Issue 1 2008

New Alcohol Health Alliance calls for tougher measures on alcohol

A new coalition launched in November is calling on the Government to do more to prevent the rise in alcohol-related diseases. The Alcohol Health Alliance UK is a ground-breaking coalition of 24 organisations, including the Institute of Alcohol Studies, and headed by the Royal College of Physicians. Its mission is to reduce alcohol related health harm which it says continues to spiral.

AHA says:

• 13 children a day are hospitalized as a result of alcohol misuse

• Alcoholic liver cirrhosis has increased by 95% since 2000, and by 36% over the last two years to 2006 and is still increasing

• Overall alcohol related deaths increased by 18% from 2002-2005

• More people die from alcohol related causes than from breast cancer, cervical cancer and MRSA combined

• The ‘passive effects’ of alcohol misuse are catastrophic – rape, sexual assault, domestic and other violence, drunk driving and street disorder

• alcohol affects thousands more innocent victims than passive smoking

The members of the Alcohol Health Alliance are committed to working together to:

• Highlight the rising levels of alcohol related health harm

• Propose evidence-based solutions to reduce this harm

• Influence decision makers to take positive action to address the damage caused by alcohol misuse

• Advocate a policy platform consisting of:
  • Dedicated funding for alcohol treatment and prevention strategy
  • Increased taxation on alcohol
  • A ban on alcohol advertising before 9.00 pm and in cinemas apart from 18 rated films
  • Promotional material to carry information on health related harm
  • The drink driving limit to be reduced to the EU standard of 0.5g/l and a near zero limit for new drivers

Not unexpectedly, the new Alliance was vigorously attacked by representatives of the alcohol industry. Speaking at the Publican Conference in central London before the AHA had been officially launched, Mark Hastings, Communication Director at the British Beer & Pub Association, warned the industry that it faced one of the most “concerted and sustained threats to its commercial viability ever.

That’s coming from the level of the World Health Organisation, from the European Union and our own government,” he said. “Alcohol is the big issue at the moment and it’s absolutely essential that our industry gears up for what is going to be a considerable battle over the next few months and years.” Hastings said that the issue over how to deal with the problems associated with alcohol would heat up when the Alcohol Health Alliance, “made up of 21 health and temperance groups”, was launched.

Hastings claimed many lobbyists working for public health groups, who campaigned on tobacco, had moved across to focus on alcohol.

“The same skills set, the same tactics, the same people are involved with the issue of alcohol lobbying, that’s what gives it the profile it now has,” he said.

Later, an open letter was sent to Professor Ian Gilmore,Chairman of the AHA, on behalf of the five leading organisations representing the alcoholic drinks sector: the British Beer & Pub Association, Gin & Vodka Association, National Association of Cider Makers, Scotch Whisky Association and the Wine & Spirits Trade Association.

The letter requested a meeting with the AHA to discuss the Alliance’s policy platform. Rob Hayward, Chief Executive of the British Beer & Pub Association said:

“We are challenging some of the basic assumptions at the heart of this campaign. We do not believe the evidence base supports their call for higher taxes, more regulation and health warnings. Indeed, these concerns are heightened because our experience from around the world strongly suggests that the measures this lobby group are seeking could make the situation worse.”

Critics of the alcohol industry will regard these staements as turning the truth on its head. The scientific concensus on alcohol taxation for example is that it is probably the single most effective means of limiting the harm associated with alcohol available to modern governments.

Alcohol Health Allilance

The present membership of the Alcohol Health Alliance is:

Academy of Medical Royal Colleges
Action on Addiction
Alcohol and Health Research Trust
Alcohol Concern
Alcohol Education and Research Council
British Association for the Study of the Liver
British Liver Trust
British Society of Gastroenterology
College of Emergency Medicine
Faculty of Dental Surgery
Faculty of Occupational Medicine
Faculty of Public Health
Institute of Alcohol Studies
Medical Council on Alcohol
National Addiction Centre
National Organisation for Fetal Alcohol Syndrome – UK
Royal College of General Practitioners
Royal College of Nursing
Royal College of Physicians Edinburgh
Royal College of Physicians London
Royal College of Physicians and Surgeons,Glasgow
Royal College of Psychiatrists
Royal College of Surgeons London
Scottish Intercollegiate Group on Alcohol

‘Sensible drinking’ limits not ‘useless’ after all

It is customary for stories about alcohol to attract media attention in the run up to Christmas, but towards the end of 2007 one alcohol story received unusually wide coverage.

This was the allegation that first appeared in the Times that the original ‘safe drinking’ limits of a maximum of 21 units of alcohol per week for men and 14 for women, dating from 1987,“had no firm scientific basis whatsoever”.

The Times, in a report headed “Drink limits ‘useless’”, quoted Dr Richard Smith, a former editor of the British Medical Journal and a member of the Royal College of Physicians working party that proposed the limits, as saying that the limits had really been “plucked out of the air. They were not based on any firm evidence at all. It was a sort of intelligent guess by a committee.”

The fact that the very next day Dr Smith attempted to retract the statement, saying “The suggestion that the guidelines were ‘useless’ is not what I meant at all. That would be a very serious misinterpretation”, did not prevent the original story from fully going the rounds, being fastened upon with particular relish by commentators keen, for whatever reason, to challenge the credibility of the current official advice on alcohol and health. There were frequent references to the new Puritanism, health fascism, and do-gooders attempting to meddle in other people’s lives.

