitted from the new warning to be placed on labels. And as the advice no longer warns against drinking up to the maximum recommended amount every day, and there are seven days a week, it seems that the weekly guidelines are now 21 and 28 units for women and men respectively, rather than the previously recommended 14 and 21 units.

No new evidence to justify raising the limits has been produced, and no official statement confirming the limits have been raised has been made. However, on the face of it, the new advice cannot be interpreted in any other way. As the new limits represent a 50% increase in the recommended maximum consumption for women this might be considered worthy of note, particularly at a time when there is considerable medical and public concern about increased female consumption and the consequences of the ‘binge drinking’ epidemic

Alcohol industry ambivalence However, despite the apparent raising of the drinking limits, the press reported considerable misgivings on the part of the alcohol industry about the new initiatives. The Daily Telegraph reported that “Plans to put detailed health warnings on bottles of alcohol have been undermined by disagreements between drinks companies and the Department of Health”. The newspaper went on to report that while most in the industry supported the principle of better labeling,many had reservations about what to put on their bottles and objected to being forced to follow a Government template. Advising pregnant women to avoid all alcohol was another cause of unhappiness in industry circles.

‘Alcohol can kill’ In contrast, the British Liver Trust criticized the Government’s proposed messages for not going far enough. While the Trust welcomed the move towards universal unit labelling on alcoholic drinks, it said that the Department of Health, in suggesting that the industry puts a sensible drinking message for pregnant women on labels, was missing the key point – that almost every sector of the UK population drinks excessively. Alison Rogers,Chief Executive of the British Liver Trust said: “We have a rising rate of cirrhosis and alcohol-related deaths in the UK. The government’s own figures show that 22,000 people die prematurely each year as a result of alcohol.The Trust has previously suggested to the Department of Health that unit labels should include messages such as ‘Alcohol can kill’. This is a softer version of cigarette packets’ message that ‘Smoking kills’, but nonetheless a fair reflection of the harm that alcohol wreaks on the UK population.”

Ms Rogers said that this was backed up by the recent scientific review which placed alcohol as fifth up the list of harmful drugs – far above many that are classed as illegal substances such as cannabis and ecstasy. “If we continue to adopt a very ‘softly softly’ approach to the whole issue of alcohol” she said, “it will be at a horrendous health, social and economic cost to the UK. Cheap and accessible booze coupled with the UK’s ‘anytime anywhere anyplace’ mentality is costing us all very dear, and far too many are literally paying with their lives.”

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Alcohol in pregnancy

• The revised Department of Health advice says:
  • Pregnant women or women trying to conceive should avoid drinking alcohol.
  • If they do choose to drink, to minimise the risk to the baby, they should not drink more than one to two units of alcohol once or twice a week and should not get drunk.

  The Department of Health explained that the new guidance had been introduced to provide stronger, consistent advice for the whole of the UK. It was not the result of new scientific evidence, but it was consistent with the current evidence. The Government had revised the advice to make it easier to understand and to provide consistent advice across the UK.

  Deputy Chief Medical Officer Dr Fiona Adshead said; “We have strengthened our advice to women to help ensure that noone underestimates the risk to the developing foetus of drinking above the recommended safe levels. Our advice is simple: avoid alcohol if pregnant or trying to conceive. This advice could also be included on alcohol packaging or labels.

  “The advice now reflects the fact the many women give up drinking alcohol completely during pregnancy. It is now straightforward and stresses that it is better to avoid drinking alcohol altogether.”

  The National Organisation on Foetal Alcohol Syndrome estimates for the UK as a whole that there are more than 6,000 children born each year with Foetal Alcohol Spectrum Disorder.

  Excessive alcohol can cause damage to the unborn baby at all stages in pregnancy and of course many women don‘t confirm they are pregnant until a number of weeks into the pregnancy. Therefore, for women who are planning to conceive it makes sense to avoid alcohol or limit their consumption to no more than 1-2 units once or twice a week.

  Dr Sheila Shribman, the National Clinical Director for Children,Young People and Maternity Services said: “Alcohol and pregnancy advice is now consistent across the UK.

  “Our last survey of pregnant women showed that nine per cent were still drinking above the recommended levels. It is vital that we alert pregnant women and women hoping to conceive about the potential dangers of excessive alcohol consumption during pregnancy.

  “Although there is still scientific uncertainty about the precise impact of excess alcohol on unborn babies we believe the time is right to introduce a strong consistent approach across the whole of the UK. This revised advice has been agreed by the four Chief Medical Officers across the UK.”

  The previous advice in England was: pregnant women or women trying to conceive should not drink more than one to two units of alcohol once or twice a week and should avoid getting drunk.

  Pregnancy and alcohol – a dangerous cocktail, says a new BMA report Learning and physical disabilities and behavioural problems are part of foetal alcohol spectrum disorders [FASD]. These lifelong conditions can drastically impact on the lives of the individuals and those around them. A new BMA report says the reality is that these conditions are completely preventable by not drinking any alcohol during pregnancy.

  The report, ‘Fetal alcohol spectrum disorders’, highlights how difficult it can be to detect FASD and how healthcare professionals need more guidance to help them diagnose and treat children suffering from the disorder.

  The BMA report says the advice can be misinterpreted, as individuals may not clearly understand how many units correspond to what they are drinking. The alcoholic strengths of different beers and wines, and the considerable variation of standard measures used in bars and restaurants and in the home, can make it difficult for women to tell how many units they are consuming.

