Category Archives: Alcohol facts and figures

Consumption theory, the four P’s & the Pareto Principle

the four p'sIn April Professor’s Nick Sheron and Sir Ian Gilmore wrote an analysis piece for the British Medical Journal entitled ‘Effect of policy, economics, and the changing alcohol marketplace on alcohol related deaths in England and Wales’.  What stood out for me was their analysis of consumption theory, the alcohol industries use of the 4 P’s of marketing and the Pareto Principle.  I’ve chosen to cherry pick and focus on these elements of their analysis as this information and the way it was presented was new to me.  Over to the experts:

Consumption theory:

The population consumption theory1 2 3 links population level alcohol consumption to alcohol related harm, forming a theoretical basis for modern alcohol control policy. As the late Professor Griffith Edwards stated, other things being equal, “the overall level of a population’s drinking is significantly related to the level of alcohol related problems which that population will experience.”2 The factors that drive alcohol consumption apply to harmful drinkers as well as low risk drinkers, and alcohol related harm is dose related, at both individual and population levels.

Patterns of consumption are known to be related to price. Mathematical coefficients, termed “elasticities,” linking the consumption of alcohol to price and taxation are used by the Treasury to model fiscal policy11 and by the drinks industry to lobby the Treasury.12 Further coefficients link alcohol related mortality and morbidity to consumption and price, and are central to the modelling of alcohol policy by the Organisation for Economic Cooperation and Development (OECD), World Health Organization, and the UK government.13 14 15 16 17

The population consumption theory suggests that alcohol related deaths have increased as a direct result of an increase in alcohol consumption.

The 4 P’s:

wkd marketing strategyIn marketing terminology sales of any product are driven by the four Ps—place, product, promotion, and price—and all these factors have changed considerably. Numbers of on-sales (pubs, etc) licences increased from 131 000 in 1980, to 148 000 in 2012; off licences increased from 42 000 to 56 000 and consumption shifted from pubs to alcohol bought to be consumed at home.4 The nature of the product changed as sales of weaker draught beers decreased and sales of strong lager and cider increased. Furthermore, as a wartime generation of whisky drinkers passed away, the spirits industry shifted its target demographic to a younger audience, introducing “alcopops.”24 25 26 Consumption of spirits and alcopops by children aged 10-15 increased fourfold, followed a few years later by a huge increase in sales of vodka and related spirits (fig 3).29 Wine consumption also rose as a result of cultural globalisation and the increased marketing and availability as supermarkets became the major alcohol retailers.30 31 Overall, the trends in alcohol related deaths coincide with trends in consumption of cider, wine, and to some extent white spirits and strong lager, and are consistent with the population consumption theory (fig 4).

The Pareto Principle:

pareto principleThe corporate global drinks industry likes to frame alcohol related harm as a minority problem affecting a small group of “alcoholics” who are unable to control their drinking. The population consumption theory represents an inconvenient truth and on the whole the industry refuses to accept the evidence that links price to consumption and harm.34 35 But another economic fundamental is relevant to the alcohol marketplace—the Pareto principle or 80:20 rule,36 which states that 20% of highest consumers consume around 80% of any product. Combined data from the 2011-13 Health Surveys for England show how the principle applies to the alcohol market (table 1).

Harmful and extreme drinkers comprise a tiny minority, 4.4% of the population, but consume one third of all alcohol sold; the combination of hazardous, harmful, and extreme drinkers provides almost 70% of drinks industry sales by volume. The drinks industry uses its influence on government to protect this market.12 34 This has brought about remarkable changes in affordability—as the ’90s economy boomed and wages increased, taxation of alcohol was reduced in real terms. By 2008 it was possible to buy almost four bottles of vodka for the price of one bottle in 1980—and four bottles represents the weekly alcohol consumption of an average patient presenting with alcohol related liver cirrhosis.38 As the affordability of stronger alcohol increased, so did liver and related mortality (fig 5).  From 2007-08 onwards the affordability of wine fell by 54%, spirits 50%, cider 27%, and beer 22%.

It may be surprising that changes in alcohol affordability could have a rapid effect on alcohol related deaths; it can take 10 years or more of very heavy drinking to develop liver cirrhosis. But this is exactly what would be predicted from experience in other countries. When the minimum price of alcohol increased by 10% in a Canadian province, a 32% decrease in directly attributable alcohol related mortality occurred within 12 months, and most deaths were from liver disease.45 Similarly, when Mikhail Gorbachev introduced alcohol reform in Russia in the 1980s, the maximum impact on mortality occurred within 18 months, including for liver disease.46 Alcohol related liver deaths occur from acute-on-chronic liver failure related to the severity of recent drinking.