Some blog spots featured the story with headlines such as “Anti-alcohol campaigners – I told you those lying b******ds were making it up”, and “Statistics, data and damned liars”. Rather more up-market publications also got in on the act. In a review in The Spectator of a book on largely bogus health scares, the reviewer took the opportunity to have a swipe at the drinking guidelines despite their not featuring in the book he was reviewing:

“For 20 years we were solemnly and repeatedly lectured that 21 alcoholic units a week for men and 14 units for women were the upper limits of what is safe to drink. A couple of months ago we discovered that these figures were, in the belated admission of their author, ‘plucked out of thin air’. But did anyone think to query the evidence at the time? No, we were taken in by the government-endorsed expert. The only wonder is that he has not been knighted.” (Spectator,2 January 2008,Graham Stewart,Review of Scared to Death: From BSE to Global Warming by Christopher Booker and Richard North)

The Times itself continued its attack by claiming that the current drinking guidelines disregard a host of epidemiological studies proving that large quantities of alcohol are good for us, and that consumption of more than 50 units a week cuts the risk of premature death by half.

However, if the author of the article had taken the trouble to read the 1995 Joint Publication of the Medical Royal Colleges, she would have found the very studies she claimed were being disregarded were included among the references.The publication was entitled ‘Alcohol and the Heart in Perspective:Sensible Limits Reaffirmed’.

The inaccuracies contained in the Times report are likely to have added to public confusion about what the ‘sensible drinking’ limits are or should be, and to have reinforced the suspicion, welcomed by some very influential participants in the alcohol debate, that the official guidelines have been discredited.

The latest promotion of the idea by some in the media that the UK drinking guidelines are not only too low but are arbitrary and unscientific coincided with the publication of a major scientific review of the drinking guidelines in Australia. Ironically, contrary to the whole implication of the media coverage in the UK, the review concludes that the current Australian drinking limits are too high and should be lowered. If this policy is adopted the new Australian limits will be lower than the British ones.

What are drinking guidelines?

Drinking guidelines are designed essentially to answer the question of at what level of regular consumption of alcohol the average adult is likely to experience a significantly raised risk of health damage.

The guidelines originally formulated by the medical Royal Colleges of Physicians, Psychiatrists and General Practitioners, and adopted by Government, all agreed on the graded nature of the relationship between alcohol consumption and risk. Consumption of 1-14 units of alcohol per week for women, 1-21 units for men, was defined as low risk. Consumption of 15-35 units per week for women, 22-50 units for men was defined as hazardous and consumption of more than 35 and 50 units per week for women and men respectively as definitely harmful.

In 1995, the official guidance was changed from weekly to daily limits – no more than 3-4 units per day for men, no more than 2-3 units per day for women, with the qualification that these maximum levels of consumption should not be reached every day of the week.

These guidelines are broadly similar to those provided in other countries. In Canada, for example, the advice is for women to drink no more than 9 drinks per week and men no more than 14 drinks per week. At first sight, these appear to be lower than the UK limits, but, allowing for the fact that Canadian units are larger than British ones, they are in fact comparable.

The similarities are not surprising, given that the guidelines are based on epidemiological evidence in relation to alcohol-related disease and mortality which is international in character. This evidence has grown substantially over the years and there is no truth to the claim in the Times that those setting the guidelines have disregarded evidence showing regular, heavy consumption of alcohol to be safe or even beneficial. In fact, the truth lies in the opposite direction, the more recent research suggesting that alcohol is, if anything,more dangerous than was previously believed. It has become clear, for example, that there is a significantly increased risk of some diseases at consumption levels below the 21/14 drinks per week level. It is significant that a recent, major British study of health and disease found that mortality risk increased above a consumption level of 14 drinks per week in both men and women. And in Australia, the new proposed guideline for low risk drinking is that neither men nor women should exceed 20 grammes of pure alcohol per day. This is equivalent to 2.5 standard UK drinks. The Australians define ‘low risk’ as the level of alcohol intake that, for healthy adults, will reduce the lifetime risk of death from an alcohol-related injury or disease to less than 1 in 100 (that is, one death for every 100 people who drink at that level).

Below: The graph presents some of the evidence, in this case mortality, that is taken into account when setting the guidelines. Some argue that this evidence suggests that the guidance is deficient, though hardly in the way implied by The Times. For in relation to the diseases shown, it can be seen that there is no clear threshold of consumption below which there is no risk at all.

Anti-drunkenness advertisements ‘misconceived’

As a key component of its Alcohol Harm Reduction Strategy, the Government has invited tenders for the next generation of ‘safer drinking’ advertisements. However, research funded by the Economic and Social Research Council suggests that the kind of anti-’alcohol abuse’ advertisements the Government has in mind, and which drinks companies such as Diageo have already produced, may be ‘catastrophically misconceived’ and possibly counter productive.

Government Campaign

Three advertising agencies have been invited to submit proposals for the next generation of public information campaigns to raise awareness of the harm associated with alcohol abuse and to promote a ‘sensible drinking’ culture.

The communications drive, worth an estimated £10 million this year and expected to be funded at a similar level over subsequent years, will run from April 2008 and will put into practice proposals contained in the Government’s alcohol strategy, ‘Safe. Sensible. Social’, published in June 2007 and led by the Home Office and the Department of Health.

The brief requires the agencies to develop a strategic approach that includes the key communication objectives of the strategy.These include:

• Raised public awareness of units of alcohol
• Sustained campaigning to challenge public acceptance of drunkenness and
• Information and advice for harmful drinkers and their friends and family

Member of the cross-Government Alcohol Strategy Delivery Group Cerys Adams said:

“Changing our drinking culture is one of the most challenging briefs facing Government. This marks a significant change of gear in how we communicate with the public about alcohol and I look forward to seeing the agencies’ creative propositions over the coming months.”

The new generation of campaigns will build on the successful Know Your Limits campaign brand,which is targeted at 18-24 year old binge drinkers. It will communicate a broader range of messages to more audience groups.

However, researchers have found that adverts that show drunken incidents, such as being thrown out of a nightclub, being carried home or passing out in a doorway, are often seen by young people as being a typical story of a ‘fun’ night out, rather than as a cautionary tale.

Whilst these adverts, such as Diageo’s The Choice is Yours campaign, imply that being very drunk with friends carries a penalty of social disapproval, for many young people the opposite is often the case, the researchers conclude.