  The new advice from the English government was disputed by some medical experts and the BMA is now calling for clear, evidence-based guidelines on alcohol consumption during pregnancy and for women who are planning a pregnancy.

  Dr Vivienne Nathanson, Head of BMA Science and Ethics, said today: “The UK has one of the highest levels of binge-drinking in Europe and the highest rate of teenage pregnancies in Western Europe. Many women will not know they are pregnant during the early part of pregnancy, during which time they may continue to drink in their pre-pregnancy fashion with no awareness of the risk to their unborn child.”

  There is proven risk that heavy drinking by pregnant women can cause these disorders in their children, says the BMA. The report states that evidence is continuing to emerge on the effects of low or moderate prenatal alcohol exposure and until there is clarification the only message is that it is not safe to drink any alcohol during pregnancy or when planning a pregnancy.

  Dr Nathanson, added: “What is clear is that this is a complex concern and there is still so much that we do not know about this issue. It‘s important that women who drank alcohol before realising they were pregnant do not panic. But pregnant women should try to reduce their alcohol intake, or better still give up completely. If they are anxious they should talk to their doctor or midwife at their next antenatal appointment.

  “We need to raise awareness of the emerging evidence on FASD among healthcare professionals. They need training and guidance on how to identify these disorders so that children are diagnosed quickly and get the help they need. Early intervention is crucial in decreasing the risk of additional problems commonly found in individuals affected by these disorders. These include mental health problems, disrupted school experience, alcohol and drug addictions. The lack of awareness and research in the UK on this subject, together with the complexity of the syndrome itself is leading to delays in diagnosis and referral.

  “Healthcare professionals also need to get the message across to expectant mothers that consuming alcohol can cause irreversible harm to their unborn child. It‘s about giving people the right information so that they can act responsibly – and save children from completely preventable life-long disabilities.”

  Recommendations in the report include:

  • There is an urgent need for further UK and international research on FASD.
  • Research should be undertaken to examine the relationship between different levels of prenatal exposure and the range of conditions associated with FASD.
  • The UK health departments should implement guidance and training programmes for healthcare professionals on the prevention, diagnosis and management of FASD.
  • Women who are pregnant, or who are considering a pregnancy, should be advised not to consume any alcohol.
  • Research should be undertaken to identify the most effective ways to educate the public about FASD and to alter drinking behaviour. This requires systematic studies that compare various universal strategies and their impacts across the different social groups.
  • All healthcare professionals should provide clear and coherent advice for expectant mothers and anyone planning a pregnancy on the risks of maternal alcohol consumption. This should be provided by GPs as part of routine clinical care and targeted at women of childbearing age. Members of the antenatal care team should provide continued advice and support to expectant mothers throughout pregnancy.
  • Any woman who is pregnant, or who is planning a pregnancy, and who has a suspected or confirmed history of alcohol consumption at low-to-moderate levels should be offered brief intervention counselling to help them stop drinking. This should occur at the earliest possible stage in a pregnancy and be considered as part of routine antenatal care where required.
  • Any woman who is identified as being at high-risk of prenatal alcohol exposure should be offered referral to specialist alcohol services for appropriate treatment. Any referral should be followed up and assessed at regular intervals.

‘Safe. Sensible. Social. – the next steps in the National Alcohol Strategy’

The new Alcohol Harm Reduction Strategy for England was announced by the Government in June. It supersedes the Strategy launched in 2004,which was heavily criticised by the public health lobby for being too dependent on the voluntary co-operation of the alcohol industry and too cosmetic in intent.

The new Strategy got a generally favourable reception from alcohol problems and public health bodies apart from some complaints concerning lack of consultation. However, there is a question of whether the Government has surreptitiously raised the ‘sensible drinking’ limits.

The New Strategy The Government says that the new Strategy builds on the foundations laid and the lessons learnt since 2004 and that it will ensure the laws and licensing powers introduced ‘to tackle alcohol-fuelled crime and disorder’, protect young people and tackle irresponsibly managed premises are being used widely and effectively. It also sharpens the focus on ‘the minority of drinkers who cause the most harm’.

The ultimate aim, the Government says, is to reduce the harm to health, violence and anti-social behaviour associated with alcohol while ensuring that people are able to enjoy alcohol safely and responsibly.

Problem drinkers The strategy highlights the country’s ‘problem drinkers’:

• 18-24 year old binge drinkers.

• Young people under 18 who drink alcohol.

• Harmful, adult drinkers who don’t necessarily realise their drinking is damaging their physical and mental health.

Focus on partnership and communications to promote sensible drinking The Government says the strategy reflects its commitment to work together with all those involved in reducing the harm alcohol can cause, including the police, local authorities, prison and probation staff, the NHS, voluntary organisations, the alcohol industry, the business community, media and local communities, to shape an environment which actively promotes sensible drinking.

Key actions in the strategy include:

• Sharpened criminal justice for drunken behaviour.

• A review of NHS alcohol spending.

• More help for people who want to drink less.

• Toughened enforcement of underage sales.

• Trusted guidance for parents and young people.

• Continued investment in communications campaigns to promote a new ‘sensible drinking’ culture.

• Public consultation on alcohol pricing and promotion.

• Compulsory local alcohol strategies.

Reactions Speaking for the Royal College of Physicians, Professor Ian Gilmore, RCP President and a liver specialist, welcomed the review of the Government’s Alcohol Strategy: “We particularly welcome the review’s focus not just on younger drinkers and binge drinkers, but on the previously neglected issue of adults drinking harmfully at home, unaware that they are damaging their health. It is clear that depending on voluntary partnerships with the drinks industry has not worked, and it is now time for much stronger cross-Governmental action on alcohol issues.