Though the causative link between this changing trajectory of alcohol related deaths and economic factors remains unproved, the deaths are clearly alcohol related (fig 2) and occur in people drinking very large quantities of the cheapest alcohol available; the median alcohol consumption of patients with alcohol related cirrhosis is around 120 units/week, and in other dependent drinkers it is even higher.38 49

And here’s the kicker:

Incomes are starting to rise, and following a fierce campaign of lobbying by the Wine and Spirits Trade Association (WSTA) the duty escalator was dropped in 2014. In the budget of March 2015 alcohol duty was cut by a further 2% for spirits and cheap cider.38 An influential Ernst and Young impact analysis commissioned by WSTA omitted to mention any of the economic costs of alcohol related harm outlined by the OECD12 but appeared to persuade the Treasury that the health of the drinks industry was more important than that of alcohol consumers. Support for the “drop the duty” campaign came from unlikely sources; Jane Ellison, undersecretary of state for public health, was featured on the front page of drinks industry website Harpers.co.uk stating that she had forwarded a “drop the duty” email in support of the duty reduction to the chancellor of the exchequer.50

The whole analysis is worth a read and you can do so here.  How the Govt can continue to deny the impact and link between alcohol, pricing and health when Prof Sheron & Gilmore lay out the evidence so clearly is beyond me.

And this is what Alcohol Policy UK had to say about it:

Price & taxation: new analysis published as Scottish MUP decision expected

And the Institute of Alcohol Studies provided a report to look at the socio-economic costs that the Treasury thought were less important than the health of the drinks industry …..

The economic impacts of alcohol (PDF)

Edited to add: 10/10/16

4 Ps influence on children’s drinking behaviour “mixed”

 

 

Dereliction of duty: Are UK alcohol taxes too low?

pigouvian taxationThis is a new report from the Institute of Alcohol Studies, that claims that the Government’s own estimates of the social costs of alcohol imply that alcohol duty should be raised. The report summarises the economic theory underpinning alcohol taxation (including the theory of pigouvian taxation which I’m not even going to try to explain or pretend I understand!) and considers it a dereliction of duty.

Here’s the summary to their report:

There are three standard reasons why governments tax alcohol:

1. Externality Correction: to ensure that alcohol prices reflect the cost to third parties who are harmed by drinking
2. Paternalism: to reduce people’s consumption for their own good
3. Revenue Raising: to fund the government.
The UK Government estimates that externalities associated with alcohol cost England and
Wales £21 billion every year.
Alcohol duty in England and Wales currently generates only £9 billion, less than half of the
value of these externalities.
This suggests higher alcohol taxes can be justified on the basis of the harm drinking
causes to wider society alone, without considering the impact on the drinker themselves.
The lost enjoyment suffered by moderate consumers as a result of alcohol duty is
relatively small – we estimate £1.2 billion (less than 2% of market value) to be the absolute
possible ceiling of the impact. This is dwarfed by the benefits of duty, in terms of reducing
crime, healthcare savings and improving economic output, which total a value of at least
£4.4 billion.
Under certain assumptions, tax revenue should not just equal, but exceed the cost of
externalities:
•If externalities are disproportionately higher at higher  levels of consumption i.e. if moving from the fourth to the fifth drink is substantially worse than moving from the first to the second
•If we think that avoiding harm to third parties should be given greater weight than the enjoyment of drinkers.  There is a strong case for paternalistic taxes on alcohol, as it is highly plausible that many people drink excessively, and this over consumption can be deterred by alcohol taxes – this adds a further reason for raising duty.  Economists are divided as to whether alcohol taxes cause less distortion to the economy than other taxes and are therefore a particularly desirable way of raising government revenue.
The interaction of alcohol taxes with other policies is complicated – stricter licensing and drink driving regulations, all else equal, mean that taxes should be lower.
On balance, these arguments suggest to us that alcohol taxes in the UK are too low.
We believe the Government should be committed to higher alcohol taxes as a result
of its claim that alcohol externalities cost England and Wales £21 billion each year.
And this was the response from Alcohol Policy UK following the recent UK March Budget
A Government release on the duty impacts though says the freeze ‘is likely to lead to a minor increase in overall alcohol consumption in the UK’, as alcohol is of course price sensitive. Indeed on the headline hitting sugar tax announcement, Osborne stated “We understand that tax affects behaviour. So let’s tax the things we want to reduce, not the things we want to encourage.” Twitter of course raised questions, including whether sugary alcoholic drinks would be affected, or whether parallels could be drawn with the 2012 headline grabbing announcement of minimum pricing – subsequently dropped – which was also timed around a budget with less than impressive economic news.
Edited to add 6th June 2016:
Minimum pricing for alcohol targets harm better than tax rises