“Extreme inebriation is often seen as a source of personal esteem and social affirmation amongst young people,” said Professor Christine Griffin from the University of Bath, who led the research with colleagues from Royal Holloway, University of London and the University of Birmingham.

“Our detailed research interviews revealed that tales of alcohol-related mishaps and escapades were key markers of young peoples’ social identity. These ‘drinking stories’ also deepen bonds of friendship and cement group membership.

“Not only does being in a friendship group legitimise being very drunk – being the subject of an extreme drinking story can raise esteem within the group.”

Professor Chris Hackley in the School of Management at Royal Holloway added: “Inebriation within the friendship group is often part of a social bonding ritual that is viewed positively and linked with fun, friendship and good times, although some young people can be the target of humiliating or risky activities.

“This suggests that anti-drinking advertising campaigns that target this kind of behaviour may be catastrophically misconceived.”

The research,which was funded by the Economic & Social Research Council, involved in-depth interviews with 94 young people in three UK regions over a period of three years.

“The study suggests a radical rethinking of national alcohol policy is required which takes into account the social character of alcohol consumption and the identity implications for young people,” said Professor Hackley.

Professor Isabelle Szmigin from Birmingham Business School, University of Birmingham, added:

“Whilst many young people recognise the damage that ‘drinking too much’ can do to their health, and the associated risks of physical and sexual assault, few view these as more than short term problems.”

Diageo hit back at the allegations that its ‘responsible drinking’ advertising may actually encourage young people to get drunk. A Diageo spokesman said:

“In developing ‘The Choice is Yours’ campaign we carried out extensive research amongst 3,500 18 – 35 year olds across Europe to ensure we delivered a campaign that would resonate strongly with this age group. Bath University talked to 94 people. Our research – both qualitative and quantitative – showed that young adults were much more likely to consider drinking responsibly if they believed that by drinking excessively they would be in danger of losing their social credibility and standing – precisely the message our campaigns convey.”

Diageo said assessment of its previous responsible drinking campaigns ‘Mirror’ and ‘Many Me’ showed that 71 per cent of people were much more likely to consider drinking responsibly once they had been exposed to the adverts.

“Based on our extensive research, coupled with our experience of developing and delivering these campaigns over a number of years now, we are confident they have a proven positive effect,” said the spokesman.

“We’re proud of our adverts. They are strategically sound, evidence based and not designed to simply grab headlines.”

Downing Street Summit on binge drinking

As a key component of its Alcohol Harm Reduction Strategy, the Government has invited tenders for the next generation of ‘safer drinking’ advertisements. However, research funded by the Economic and Social Research Council suggests that the kind of anti-’alcohol abuse’ advertisements the Government has in mind, and which drinks companies such as Diageo have already produced, may be ‘catastrophically misconceived’ and possibly counter productive.

Government Campaign

Three advertising agencies have been invited to submit proposals for the next generation of public information campaigns to raise awareness of the harm associated with alcohol abuse and to promote a ‘sensible drinking’ culture.

The communications drive, worth an estimated £10 million this year and expected to be funded at a similar level over subsequent years, will run from April 2008 and will put into practice proposals contained in the Government’s alcohol strategy, ‘Safe. Sensible. Social’, published in June 2007 and led by the Home Office and the Department of Health.

The brief requires the agencies to develop a strategic approach that includes the key communication objectives of the strategy.These include:

• Raised public awareness of units of alcohol
• Sustained campaigning to challenge public acceptance of drunkenness and
• Information and advice for harmful drinkers and their friends and family

Member of the cross-Government Alcohol Strategy Delivery Group Cerys Adams said:

“Changing our drinking culture is one of the most challenging briefs facing Government. This marks a significant change of gear in how we communicate with the public about alcohol and I look forward to seeing the agencies’ creative propositions over the coming months.”

The new generation of campaigns will build on the successful Know Your Limits campaign brand,which is targeted at 18-24 year old binge drinkers. It will communicate a broader range of messages to more audience groups.

However, researchers have found that adverts that show drunken incidents, such as being thrown out of a nightclub, being carried home or passing out in a doorway, are often seen by young people as being a typical story of a ‘fun’ night out, rather than as a cautionary tale.

Whilst these adverts, such as Diageo’s The Choice is Yours campaign, imply that being very drunk with friends carries a penalty of social disapproval, for many young people the opposite is often the case, the researchers conclude.

“Extreme inebriation is often seen as a source of personal esteem and social affirmation amongst young people,” said Professor Christine Griffin from the University of Bath, who led the research with colleagues from Royal Holloway, University of London and the University of Birmingham.

“Our detailed research interviews revealed that tales of alcohol-related mishaps and escapades were key markers of young peoples’ social identity. These ‘drinking stories’ also deepen bonds of friendship and cement group membership.

“Not only does being in a friendship group legitimise being very drunk – being the subject of an extreme drinking story can raise esteem within the group.”

Professor Chris Hackley in the School of Management at Royal Holloway added: “Inebriation within the friendship group is often part of a social bonding ritual that is viewed positively and linked with fun, friendship and good times, although some young people can be the target of humiliating or risky activities.

“This suggests that anti-drinking advertising campaigns that target this kind of behaviour may be catastrophically misconceived.”

The research,which was funded by the Economic & Social Research Council, involved in-depth interviews with 94 young people in three UK regions over a period of three years.

“The study suggests a radical rethinking of national alcohol policy is required which takes into account the social character of alcohol consumption and the identity implications for young people,” said Professor Hackley.

Professor Isabelle Szmigin from Birmingham Business School, University of Birmingham, added:

“Whilst many young people recognise the damage that ‘drinking too much’ can do to their health, and the associated risks of physical and sexual assault, few view these as more than short term problems.”