“We need to review and increase the NHS alcohol budget to address the gross deficiencies in both acute hospital services and community treatment services. For example, the RCP in it’s 2001 report ‘Alcohol: Can the NHS Afford It?” called for every acute hospital to have a specialist alcohol nurse as a cost-effective way of reducing harm, yet most are yet to employ one.

“International evidence shows that increasing price and reducing availability are the two main ways of reducing people’s drinking, and while we welcome the review of retailing and promotions, this should not be used to delay action in this area, as we already have enough evidence to make the necessary decisions.”

British Liver Trust The British Liver Trust also welcomed the Strategy, particularly the government’s commitment to spend £10 million a year on alcohol campaigning. However, the Trust said that the government’s warning must be focused with an overwhelming priority on the health effects of alcohol.

“People in Britain are storing up huge health problems for the future if they continue to drink to excess.” said Alison Rogers, Chief Executive of the Trust.

“Hopefully the Strategy will put forward a clear health message. The habit of heavy drinking is leading to a frighteningly short road to liver clinics and transplant units. With the total UK household expenditure on alcohol running up £41.9 billion in 2005, making people more aware of the health issues associated with alcohol is going to be a long-term battle. Until people realise that a bottle of wine a night is damaging to their liver and their general health there will not be a change in behaviour.” added Ms Rogers.

Alcohol Concern welcomed the new Strategy as “a major step forward in Government thinking on the issue of alcohol misuse.” However, the charity added that there were some significant gaps in the Strategy, particularly with regard to service provision for people with alcohol problems.

For drug prevention charity Mentor UK, Eric Carlin, its chief executive officer, said: “I am disappointed with the lack of consultation on the next steps in the national alcohol strategy, not only with drug prevention agencies such as ourselves, but with young people who are key to minimising the problem of future alcohol misuse. Although the need for early intervention is already recognised at government level, with guidance issued from the DfES that education should start in primary schools before drinking patterns become established, there is no focus on prevention initiatives and the younger age group in this alcohol strategy.”

Industry reactions

Reactions from the alcohol industry were also fairly restrained, though there was obvious unhappiness at not being fully consulted. A clear division began to appear between different sections of the industry, with spokesmen for the on-trade welcoming the proposed review of cut price alcohol promotions while those speaking for the off-trade took the opportunity to deny any responsibility for promoting the binge drinking culture.

John Grogan, MP for Selby and chairman of the All-Party Parliamentary Beer Group and a well-known spokesman for the on-trade said: “The announcement that the government is planning to hold a public consultation on alcohol pricing and promotion is excellent news. This is a major step forward for the campaign to get the supermarkets to end irresponsible drinks promotions. It is the first sign that government ministers are now taking this issue seriously.”

Tony Payne, chief executive of the Federation of Licensed Victuallers’ Associations,welcomed news that supermarket pricing would be targeted.He said: “Cheap prices are just encouraging people to buy more and drink more. It’s good the government is to look at supermarkets and venues that offer promotions such as ‘drink as much as you want’ for a fixed price.”

British Institute of Innkeeping chief executive John McNamara commented: “A pub can be one of the most responsible places to drink alcohol. While binge-drinking is an issue that needs to be continually tackled, I am heartened that the government has recognised the impact of drinking in the home.”

The British Beer & Pub Association also welcomed news that supermarkets’ loss-leading on alcohol will be investigated.

The Wine & Spirit Trade Association questioned why the Strategy had been drawn up without full consultation with the trade.

British Retailers Consortium However, the British Retailers Consortium took a different view. It joined with major retailers to meet with MPs to “debunk a series of myths and spell out their commitment to public health and responsible alcohol retailing”.

The BRC’s Parliamentary Briefing was held on the same day the Government published the Alcohol Strategy. The BRC denied that supermarkets caused excessive drinking and claimed that, in fact, they were at the forefront of the drive to encourage responsible consumption and prevent underage sales.

BRC ‘evidence’ showed supermarkets were rarely the outlet of choice for people buying alcohol to drink immediately. Overwhelmingly, alcohol was bought from supermarkets as part of a routine shop for a full range of groceries with only one in a hundred transactions being of alcohol alone.

BRC Director General Kevin Hawkins said: “Alcohol price cutting by supermarkets does not create problem drinking. Very few supermarket customers buy just alcohol and it isn’t aimed at immediate consumption. Banning discounting, even if it was possible under competition law, would simply penalise the vast majority of customers who take it home to drink over a period or at family events.

“Retailers are leading the alcohol industry on efforts to prevent underage sales and they are providing customers with clear information to enable them to make sensible choices.

“On excessive drinking and its effects, retailers are an easy target but not the right one.”

For the Conservative Party, shadow Home Secretary David Davis described the new Alcohol Strategy as an admission of failure on the part of the Government. Mr Davis was particularly worried by the Government’s proposal to introduce conditional cautions for drunken behaviour.

Political reactions

Mr Davis said:“We will look at these proposals in detail but it is important they do not become yet another stealth mechanism for the Government to ditch their responsibility to tackle serious crime. People should remember that half of all violent crime is fuelled by alcohol.

“The public will not tolerate a situation where – as with shoplifters – alcohol- fuelled crime becomes effectively decriminalised with offenders getting a caution in exchange for undergoing a course that may not work.