Whether alcohol tax rises would be an acceptable and effective alternative could determine the legality under EU law of Scotland’s law permitting a minimum unit price for alcohol. This analysis predicts tax rises would curb consumption and save lives, but not without perhaps unacceptably hitting the pockets of non-harmful drinkers | Drug and Alcohol Findings, UK

Bearing in mind there has been a rash of stories in the last few days about rising poisonings amongst teenagers and alcohol is behind this increase one has to question pricing as a factor as the first piece from The Independent does ….

Surge in girls’ alcohol poisoning behind rise in teenage poisonings

The authors said: “One potential explanation for the increase in alcohol poisonings over time is increased availability, with the relative affordability of alcohol in the UK increasing steadily between 1980 and 2012, licensing hours having increased since 2003, and numbers of outlets increasing alongside alcohol harm.”

Sharp rise in UK teen poisonings over past 20 years, particularly among girls

The number of teenage poisonings over the past 20 years in the UK has risen sharply, particularly among girls, according to a new study by researchers at The University of Nottingham | University of Nottingham, UK

Rise in ‘intentional’ alcohol poisoning among teens – BBC iPlayer radio

There has been a sharp rise in the overall number of teen poisonings over the past 20 years in the UK, particularly among girls and young women, according to a new report | BBC, UK

Edited to add: 15th July 2016

Small rise in booze duty might cut violence-fuelled emergency department visits by 6000/year, UK

Tax system reforms in England and Wales might be better than minimum unit pricing | MNT, UK

Adult drinking habits in Great Britain

ONS 2014This is the Office for National Statistics report for 2014 looking at the adult drinking habits in Great Britain.  It makes for interesting reading and you can find the whole report here.

Here’s the main findings:

  • 28.9 million people report that they had drunk alcohol in the week before interview.
  • 2.5 million people drink more than 14 units of alcohol on their heaviest drinking day.
  • Almost 1 in 5 higher earners drink alcohol on at least 5 days a week.
  • Young people are less likely to have consumed alcohol in the last week than those who are older.
  • A higher percentage of drinkers in Wales and Scotland drink over the recommended weekly amount in one day.
  • Wine is the most popular choice of alcohol.

In Great Britain in 2014, there were 28.9 million people who reported that they drank alcohol in the week before being interviewed for the Opinions and Lifestyle Survey. This equates to 58% of the population.

Focusing on those who drank alcohol, 12.9 million (45%) drank more than 4.67 units (around 2 pints of 4% beer or 2 medium (175 millilitre) glasses of 13% wine) on their heaviest drinking day. This is a third of the recommended weekly limit – the value you would drink if you drank 14 units spread evenly over 3 days. Of these, 2.5 million (9%) drank more units in one day than the weekly recommended amount of 14 units (6 pints of beer or 1.4 bottles of 13% wine).

Young people were less likely to have consumed alcohol; less than half (48%) of those aged 16 to 24 reported drinking alcohol in the previous week, compared with 66% of those aged 45 to 64.

While overall being less likely to drink alcohol, young drinkers were more likely than any other age group to consume more than the weekly recommended limit in one day. Among 16 to 24 year old drinkers, 17% consumed more than 14 units compared with 2% of those aged 65 and over.

I was really struck by some of the graphics as they paint such a clear picture – so for example this one about earnings and alcohol consumption:

income and drinkingFocusing on frequent drinkers, those who drink on at least 5 days of the week, individuals with an annual income of £40,000 and over were more than twice as likely (18%) to be frequent drinkers compared with those with an annual income less than £10,000 (8%).

It presents a fascinating insight into teetotalism, drinking in the week before interview, frequent drinking and units drunk, including changes in drinking patterns in recent years.