Diageo hit back at the allegations that its ‘responsible drinking’ advertising may actually encourage young people to get drunk. A Diageo spokesman said:

“In developing ‘The Choice is Yours’ campaign we carried out extensive research amongst 3,500 18 – 35 year olds across Europe to ensure we delivered a campaign that would resonate strongly with this age group. Bath University talked to 94 people. Our research – both qualitative and quantitative – showed that young adults were much more likely to consider drinking responsibly if they believed that by drinking excessively they would be in danger of losing their social credibility and standing – precisely the message our campaigns convey.”

Diageo said assessment of its previous responsible drinking campaigns ‘Mirror’ and ‘Many Me’ showed that 71 per cent of people were much more likely to consider drinking responsibly once they had been exposed to the adverts.

“Based on our extensive research, coupled with our experience of developing and delivering these campaigns over a number of years now, we are confident they have a proven positive effect,” said the spokesman.

“We’re proud of our adverts. They are strategically sound, evidence based and not designed to simply grab headlines.”

Government targets youth drinking

The Government is to draw up a youth alcohol action plan by Spring 2008 in order to tackle the problems relating to binge drinking.This forms one element of a wider package of measures to tackle risky adolescent behaviour as part of the new ‘Children’s Plan’, launched by the Department for Children, Schools and Families, headed by Secretary of State Ed Balls.

The Children Plan is described as a long term vision to improve schools and a step-change in the way parents and families are supported to deal with the new challenges faced by young people in the 21st century.

On risky behaviour, the Government says that early teenage years and adolescence can expose young people to risks and where they fail to make informed or sensible choices, they can put their health and future at risk. To tackle this issue:

• a youth alcohol action plan will be published in the Spring 2008, around the same time as the new drugs strategy which will improve alcohol education in schools and consider the case for further action on alcohol advertising;

• there will be a review of best practice in effective sex and relationship education and how it is delivered in schools;

• working with the Home Office, £66m will be available to target those young people most at risk of offending;

• a restorative approach to youth offenders will be piloted;

• a Green Paper will be published in Spring 2008 to look at what happens when young offenders leave custody on how to improve the education they receive in custody.

Issues of teenage drinking

In preparing its youth alcohol plan, the Government has identified two particular issues as requiring investigation,what is ‘safe’ or ‘sensible drinking’ in adolescents, and the influence of alcohol advertising.

The fact that significant numbers of even young teenagers are now drinking substantial amounts of alcohol on a regular basis is not surprisingly, causing some unease to public health practitioners and policymakers, given that the existing guidance on ‘sensible drinking’ was derived from evidence pertaining only to adults, and it is not known whether or to what degree it is applicable to younger populations.

In response, the Department for Children, Schools and Families has convened a panel of experts, on which the Institute of Alcohol Studies is represented, to review the latest scientific evidence on the effects of alcohol on young people’s physical and emotional health, cognitive development and brain function. This review will then form the basis for the Government’s publication of authoritative, accessible guidance about what is and what is not ‘safe and sensible’.

Commercialisation of childhood

The issue of advertising was repeatedly raised by parents during consultations on the Children’s Plan. Concern was expressed at what is perceived to be the increasing commercialization of childhood. In response, the Government is to commission research on commercialization and a Ministerial Group will examine alcohol advertising specifically.

A National Consumer Council study found a growing range of internet pop-ups and advertisements aimed at children. It estimates that young people see about 27 TV advertisements a day, adding up to 10,000 a year.

On commercialization, Mr Balls said: “Families today worry about this more because there are more (TV) channels, more advertising and children are exposed to it more than was the case 20 or 30 years ago.”

In what was taken to be a hint at additional Government-imposed regulation, Mr Balls said a study by Alcohol Concern revealed a spike in television drinks advertisements between 4pm and 6pm, when many children watch. There was a concern that alcohol advertising could be contributing to the binge drinking problems affecting teenagers and young people.

New NICE guidance for schools published to prevent and reduce alcohol use in children and young people

The National Institute for Health and Clinical Excellence (NICE) has issued national guidance on effective ways to encourage children not to drink, delaying the age at which young people start drinking and reducing the harm it can cause among those who do drink.The guidance is aimed at anyone who works with children and young people in schools and other education settings. It gives advice on incorporating alcohol education into the national science and personal, social and health education (PSHE) curricula, and helping children and young people access the right support. In 2006, 21 per cent of pupils in England aged 11-15 reported drinking alcohol in the previous week.

Launching the new guidance, Andrew Dillon, chief executive of NICE said: “Many different factors have an influence on alcohol consumption among children and young people, including peer pressure, the media and the availability and cost of alcohol. It is important that we now have national guidance for tackling this issue so that we can do everything possible to delay the onset of drinking and reduce the harmful effects of alcohol use.”

Key recommendations of the guidance include:

• Head teachers, teachers, school governors and others who work in (or with) schools should ensure that alcohol education is an integral part of the national science, PSHE and PSHE education curricula, in line with Department for Children, Schools and Families (DCSF) guidance. Education programmes should increase knowledge of the potential damage alcohol use can cause and provide the opportunity to explore attitudes to – and perceptions of – alcohol use.

• Where appropriate, parents or carers should be offered information about where they can get help to develop their parenting skills. This includes problem-solving and communication skills, and advice on setting boundaries for their children and teaching them how to resist peer pressure.

• If children and young people are thought to be drinking harmful amounts of alcohol, teachers, school nurses and school counsellors should offer brief, one-to-one advice on the harmful effects of alcohol use, how to reduce the risks and where to find sources of support.

• Head teachers, school governors, healthy school leads, school nurses and extended services should maintain and develop partnerships to support alcohol education in schools as part of the national science and PSHE education curricula.

Change of direction?

The NICE guidance begins to put into effect the objectives in relation to preventing harm to the under- 18s contained in the revised national alcohol harm reduction strategy for England, ‘Safe. Sensible. Social’. The Strategy document refers to evidence showing that children and adolescents are drinking alcohol at a younger age and those who do so are drinking in greater quantities than ever before. The evidence also shows, the document explains, that alcohol has serious consequences for young people both now and later in life, and the Strategy goes on to outline three objectives:

• Delaying the onset of regular drinking, primarily by changing the attitudes of 11-15 year olds and their parents about alcohol;

• Reducing harm to young people who have already started to drink.