“In any event this is an admission that the Government has failed on alcohol abuse. They are now acknowledging the serious harm alcohol does both to public health and public safety. If this is the case why did they simply unleash 24-hour drinking on our towns and communities instead of listening to our calls to pilot the scheme so its effects could be properly assessed?”

For the Liberal Democrats, Norman Lamb MP said: “A fresh look at tackling the growing problem of excessive drinking is long overdue. Too little has been done by this Government, which has allowed public health budgets to be raided to cover deficits elsewhere. The Government’s trumpeted 2004 Alcohol Strategy is now merely gathering dust. The same must not be allowed to happen to these latest plans. Urgent action is needed to stem the binge drinking culture which takes root in so many people at a young age and leaves them with health problems for life. Someone drinking as a young teenager is far more likely to be dependent on alcohol in adult life.”

The new timetable for action

An end to the Carlsberg baby in sight?

Alcohol branding on children’s replica shirts is to be phased out under new marketing rules agreed by the drinks industry. The move, announced by the Portman Group, will be seen as a gesture by the multi-billion-pound drinks industry to head off more draconian government action amid growing concern about levels of alcohol consumption and harm among the young, including children.

The Portman Group announced the new initiative just ahead of the publication of the Government’s revised alcohol strategy which will require pubs, supermarkets and off-licences to display alcohol health warnings at the bar or tills, as well as labels on drinks bottles and cans.

The decision by the Portman Group follows a public consultation on its Code of Practice on the Naming, Packaging and Promotion of Alcoholic Drinks which applies to all alcohol marketing. Industry insiders are reported as believing the ban could effectively end the long history of drink companies sponsoring football teams.

Nine county cricket clubs, two Premiership football teams, three Scottish Premier League clubs and a number of rugby clubs are currently sponsored by drinks companies.

David Poley, Chief Executive of the Portman Group, the industry’s ‘social responsibility’ organisation, said: “There is no evidence to link this marketing with under-age drinking. Even so, drinks companies are concerned about the negative perception caused by their logos appearing on children’s shirts.

“Despite producers having only ever been interested in marketing their drinks to adults, some critics see children in replica kit as walking billboards for alcohol. This side effect of sponsorship is set to end. Drinks companies are taking the lead even though this decision may lessen their commercial appeal as sponsors if clubs sell fewer shirts.”

The alcohol industry insists it is not targeting children but critics claim the firms are using sophisticated techniques – including football sponsorship – to target the young. France has barred all televised sports sponsorship by alcohol companies, and medical experts are pushing for similar rules in Britain.

Professor Ian Gilmour, a liver specialist and president of the Royal College of Physicians who led calls for the ban, said: “I welcome the announcement and hope it’s a move towards the complete withdrawal of the alcohol industry from sports events. Every statistic that comes out shows an increasingly concerning situation surrounding alcohol use by the young.”

However, the new restriction will only apply to sponsorship contracts signed after 1 January 2008, which means that Carlsberg, which sponsors Liverpool, and is thought to have agreed a new three year deal just prior to the Portman Group announcement, will therefore evade the restriction initially. The deal is said to be worth more than £20m. A spokeswoman for the Danish brewer said it supported the new Portman Group code but the firm was confident its new sponsorship deal would not be affected.

Among the teams sponsored by alcohol producers are Derbyshire, Essex, Glamorgan, Gloucestershire, Kent, Lancashire, Surrey, Warwickshire, and Worcestershire cricket clubs, and Everton,Liverpool, Celtic, Hibernian and Rangers Football Clubs. A children’s size shirt is defined by its VAT classification.

The rule change is included in the 4th Edition of the Portman Group’s Code of Practice on the Naming, Packaging and Promotion of Alcoholic Drinks. The full version of the new Code was published in June 2007.

NUT attacks alcohol sports sponsorship An example of the kind of pressure and negative publicity that drinks companies have begun to suffer in relation to sports sponsorship was provided by the demand of National Union of Teachers’ General Secretary Steve Sinnott to end the practice. He was speaking at the Union’s annual meeting in Harrogate.

Referring to the ‘massive assault of the drinks industry’ on sport through advertising and sponsorship, Mr Siinnott warned beer firms which sponsor football “are exposing impressionable children to highly damaging messages.”Mr Sinnott said:

“This exposure to alcohol is damaging young people’s lives and their futures. We are failing our youngsters. The sponsorship of sport by the drinks industry must end in advance of the Olympics in 2012.”

Mr Sinnott told delegates at the conference that 20 per cent of pupils who are excluded from school are thrown out for drinking alcohol, while 16 per cent drink alcohol every day. He also said drink-related deaths among young people were up 60 per cent since 1991.

To illustrate his point he said if a young Everton fan went to a Carling Cup match against Liverpool he would see the Carlsberg motif on the opposing team’s strip and “on the chest of his heroes” he would see the logo of the Thai beer, Chang.

“He sees the scorer of Everton’s winning goal presented with the man of the match award – a bottle of champagne. The effects on the young are stark,” he added.

Tough action called for on youth drinking

The binge drinking epidemic has prompted calls for tougher action to protect children and teenagers from being caught up in the unhealthy drinking culture. An article in the journal of a leading think tank with close links to the Labour Government argued that the minimum age for buying alcohol should be raised to 21, while Alcohol Concern proposed that supplying alcohol to adolescents aged under 15 be made a criminal offence. Both proposals provoked considerable controversy and appeared to divide opinion in the public health field, and both were rejected by the Government.