And these were all the news stories that followed:

2.5m Brits bust weekly alcohol limit in a day

Around 2.5 million people in Great Britain – 9% of drinkers – consume more than the new weekly recommended limit for alcohol in a single day, latest figures from the Office for National Statistics show. The 2014 data predates the new limit of 14 units of alcohol per week for men which began in January 2015 | BBC, UK

Younger people drink less but binge when they do, figures show

ONS study reveals picture of UK’s drinking habits and shows higher earners drink at least five days a week | Guardian, UK

Wales tops alcohol binge drinking stats in ONS survey

People in Wales are more likely to be binge drinkers than anywhere else in Britain, new figures have revealed | BBC, UK

I’m sick of explaining why I am teetotal

The UK is slowly drying out but as a teetotaler, I can tell you our attitudes toward drink aren’t changing anytime soon | Independent Voices, UK

The party’s over for young people, debt laden and risk averse

The drinks industry seeks to solve the conundrum of the monastic twentysomething by “premiumisation” (getting them to spend more on the few drinks they will buy). We have to understand it as a challenge broader than the market | Guardian, UK

Any thoughts from you?

 

Effects of Different Alcohol Taxation and Price Policies on Health Inequalities

uk taxation and alcoholSo before we discuss this new research looking at and exploring the estimated effects of different alcohol taxation and price policies on health inequalities from a mathematical modelling study point of view I thought it beneficial to provide some context.  The graphs to the left show the tax receipts for the UK govt in 2015.  As you can see alcohol duty plays an important role in raising taxes for the govt and makes up 1/6th of the minor tax take, not so minor after all at £10.5 billion.

Here’s the study abstract:

Introduction

While evidence that alcohol pricing policies reduce alcohol-related health harm is robust, and alcohol taxation increases are a WHO “best buy” intervention, there is a lack of research comparing the scale and distribution across society of health impacts arising from alternative tax and price policy options. The aim of this study is to test whether four common alcohol taxation and pricing strategies differ in their impact on health inequalities.

Methods and Findings

An econometric epidemiological model was built with England 2014/2015 as the setting. Four pricing strategies implemented on top of the current tax were equalised to give the same 4.3% population-wide reduction in total alcohol-related mortality: current tax increase, a 13.4% all-product duty increase under the current UK system; a value-based tax, a 4.0% ad valorem tax based on product price; a strength-based tax, a volumetric tax of £0.22 per UK alcohol unit (= 8 g of ethanol); and minimum unit pricing, a minimum price threshold of £0.50 per unit, below which alcohol cannot be sold. Model inputs were calculated by combining data from representative household surveys on alcohol purchasing and consumption, administrative and healthcare data on 43 alcohol-attributable diseases, and published price elasticities and relative risk functions. Outcomes were annual per capita consumption, consumer spending, and alcohol-related deaths. Uncertainty was assessed via partial probabilistic sensitivity analysis (PSA) and scenario analysis.

The pricing strategies differ as to how effects are distributed across the population, and, from a public health perspective, heavy drinkers in routine/manual occupations are a key group as they are at greatest risk of health harm from their drinking. Strength-based taxation and minimum unit pricing would have greater effects on mortality among drinkers in routine/manual occupations (particularly for heavy drinkers, where the estimated policy effects on mortality rates are as follows: current tax increase, −3.2%; value-based tax, −2.9%; strength-based tax, −6.1%; minimum unit pricing, −7.8%) and lesser impacts among drinkers in professional/managerial occupations (for heavy drinkers: current tax increase, −1.3%; value-based tax, −1.4%; strength-based tax, +0.2%; minimum unit pricing, +0.8%). Results from the PSA give slightly greater mean effects for both the routine/manual (current tax increase, −3.6% [95% uncertainty interval (UI) −6.1%, −0.6%]; value-based tax, −3.3% [UI −5.1%, −1.7%]; strength-based tax, −7.5% [UI −13.7%, −3.9%]; minimum unit pricing, −10.3% [UI −10.3%, −7.0%]) and professional/managerial occupation groups (current tax increase, −1.8% [UI −4.7%, +1.6%]; value-based tax, −1.9% [UI −3.6%, +0.4%]; strength-based tax, −0.8% [UI −6.9%, +4.0%]; minimum unit pricing, −0.7% [UI −5.6%, +3.6%]). Impacts of price changes on moderate drinkers were small regardless of income or socioeconomic group. Analysis of uncertainty shows that the relative effectiveness of the four policies is fairly stable, although uncertainty in the absolute scale of effects exists. Volumetric taxation and minimum unit pricing consistently outperform increasing the current tax or adding an ad valorem tax in terms of reducing mortality among the heaviest drinkers and reducing alcohol-related health inequalities (e.g., in the routine/manual occupation group, volumetric taxation reduces deaths more than increasing the current tax in 26 out of 30 probabilistic runs, minimum unit pricing reduces deaths more than volumetric tax in 21 out of 30 runs, and minimum unit pricing reduces deaths more than increasing the current tax in 30 out of 30 runs). Study limitations include reducing model complexity by not considering a largely ineffective ban on below-tax alcohol sales, special duty rates covering only small shares of the market, and the impact of tax fraud or retailer non-compliance with minimum unit prices.