• Creating a culture in which young people feel they can have fun without needing to drink.

No more ‘sensible drinking’ for teenagers?

The objective of delaying the onset of regular drinking appears to represent a departure from the idea of teaching children to ‘drink sensibly’, and possibly introducing children to alcohol early in life in family settings in the hope of inoculating them against excessive consumption.

The merits of this view were expressed to NICE by ‘Alcohol in Moderation’ (AIM), an advocacy group strongly linked to the alcohol industry. In its submission to NICE, AIM argued that the new guidance to children and adolescents “should include a message to encourage responsible use and sensible drinking patterns. AIM went on to state that “evidence shows parental introduction of small amounts of alcohol in the home with meals does not encourage irresponsible use…”

In response, NICE said it would be grateful if AIM would provide the references for this evidence. So far as is known, no references were forthcoming.

However, the present Government has itself often appeared to favour the AIM approach, notably in relation to its licensing law reforms which were in part designed to make licensed premises more family-friendly and to encourage children, even those unaccompanied by adults, into licensed premises. In preparing what finally became the Licensing Act 2003, the Government also clearly considered reducing the legal age for purchasing and consuming alcohol in public places to 16 or 17, though it finally decided against doing so.

Gearing national policy to delaying introducing alcohol to children thus seems to represent a significant change of direction. No explanation of this change has been provided but an obvious possibility is that the idea of positively encouraging children and adolescents to drink ‘sensibly’ has lost some of its plausibility as a preventative measure, given that the current anxieties about binge drinking concern primarily a generation raised on the very ‘sensible drinking’ message that is supposed to prevent such problems.

Drink driving and the wider purpose of insurance

By Jonathan Goodliffe

It is a commonplace that the effective combating of drink driving requires the participation of a wide range of bodies both public and private.The insurance industry is one body which obviously has an important role to play, indeed it cannot avoid being involved, and yet arguably the industry could and should take a more active role, not only in reducing deaths and injuries caused by drink driving, but also in the wider development of policy relating to the reduction of alcohol related harm.

In 2006, 540 people are estimated to have been killed in motor accidents involving illegal alcohol levels. 1,960 people were seriously injured and 11,880 slightly injured. In 1995, when the figures for deaths were similar, the Government estimated that another 250 people were killed in accidents involving drivers and riders with raised blood alcohol levels, but below the legal limit.

The UK drink driving problem

The blood alcohol limit for driving in the UK is 80 milligrammes of alcohol in 100 millilitres of blood. In most of the rest of Western Europe it is 50mg%. Over the last 10 years the police, magistrates and the medical profession have supported a reduction in the current UK limit, but it is not clear whether this will ever be done.

There are other things that might help to reduce deaths and injuries. Examples include more publicity for “don’t drink and drive” and more resources for police enforcement. Subject to human rights considerations blood testing might be carried out at random. Ensuring that banned drivers are not driving without a licence and insurance is also crucial.

The responsibility of society

In the latest government paper on its alcohol strategy, Vernon Coaker, Under-Secretary of State at the Home Office, identified an equally important approach to reducing alcohol related crime. He said that “promoting a sensible drinking culture that reduces violence and improves health is a job for us all … Business and industry should reinforce responsible drinking messages at every opportunity.”

I recently asked for an interview with Nick Starling,who is the head of general insurance at the Association of British Insurers (ABI). Mr. Starling has recently joined an alcohol policy panel convened by Alcohol Concern. I wanted to ask Mr. Starling about the insurance industry’s role in reducing the problems arising from drink driving.There was nothing on this subject on the ABI’s website.

I heard back from the ABI’s press office: “[Mr. Starling] feels that, given that he has had only a very brief contact with Alcohol Concern and that we have relatively little to say on this, that it would not be worthwhile your interviewing him. I am happy to outline the main insurance implication of drink driving – higher motor insurance premiums – if you wish.”

The wider purpose of insurance

This response hardly does justice to the role of insurance in modern society. Insurance not only protects the financial interests of policyholders and of people whom they have harmed. It also may encourage a more creative approach to the management of risk, including alcohol related risk.

For example in some US states insurers underwriting lawyers’ malpractice cover have taken a lead in founding programmes for helping addicted lawyers. These programmes also educate other lawyers about how to recognise the problem in colleagues and to provide help. No doubt the insurers hoped that they would reduce claims rates and increase their profits. They also helped the individuals concerned and their families and contributed to improving the quality of the legal service provided to their clients.

Another example of “enlightened self-interest” is the insurance industry’s involvement in the subject of climate change. It (and the ABI) has a leading role in the long term planning of counter-measures, such as flood defences, and in promoting climate awareness.

What about motor insurance?

No equivalent process is apparent in the field of motor insurance. People who take out motor insurance (in contrast to, for instance, life or illness insurance) are not usually asked about their drinking habits. The applicant for cover will, however, be required to declare any motoring convictions for drink driving. In the absence of such a conviction alcohol misuse will not be identified. So, in a sense, motor insurers underwrite against the risk arising from alcohol misuse only after the risk has materialised. A part of the wider social purpose of the underwriting process is therefore lost.

20 years ago alcohol and other health issues were more systematically covered on proposal forms for motor insurance. The insurer is liable, however, to anyone injured by the motorist’s drink driving even if it repudiates the insurance because of the motorist’s fraud. The insurer may sue the motorist to recover its payout to the victim, but that will generally not be cost effective. It may be like trying to get blood out of a stone. So losses can only be recouped when the motorist gets his licence back and is charged a penal premium.