Legal drinking age of 21?

Writing in the magazine of the left leaning Institute for Public Policy Research, columnist Jasper Gerrard argued that “society has lost its sense” when it comes to alcohol. He said that “society is increasingly reluctant to tolerate passive smoking, so why passive boozing – which is what innocent people experience when a drunken, clunking fist attacks them on a Saturday night?”

Citing evidence that the UK has one of the highest rates of teenage alcohol drinkers, and teenage drunkenness, anywhere in the world, Gerrard argued that current regulations are failing to tackle the growing trend of underage and binge drinking.

By raising the age threshold, he claimed: “It is at least possible that those in their early and mid teens will not see drink as something they will soon be allowed to do so therefore they might as well start doing it surreptitiously now. Instead they might come to see it as it should be: forbidden.”

Alternatively, all 18 year olds could be issued with smart cards which would record how much they drank each night, and making it an offence to serve more alcohol to anyone under-21 who had already consumed more than three units (one and a half pints of beer, or a large glass of wine).

Additionally, Gerrard argued that taxes on alcopops should be increased, and that there should be harsher sentences for those who sell alcohol to under 18’s.

A government spokesman responded: “The majority of people drink sensibly and responsibly and the government has no plans to raise the minimum drinking age. Instead, we are using a combination of effective education and tough enforcement to change the behaviour of the minority that don’t.”

‘Prosecute parents’

In responding to the Gerrard article, Alcohol Concern, the national agency on alcohol misuse, agreed that further action was needed, but did not think raising the legal drinking age would help. Later, however, it made a proposal of its own which appeared to be even less well received than Jasper Gerrard’s.This was to make it a criminal offence to supply alcohol to under-15s.

Srabani Sen, director of Alcohol Concern, said that binge drinking by children can have serious consequences for brain function, significantly raises the risk of alcohol dependency in later life and diminishes their life chances. She said that not enough was being done to protect our children from alcohol and that what was needed was to limit the access children and teenagers have to alcohol and and to challenge more aggressively the drivers of underage consumption. Srabani Sen listed a number of initiatives Alcohol Concern would like to see implemented:

“Make it illegal to provide alcohol to anyone under the age of 15. Currently it is legal to provide children as young as five with alcohol in a private home. Raising the age limit to fifteen would send a stronger message to parents of the risks associated with letting very young people consume alcohol.

“Enforce the law around underage purchase. Data from the most recent Home Office AMEC (test purchasing) campaign showed that 29% of underage participants were able to buy alcohol in pubs and bars, while 21% did so successfully in off-licenses. Local police forces and trading standard units must devote more resources to identifying and prosecuting those outlets in breach of the law.

“End advertising of alcohol on TV before the watershed and in cinemas when films with ratings below 18 are shown. The European Court of Justice has already refuted advertisers’ arguments and ruled, it is in fact undeniable that advertising acts as an encouragement to consumption. Reports show that supermarket alcohol promotions are shown twice as often before 9pm (which is when children are more likely to be watching TV) compared to after. Furthermore, 82% of films shown in cinemas featuring alcohol adverts have ratings of 15 or below.”

“Make alcohol education part of the National Curriculum. Inappropriate use of alcohol by young people has been shown to have an impact on school performance. Alcohol is a factor in many school exclusions and suspensions. Around 14% of pupils excluded from school were suspended for drinking alcohol at school. The PSHE components of the National Curriculum should provide an important opportunity for conveying to young people the risks associated with bingeing.”

The Alcohol Concern proposals received extensive media coverage but limited support, even from within the public health field. Professor Martin Plant, director of the Alcohol and Health Research Trust at the University of the West of England, described the proposals as “very strange”. He said: “The bottom line is the number of alcohol related deaths is connected to the affordability of alcohol. Alcohol education is a complete waste of time as is drug education. These are politically cowardly get-outs”.

Most of the media and political comment, however, focused on the proposal to raise the legal drinking age to 15, an idea which most seemed to see as undesirable or unworkable. The consequences of such a move in relation to the prosecution of parents were generally regarded as particularly unappealing.

Public Health Minister Caroline Flint said “I don’t think passing a law to ban alcohol for those under 15 would be enforceable or necessarily effective’’. Ms Flint added that there were signs the problem of underage drinking was reducing: “Recent figures show there has been a 5 per cent drop between 2001 and 2006 of young people aged between 11 and 15 who had drunk alcohol in the previous week. We are working closely with the alcohol industry to encourage the responsible production and sale of alcohol…The new alcohol strategy to be published this summer will continue to drive reductions in alcohol related offending and harmful behaviour through a combination of education, treatment and tough penalties.”

Ms Flint also defended the Government’s record by citing restrictions on alcohol advertising that could appeal to under 18s introduced in 2005. She added that alcohol education is already part of the National Curriculum.

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Police also call for no alcohol for under 21s

Merseyside Chief Constable Bernard Hogan-Howe has asked the new Prime Minister Gordon Brown to increase the legal age for buying alcohol to 21. Writing in the Liverpool Daily Post, Mr Hogan-Howe outlined his case for tough action.

Last week, I asked the new Prime Minister to consider some legislative changes. The ideas around alcohol sales were aimed at helping the fight against anti-social behaviour.

Each year Merseyside Police deals with 2m calls for help: 250,000 of those are about antisocial behaviour. In the hot-spot areas, where we get repeated calls about serious criminality, the main aggravating factors tend to be similar time and time again.