Heavy competition in the motor insurance market is another factor. Insurers and their intermediaries advertise how easy it is to get insurance, particularly over the internet. Too much focus on getting the motorist to ask himself whether he is fit to drive may dilute that message and lose business. Insurers give advice on their websites as to how to avoid an insurance claim. This advice does not seem to include “don’t drink and drive”.

A motorist is, of course, under a legal obligation to notify the licensing authorities if he becomes unfit to drive. Problem drinkers, however, are typically in ‘denial’. So a more effective approach might be for insurers to raise the issue when cover is taken out and every year when it is renewed.

New York legal rules

Under New York law insurers are required, when issuing or renewing motor insurance, to provide a statement on this issue to every insured (i.e. not just the policyholder but also any ‘named’ drivers). The statement outlines the legal and financial consequences of convictions for operating a motor vehicle when under the influence of alcohol or drugs. The six page statement contains the following passage: “We [i.e. the New York insurance industry] strongly endorse the message conveyed by the law – that it does not pay to drink and drive.”

Corporate social responsibility

The ABI’s apparent lack of interest in drinking and driving may not, however, be representative of the attitude of the insurance industry as a whole. Lord Sharman is Chairman of Aviva, the international insurance group which includes, among other members, the Norwich Union.He remarked in the Aviva 2007 corporate social responsibility (CSR) report:

“The board remains keenly aware of the need to develop our business to be sustainable and responsive to the needs of customers, staff and the wider communities in which we operate.”

Motor insurance and its wider purpose (in contrast to, for instance, climate change) does not seem to be covered in insurers ’CSR policies. There are, however, at least three good reasons why it should be:

• motor insurance is compulsory and therefore a captive market for insurers. The profits from that market should be counterbalanced by a more significant contribution by insurers to the development of longer term solutions to the risks which they cover

• this is not an area where the initiative is likely to come from the insurance industry’s regulator, the Financial Services Authority. The FSA’s statutory objectives do not include protecting and treating fairly people who are liable in the future to be injured in motor accidents. So motor insurance (unlike, for instance, payment protection insurance) is not currently a problem on the FSA’s regulatory agenda

• in other areas of insurance against risks where alcohol misuse may be a factor, such as professional indemnity, life, illness and fire, research carried out by Aviva and other insurers (including for instance, Swiss Re and SCOR) has provided valuable insights for the study and reduction of alcohol problems. When insurers apply their minds to these matters the result can be significant.

It is to be hoped that a dialogue between government, insurers and professionals in the alcohol field will ultimately emerge.

This article first appeared on the Complinet Insurance news service.

Experimental education programmes for binge drinking offenders

Binge drinkers arrested for alcohol-related offences in four areas across the country may be compelled by police ‘to face up to the consequences of their drinking after they have been arrested’, Home Secretary Jacqui Smith has announced. Arrest referral will make no difference to whether or not someone is charged with committing an offence, but it is hoped that getting advice about their drinking might stop someone offending in the future.

The Home Office has provided £330,000 of funding to Drug and Alcohol Action Teams in Manchester, Liverpool, Cheshire and Ealing to pilot Alcohol Arrest Referral Projects (AARP) until March 2008. In Liverpool, offenders will be required to pay £30 each towards the cost of the counselling which will be ploughed back into the scheme. If they prove successful, further funding will be available until October 2008.

The pilot schemes will be used to establish whether brief interventions reduce offending among those arrested for alcohol related offences, to investigate how referral schemes can be established to provide appropriate and effective interventions in a cost-efficient manner, and to increase the number of conditional cautions that have alcohol referral attendance as a condition.

A typical alcohol referral process might involve the following:

• An adult has been binge drinking and commits criminal damage. They are arrested and taken into custody.

• Police in the custody suite judge that alcohol played a part in the fact that the person committed the offence, and that they might benefit from advice about safer drinking.

• A resident alcohol specialist gives the person advice about unit strengths, the effects of alcohol on the body, and strategies for reducing the risk of offending – and they could be made to pay towards taking responsibility for their actions.

• Those with more complex alcohol misuse problems, and who are given a conditional caution, can be referred to more in-depth advice sessions. If they do not attend these advice sessions, they can be prosecuted for the original offence.

The Home Office says that where similar schemes have operated in Gloucestershire and Dudley, police have reported significant reductions in re-offending. In the former, reoffending among those who had attended two advice sessions approximately halved after twelve months.

The Alcohol Arrest Referral Scheme, a partnership between Gloucestershire Drug and Alcohol Service and Gloucestershire Constabulary was established in 1999. The scheme was the first of its type in the country aimed at reducing offending related to alcohol.

The Dudley Borough Alcohol Arrest Referral Scheme, developed by the Dudley Community Safety Partnership with the support of Dudley Health Authority, DudleyMBC, West Midlands Police and alcohol charity Aquarius started on 8 September 2001.

The four new pilot schemes will build on that work and provide an opportunity to collect detailed evidence about how these interventions combat alcohol-related crime and disorder. At the same time they will help to establish a blueprint of best practice for others to follow.

Home Secretary Jacqui Smith said: “We are determined to break the link between drunkenness and anti-social behaviour. People need to face up to the damage that excessive drinking can do to themselves and those around them. These pilots will complement powers already available to the police to tackle alcohol related disorder, including on-the-spot fines, confiscating alcohol in public places and closing down premises that flout the law.“

Landmark Cancer Report

Obesity and alcohol major risk factors for cancer

People should aim to be at the lower end of the healthy weight range and either not drink or cut down their alcohol consumption, according to a landmark report published by the World Cancer Research Fund (WCRF).

The WCRF report is described as the most comprehensive ever published on the link between cancer and diet, physical activity and weight. Searches at nine academic institutions across the world, for studies published since records began in the 1960s, initially found half a million – 7,000 of which were judged to be the most relevant and robust for inclusion in the report. It includes 10 recommendations from a panel of 21 world-renowned scientists that represent the most definitive and authoritative advice that has ever been available on how the general public can prevent cancer.Unicef and the World Health Organization were among the official observers of the report’s process.