There is either a street level drug market in the area or there is a particular problem with the illegal sale of alcohol or the consumption of alcohol by young people. My suggestions are to restrict the sale of alcohol to young people through off-licences and to come down hard on adults who go into off-licences to buy alcohol for youngsters.

The relative cost of alcohol has come down, while the number of off-licence points of sale has increased significantly. There is no longer a test to see whether an area “needs” a new off-licence. The control of the sale of alcohol is then left in the hands of young and low-paid staff.

They have to challenge young people late at night, often alone and when dealing with a crowd of potential customers. Would you challenge that crowd? I have suggested reducing the points of sale, increasing prices and allowing home deliveries only during the day. If we reduce the sugar content in some drinks, then we may change the binge drinking culture.

Alcoholic drinks should not be made to appeal to young people by appearing more like everyday soft drinks. With the medical profession alerting us to the high level of chronic liver disease in the young, we need to do something. We can make a difference. Anti-social behaviour is not new. Twenty-three years ago in his annual report, Sir Kenneth Oxford said: “As everyone knows, the biggest problem today is young people causing annoyance.”

What has changed is people now have easy access to communications with mobile phones and are more able to report incidents as they are happening. That gives us a clearer picture of the size of the problem our communities are facing. Most importantly, the availability of alcohol and drugs has significantly changed young people’s behaviour. In my view, we need to do something about it.

I believe my suggestions are considered and balanced.

Meanwhile Durham Police called on licencees to sign up to a ‘21 or over’ scheme which only allows those 21 and over to buy alcohol. The move is an effort to reduce the problem of young adults buying alcohol for under 18s. Speaking for the trade about the deal, John Hudson condemned the idea as ‘draconian’. He said the licencees would be unable to administer the scheme effectively and it would cost them a lot of money.

Insurance – solving some alcohol problems and causing others

Insurance cover is often taken out for risks that are related to problem drinking. Examples include death, illness, criminal behaviour, accidents (on the road and otherwise) and fire.

Insurance can sometimes pay for treatment for the effect of alcohol misuse. It can help to meet the cost of alcohol-related harm. Sometimes the insured may be encouraged to avoid alcohol problems by risk management procedures required by the insurer or by the prospect of paying higher premiums if those procedures are not adopted.

Often alcohol-related risks may be excluded from the scope of the cover. Sometimes the non-payment of an insurance claim is an alcohol problem in its own right. Non disclosure of (among other things) problem drinking by the person applying for cover (‘the proposer’) may invalidate the insurance. Insurance can also be problematic when it contributes to dangerous behaviour by protecting people from the consequences, as when an alcoholic makes a suicide attempt believing that his family will be able to claim on his insurance.

Alcohol problems are studied within the scientific community. Addiction professionals, including doctors and counsellors, help their patients and clients to face up to their problems. In the insurance industry, alcohol-related risk is an issue for medical staff and risk management professionals. The insurance regulator, the Financial Services Authority, has focused on the mis-selling of, for instance, insurance against critical illness where customers are not given appropriate advice about making full medical declarations. Problem drinking is one of the main conditions which people do not disclose adequately when taking out insurance.

A new paper published by the Institute of Alcohol Studies considers the common ground between the scientific, medical and insurance perspectives and the scope for co-operation in future research and initiatives in addressing problem drinking.

Insurance: solving some alcohol problems and causing others Jonathan Goodliffe IAS Occasional Paper 2007

Date rape dangers

Drug facilitated sexual assault (DFSA), including rapes in which drugs are mixed with alcohol, is a significant problem, the Advisory Council on the Misuse of Drugs (ACMD) says in a new report, ‘Drug Facilitated Sexual Assault’. The Council makes several recommendations to help tackle date rape. These include:

• the Association of Chief Police Officers (ACPO) should enhance evidence gathering so that the Forensic Science Service can test for date rape drugs;

• the Department of Health should ensure hospitals have early evidence kits to allow for similar tests;

• the Government should seek advice on whether the Sexual Offences Act should be strengthened;

• drug facilitated sexual assault should be part of the British Crime Survey and be recorded by police; and schools and other educational establishments should alert people to take common sense measures, such as minding drinks, to avoid being a victim.

Two drugs – gammabuterolactone and 1,4-butanediol – are reportedly used in date rape but are not currently illegal. The Council will report on the potential for classification of these in the near future. However, most drugs used in DFSA, including flunitrazepam, also known as Rohypnol, gammahydroxybutyl rate (GHB), ketamine and cocaine are already controlled under the Misuse of Drugs Act 1971 at an appropriate level and the Council makes no recommendations to reclassify any of them.

The report also highlights the very significant role played by alcohol, either alone or in combination with other substances, in date rape. It also provides an assessment of two reports : ‘Operation Matisse: investigating drug facilitated sexual assault’, published by ACPO; and ‘Toxicological findings in cases of alleged drug facilitated sexual assault in the United Kingdom over a three year period’, published by the Forensic Science Service.

Professor Sir Michael Rawlins, Chair of the ACMD, said: “Drug facilitated sexual assault is a particularly disgusting offence that wrecks people’s lives. It is a significant but under reported problem. “We need more information to help tackle drug facilitated sexual assault and find out the true extent of the problem. That is why drug facilitated sexual assault should be part of the British Crime Survey and police recorded crime statistics.

“Most drugs used in drug facilitated sexual assault are already controlled under the Misuse of Drugs Act, but we are concerned that two drugs are not currently controlled and will further consider whether they should be classified. We will advise the Home Office by the end of the year.” To avoid being a date rape victim the ACMD is encouraging people to:

• avoid going to a club, pub or party alone;

• not accept a drink from strangers;

• not share or exchange drinks;

• not leave your drink unattended even when going to the toilet; and be a friend by watching out for others, and be aware of any changes in their behaviour.

The Council will continue to keep drug facilitated sexual assault under review.

Over one third of prisoners ‘have a drink problem’

The inmates of Winchester Prison have 10 times as many hazardous and dependent drinkers as are found in the general population, and 35 per cent of prisoners believe they have a drinking problem. Nearly half (46 per cent) of prisoners believe that alcohol was linked to their offence, with violent crime accounting for half of these offences.

These are among the conclusions of a new survey of Winchester prisoners conducted by Mike Webb, Alcohol Strategy Co-ordinator of the Hampshire Drug and Alcohol Action Team, and Steve Neville, Winchester Drug Services Team.

Here, MikeWebb gives an account of the survey and its main findings.

Winchester Prison is a category B local prison with an all male population of 697 prisoners who are either on remand, awaiting sentence, serving a short sentence or waiting to be moved to another prison. The majority of prisoners come from across Hampshire and are roughly split from Hampshire, Portsmouth and Southampton.

Winchester Drug Services Team is a multidisciplinary service consisting of prison staff, contracted in-service providers and clinical specialists. Other than the detoxification wing, these services are not funded to work with purely alcohol clients. An alcohol client can only be seen if an illicit drug is also involved. Alcoholics Anonymous go into the prison on a weekly basis.

The prison has a dedicated detoxification landing (34 beds), for both drugs and alcohol. Between April 2005 and March 2006, a total of 222 alcohol detoxifications were carried out, an average of 18.5 a month. Anecdotal information suggested that the level of alcohol consumption among prisoners at Winchester Prison was unusually high and potentially linked to the crimes that they had committed. The survey provided ample evidence to confirm that this picture is correct.

Prisoners were asked how much alcohol they consumed, and if they felt this to be problematic, in two ways. The first was with a closed question, “Do you have a drinking problem” with the responses “Yes, No, Don’t know” available.The second was by listing different measures of alcohol, such as a pint, and asking how many they consumed within a week. This allowed the unit total to be calculated and compared with the national guidelines for alcohol consumption. These suggest that men should drink no more than 21 units in a week. Moderate to heavy drinking is between 21–50 units a week, while those drinking over 50 units are in the serious/dependant category. The main findings are summarised in graph 1.

Graph 1 

The key comparison of this graph is with the hazardous/ dependant drinkers. Winchester Prison has 10 times as many hazardous /dependant drinkers as would be expected to be found in the general population.

The survey also compared the amount of alcohol consumed by prisoners who said that they DID NOT have a drinking problem with those who said that they did have a drinking problem.

The average consumption of the group that said they did not have a drinking problem was 43 units per week, an average that is skewed upwards by a few exceptionally heavy drinkers. 43% are drinking above the recommended limit of 21 units per week. 20% of the respondents who said that they did not have a drinking problem were actually consuming over 50 units per week. This is the level of alcohol consumption that is considered to be serious/dependant and highlights the lack of awareness around safe

levels of alcohol consumption within the prison population.

The average alcohol consumption among those who say that they do have a drink problem was a 157 units per week.

Violent Crime There was a particularly strong relationship between alcohol and violent offences. 22% of all prisoners at HMP Winchester considered that their violent crime offence was related to their alcohol consumption and violent crime accounted for half of all offences from prisoners who reported that alcohol was linked to their criminal activity. Similarly, of those prisoners who believe that they have a drinking problem, over half of the offences are for violent crime. Nearly half of those who said that they would use an alcohol service within the prison were violent offenders.

The question was also asked “How often have you carried out criminal acts while under the influence of alcohol?” The breakdown of responses for violent crime is shown in graph 2, with a comparison given with theft, burglary and other.

When asked if they believed they had a drinking problem, 143 (35%) of respondents believed that they did. Those who had been imprisoned for violent crime are again disproportionately over represented in this finding, as graph 3 illustrates.

Social problems

Respondents identified a range of social problems that they attributed to their drinking behaviour, as outlined in graph 4. Prisoners whose category of arrest was violent and other (of which nearly half are drugs related) are compared with the general prison population.

The three social areas identified where alcohol causes the greatest difficulties for the whole population were:

• Violence to others (156/405)

• Relationship problems (144/405)

• Money problems (128/405)

Within this, those whose category of arrest was violent crime accounted for around half of the violence to other category, social (e.g. housing), medical and injury (to you). The low awareness of medical problems as an issue highlights that prisoners may be unaware of the long term health implications of excessive alcohol consumption.

Domestic violence is the only category that produced an unexpected outcome, with a % that is lower than expected. This may indicate that acknowledging or recognising domestic violence as an issue is difficult.

An interesting follow up exercise would be to carry out a confidential questionnaire with the partners of prisoners to see what they viewed the main social problems caused by alcohol to be.

Service provision When asked if they would use an alcohol service located within the prison, 198 (49%) of respondents said that they would.

However, from this group of people who have expressed an interest in using a service, 67 (37%) had not used drugs in the previous year and, therefore, might not be eligible to receive a service designed to address their alcohol problem alone.