A key finding of the report is that maintaining a healthy weight (a Body Mass Index of 20-25) is one of the most important means of preventing cancer. The number of types of cancer where there is convincing evidence that body fat is a cause has risen from one to six since the last WCRF report was published in 1997, including colorectal cancer and postmenopausal breast cancer.

Prof Sir Michael Marmot, Chair of the Panel, said: “We are recommending that people aim to be as lean as possible within the healthy range, and that they avoid weight gain throughout adulthood. This might sound difficult, but this is what the science is telling us more clearly than ever before. The fact is that putting on weight can increase your cancer risk, even if you are still within the healthy range. So the best advice for cancer prevention is to avoid weight gain, and if you are already overweight then you should aim to lose weight.”

On alcohol, the report says that the evidence that alcohol is a cause of cancer is stronger now than ever before. Since the 1997 report, additional evidence has come to light that alcoholic drinks can increase the risk of a number of cancers, including breast and colon cancer. The WCRF report says that any alcohol consumption can increase the risk of cancer, though there is also some evidence to suggest that small amounts of alcohol can help protect against heart disease. Therefore, people who choose to drink should limit their consumption of alcoholic drinks to no more than 2 drinks for men and 1 for women a day. Allowing for international differences in the alcohol content of standard drinks, this is roughly equivalent to the standard guidance in the UK that men should not exceed 4 drinks per day and women 3 drinks per day.

Other findings in the report include:

There is convincing evidence that processed meats, including ham and bacon, increase the risk of colorectal cancer. People who consume them are advised to do so sparingly.

The evidence that red meat is a cause of colorectal cancer is stronger than ever before. People should not eat any more than 500g of red meat a week.

This figure is for cooked meat, and is the equivalent of between 700 and 750g of non-cooked meat.

In one of the first breast feeding recommendations made by a cancer prevention report, mothers are advised to breastfeed exclusively for six months and to continue with complementary breastfeeding after that. This is because of convincing evidence that breast feeding protects the mother against breast cancer and ‘probable’ evidence that it protects the child against obesity later in life.

Professor Martin Wiseman, Project Director of the Report, said: “This report is a real milestone in the fight against cancer, because its recommendations represent the most definitive advice on preventing cancer that has ever been available anywhere in the world.

“When individual studies are published, it is impossible for the public to put them into context and know how seriously they should be taking the findings. But the great thing about this report is that it does this job for them.

“If people follow our recommendations, they can be confident they are following the best advice possible based on all the scientific research done up to this point. These recommendations are not based on one study but are based on 7,000.”

Food, Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective. World Cancer Research Fund, 2007.

 

We’re drinking more than we thought we were

A new and more accurate way of calculating alcohol consumption shows that drinkers, especially women, are drinking substantially more than was previously believed. The new method of calculation recognizes that, nowadays, single measures of alcoholic drinks often contain more than single units of alcohol, in some cases, a lot more. The new calculations increase substantially the numbers of people exceeding the ‘sensible limits’ of drinking and engaging in ‘binge’ drinking.

The government surveys that provide most of the official statistics on alcohol consumption have always assumed that there is one unit of alcohol in half a pint of beer, a glass of wine or a single measure of spirits.Whilst this is still true for standard strength beer (3.5-4%) and smaller measures (25 ml) of spirits, larger glasses and stronger wines mean that this is now a dramatic underestimate for a glass of wine. In fact one standard glass of wine (175 ml) typically contains two units – twice the old estimate. Stronger beer, and beer sold in bottles or cans rather than pints, has also been affected.

Eileen Goddard of the Office of National Statistics,who calculated the new conversion factors, also recalculated alcohol consumption for the most recent data from the General Household Survey. Since wine was the drink most underestimated by the old system, the groups of people affected most by the revised system were wine drinkers, principally women,more affluent people and those over the age of 45. Whilst future surveys will ask for information about the size of wine glasses, the recalculation assumed a typical glass size of 175 ml.

Women:

The estimate of average weekly consumption has increased by 45%, from 6.5 units per week to 9.4. This is a much larger increase than the estimate for men, which increased by 26%, from 15.8 units per week to 19.9. The percentage of men exceeding weekly limits (21 units) was previously thought to be 24% and is now believed to be 31%, an increase of 32%. The equivalent figures for women drinking more than the weekly limit of 14 units was previously 13% and is now 21%, an increase of 65%.

The measure that has been used for binge drinking, namely the percentage of people drinking more than twice the daily limit, increased from 19% to 23% for men, an increase of 24%, and from 8% to 15% for women, an increase of 89%. These increases were smaller for the youngest age group, 16-24 year olds, who are less likely to drink wine. In this age group, the estimate of the percentage of men ‘binge drinking’ increased from 30% to 32%, an increase of 9%, and the estimate for women increased from 22% to 27%, an increase of 25%.

Affluence:

Two measures from the survey are related to ‘affluence. ’These are socio-economic classification (SEC) and income, which are both defined at a household level. The estimate of average weekly alcohol consumption of those in higher managerial or higher professional jobs increased by 45% and 43% respectively, relative to an increase of 24% for those in routine and manual jobs. The estimate of consumption for those in the highest income band (over £1000 per week) increased from 12.9 units per week to 18.2 units per week, an increase of 41%. For those in the lowest income band (up to £200 per week), the estimate increased from 9.0 units per week to 11.1 units per week, an increase of 24%.

Age group:

The survey divided people into four age groups, 16-24, 25-44, 45-64 and 65 and over. The association between getting older and drinking wine is stronger for men than for women, so the older two age groups showed the biggest increase in estimated consumption for men (29% increase in each case). For women, the biggest increase in the estimated weekly consumption was for the 45-64 year olds,with a 56% increase, closely followed by the adjacent two age groups. Only the youngest women showed a substantially smaller increase, of 21%. The older age groups also showed bigger increases in the estimates of percentage of people drinking more than the daily limit, and more than twice the daily limit.

In her report, Eileen Goddard emphasises that this new calculation does not mean that people are suddenly drinking more than they were, just that they are consuming more than was believed on the basis of previous government surveys.

National Statistics Methodological Series No. 37 Estimating alcohol consumption from survey data: updated method of converting volumes to units. Eileen Goddard December 2007

Seafarers and drinks industry workers have highest alcohol-related deaths – but doctors have sobered up

The highest levels of alcohol-related mortality are found among seafarers and workers in the drinks industry, according to a new analysis of alcohol-related deaths by occupation published by National Statistics.

In men, bar staff, publicans and managers of licensed premises top the mortality league table with twice the proportion of alcohol related deaths expected for men in England and Wales as a whole. Coal mine operatives also have particularly high rates of alcohol related deaths.

Bar staff and publicans are also the occupations with the highest proportions of alcohol-related deaths for women, and for both sexes other occupations within the drinks, catering, entertainment and hospitality industries have high indicators of alcohol-related mortality.

Particularly low levels of alcohol mortality are found in men who work as farmers, and drivers, and women who work with children.

In regard to the reasons why some occupations may be particularly prone to raised alcohol related mortality, the new analysis is consistent with previous research suggesting that a number of factors are involved, including availability of alcohol at work, social pressure to drink at work, separation from family or social relationships, freedom from supervision and collusion by colleagues. In the new analysis it is particularly clear that those employees with access to alcohol at work are more likely to die of alcohol-related causes.

Doctors on the wagon

The findings in relation to workers in the drinks and hospitality industry and most of the other occupations with high alcohol mortality replicate those of previous analyses of occupational mortality. However, one occupational group stands out as showing a marked change: male doctors, who in the past had some of the highest indicators of alcohol-related mortality, now have a substantially lower than average risk of dying from drink. This change in mortality reflects a change in drinking habits among doctors, as recent drinking surveys have found that the proportion of male doctors exceeding the ‘sensible drinking’ limits is lower than in the male population as a whole. It is thought that one factor helping to explain the changing drinking behaviour of the medical profession is the demographic shift that is taking place, with increasing proportions of the profession being drawn from ethnic minority groups, some of which have a culture of light or non-drinking. There may also be increased awareness among doctors of the risks of alcohol.

This apparently growing abstemiousness of the medical profession could be of great significance, given that the health behaviour of medical practitioners may exert a strong influence on the attitudes and health behaviour of the wider population. It is widely believed that the fact that the medical profession led the fight against tobacco smoking, with almost all doctors stopping smoking themselves, is one of the key factors explaining the success of the anti smoking campaign in the UK and elsewhere. Should doctors now begin to lead the way in regard to tackling the country’s alcohol problem, this could signal a significant change in drinking culture.

* PMRs compare the proportion of all deaths in a particular occupation that are alcohol-related to the proportion in the same sex and age group in England and Wales as a whole. If the proportion of alcohol deaths was the same as that in the whole population, the PMR would equal 100. Hence a PMR of 200 indicates twice the proportion of the whole population; a PMR of 50 indicates half the proportion.

Alcohol hospital admissions on rise

There are now almost 240 hospital admissions per day in England for which an alcohol-related diagnosis is the main reason for the patient attending hospital.The latest figures, for 2006-2007, show 87,000 admissions to English hospitals for which alcohol was the primary cause. Admissions for which alcohol was a secondary, contributory factor are additional to this figure.

These figures continue the trend of increasing numbers of alcohol-related admissions evident from the early 1990s, with a steeper increase occurring from around 2002. However, there is now a suggestion that the increase in admissions may have flattened out or even gone into reverse from around 2005. A levelling off or slight fall in admissions in some groups is consistent with the small decline in the overall level of alcohol consumption that begin in 2005.

The pattern of admissions differs somewhat for males and females and by age. One feature of particular note is that while for most age groups male admissions significantly outnumber female, for the 5 – 14 age group there are now more female admissions.

The same pattern is repeated specifically in relation to admissions for alcohol intoxication and toxic effect of alcohol, the diagnoses giving the clearest indication of the impact of the binge-drinking.

These figures continue the trend of increasing numbers of alcohol-related admissions evident from the early 1990s, with a steeper increase occurring from around 2002. However, there is now a suggestion that the increase in admissions may have flattened out or even gone into reverse from around 2005. A levelling off or slight fall in admissions in some groups is consistent with the small decline in the overall level of alcohol consumption that begin in 2005.

The pattern of admissions differs somewhat for males and females and by age. One feature of particular note is that while for most age groups male admissions significantly outnumber female, for the 5 – 14 age group there are now more female admissions. The same pattern is repeated specifically in relation to admissions for alcohol intoxication and toxic effect of alcohol, the diagnoses giving the clearest indication of the impact of the binge-drinking culture. Here, too, in the 5-14 age group, admissions for girls now out number those of boys.

Notes

• Source: Hospital Episode Statistics, the NHS Information Centre for health and social care. Data supplied to the Institute of Alcohol Studies.

• Cases are periods of admitted patient care under one consultant within one health care provider. The figures do not represent the number of patients, as a person may have more than one episode of care within the year.

• Cases are those with an alcohol-related primary diagnosis (see list below). The primary diagnosis provides the main reason why the patient was in hospital.

The diagnoses included are:
F10 Mental and behavioural disorders due to alcohol,
G31.2 Degeneration of nervous system due to alcohol,
G62.1 Alcoholic polyneuropathy,
G72.1 Alcoholic myopathy,
I42.6 Alcoholic cardiomyopathy,
K29.2 Alcoholic gastritis,
K70 Alcoholic liver disease,
K86.0 Alcohol-induced chronic pancreatitis,
T51.0 Toxic effect of ethanol,
T51.9 Toxic effect of alcohol, not specified

Graphs of ‘intoxication and toxic effect’ include F10.0,T51.0 and T51.9.