What the survey shows us The findings of the survey strongly indicate that:

• Prisoners believe that alcohol is a causative factor in their offending behaviour

• Prisoners believe that alcohol consumption has caused them a number of social problems, principally in relation to violence towards others, relationship difficulties and financial concerns

• Prisoners are drinking at very high levels, with many unaware that they have an alcohol misuse problem

• A high proportion of respondents believe that they have a drinking problem and would like to access an alcohol service if one were available in the prison. However, because a significant proportion (n=67) of these individuals have not taken illicit drugs in the previous 12 months, they may be ineligible for such a service from the Prison Drug Team.

• Prisoners who have stated that their offence is violent crime are proportionately more likely to have identified alcohol as causing them social problems, to have identified alcohol as having been linked with their offending and to be seeking a service to address their drinking. However this over representation of violent offenders may simply be reflective of the mix of prisoners within Winchester.

Where should we go from here?

This data strongly supports the view that there is indeed a significant proportion of the prison population within HMP Winchester who have serious social and offending problems that may be strongly linked to their drinking behaviour; they recognise this problem and have expressed a desire to access services to address it.

The Prison Service Alcohol Strategy for Prisoners and the Treatment Interventions Good Practice Guide provides an alcohol treatment framework but this has not yet been resourced while provision nationally is extremely limited. Given the strong link between alcohol and offending, the potential reduction in re-offending through addressing problem drinking behaviour would indicate that this would be a cost-effective intervention strategy.

‘Binge drinking’ linked to chlamydia in women

Alcohol has been shown to be a principal risk factor for chlamydia in young women in the UK. A study by Valerie McMunn and Woody Caan of Anglia Ruskin University of over 200 young women aged 16-25 found that three factors were associated with increased risk of chlamydia: alcohol comprised two of them. The two alcohol factors were the age of first drink and binge drinking. The non-alcohol factor was the number of lifetime sexual partners.

Chlamydia trachomatis has become the most common sexually transmitted infection in UK women aged 16-25. Concerns about the long-term harm to women’s well being, fertility and pregnancy and also about infant health have led the Department of Health to implement a screening programme for chlamydia. At the same time, alcohol consumption in adolescent girls has been rising and there has been, in particular, a growth in episodic heavy consumption – binge drinking – which has led, amongst other things, to a doubling in the number of intoxicated women attending accident and emergency departments.

The study, of women attending a family planning clinic in the East of England, was also designed to elucidate the relationship between hazardous drinking and unsafe sex. The mean age of the women in the sample was 19.4 years. Two particularly striking findings were the number of sexual partners reported by a high proportion of the women, and the amount of alcohol consumed per night.

The number of sexual partners ranged from 1 to 30, the average being 6.8. 20.2% of the women reported more than one sexual partner at the same time.Women being treated for chlamydia reported more lifetime sexual partners than those who had never been treated.

The number of sexual partners correlated with all the alcohol parameters, in particular the number of drinking days per week and the total amount consumed. Three quarters of the women reported a pattern of binge drinking, consuming 5 or more units on a ‘typical’ night out. However, levels of consumption on ‘heavy’ nights out were far higher, up to 50 units. Women being treated for chlamydia reportedly drank a median of 15 units on a ‘heavy’ night, compared to 12 units for those who had not been treated. Women being treated for chlamydia also reported beginning to drink on average 1.2 years earlier than those not being treated.

The authors suggest that the increased risk of chlamydia associated with alcohol use may have been mediated by several factors including reduced condom use, sex with strangers and exposure to coercive sex.

The implication of the study for policymakers is that binge drinking is not an isolated phenomenon but occurs in relation to many other behaviours involving both individuals and social networks.

A challenge to the research community is to discover the links in early adolescence (before age 16) between onset of drinking, early sexual behaviour and exposure to sexually transmitted infections.

Workplace drinking culture influences alcohol intake elsewhere

A restrictive drinking culture at work curbs an individual’s overall alcohol intake, including outside of work, suggests new research published in Occupational and Environmental Medicine.

The researchers base their findings on a detailed analysis of workplace attitudes towards drinking and drinking behaviours in over 5,000 employees in 16 different organisations, representing a range of different sectors.

The employees were quizzed about how often they drank alcohol, and when and where they did so.

They were also asked to reveal their attitudes to social drinking, including whether they thought alcohol boosted workplace morale, was good for business, alleviated boredom, improved their health, was harmful, or set a bad example.

Their responses were tied in with those of their supervisors and managers who were also quizzed about the drinking culture in their respective divisions.

Overall, women employees who often attended religious services, and those who cohabited were less likely to drink. Younger workers and smokers were more likely to do so.

Around one in five (19%) workers was classified as a heavy drinker outside of work (four or more drinks in one day in men and more than three in women).

A further 8% were classified as frequent drinkers (some alcohol on five or more days of the week) outside of work, and 11% were classified as drinking at work.

But rates of heavy, frequent, and workplace drinking were significantly lower in organisations that discouraged social drinking than in those that most tolerated it.

After taking account of other influential factors, workers in organisations that most discouraged social drinking were 45% less likely to be heavy drinkers than those in workplaces with the most relaxed attitudes to drinking.

They were also 54% less likely to be frequent drinkers and 69% less likely to drink during the working day.

The authors conclude that the workplace drinking culture is crucial for changing drinking patterns and preventing alcohol problems, and should be included in public health initiatives.

Reference [Drinking social norms and drinking behaviours: a multilevel analysis of 137 workgroups in 16 worksites Online First Occup Environ Med 2007; doi: 10.1136/oem.2006.031765]