Conclusions

Our model estimates that, compared to tax increases under the current system or introducing taxation based on product value, alcohol-content-based taxation or minimum unit pricing would lead to larger reductions in health inequalities across income groups. We also estimate that alcohol-content-based taxation and minimum unit pricing would have the largest impact on harmful drinking, with minimal effects on those drinking in moderation.

To read the full research article go here.

Bearing in mind that I featured a great piece only recently looking at alcohol and health inequality once again the case for minimum unit pricing is robust and these findings conclude that they would not impact on those who drink moderately which has been the biggest and loudest reason given not to implement to date.

And once again Scotland lead the way in collaboration with the University of Sheffield:

Model-based appraisal of the comparative impact of Minimum Unit Pricing and taxation policies in Scotland (PDF)
To achieve the same reduction in alcohol-related deaths among hazardous and harmful
drinkers as a 50p minimum unit price, a 28% increase in alcohol taxation would be required.

But no we seem to be heading in the opposite direction yet again!

The HMRC Alcohol Strategy Modernising alcohol taxes to tackle fraud and reduce burdens on alcohol businesses (PDF)

Of course we need to REDUCE the tax burden on alcohol businesses instead 🙁

Lancet psychiatry: Articles on young people and substance use

the lancetWithin the UK there are two hallowed publications within medicine –  the British Medical Journal (BMJ) and The Lancet.  This series was published within The Lancet Psychiatry in February.  The fact that it was a series of research publications indicates how serious an issue substance misuse within young people is.

Here are the links to the full series of publications which are all freely available once you have registered your email with the journal.

February 18, 2016
Why young people’s substance use matters for global health
Wayne D Hall, George Patton, Emily Stockings, Megan Weier, Michael Lynskey, Katherine I Morley, Louisa Degenhardt
 
The increasing global health priority of substance use in young people
Louisa Degenhardt, Emily Stockings, George Patton, Wayne D Hall, Michael Lynskey
 
Editorial
Drug policy: getting over the 20th century
The Lancet Psychiatry
 
Prevention, early intervention, harm reduction, and treatment of substance use in young people
Emily Stockings, Wayne D Hall, Michael Lynskey, Katherine I Morley, Nicola Reavley, John Strang, George Patton, Louisa Degenhardt
 
This is the summary for the above article:

We did a systematic review of reviews with evidence on the effectiveness of prevention, early intervention, harm reduction, and treatment of problem use in young people for tobacco, alcohol, and illicit drugs (eg, cannabis, opioids, amphetamines, or cocaine). Taxation, public consumption bans, advertising restrictions, and minimum legal age are effective measures to reduce alcohol and tobacco use, but are not available to target illicit drugs. Interpretation of the available evidence for school-based prevention is affected by methodological issues; interventions that incorporate skills training are more likely to be effective than information provision—which is ineffective. Social norms and brief interventions to reduce substance use in young people do not have strong evidence of effectiveness. Roadside drug testing and interventions to reduce injection-related harms have a moderate-to-large effect, but additional research with young people is needed. Scarce availability of research on interventions for problematic substance use in young people indicates the need to test interventions that are effective with adults in young people. Existing evidence is from high-income countries, with uncertain applicability in other countries and cultures and in subpopulations differing in sex, age, and risk status. Concerted efforts are needed to increase the evidence base on interventions that aim to reduce the high burden of substance use in young people.

As a nurse who is training to be a child and adolescent psychotherapeutic counsellor and who has a special interest in substance misuse and desire to work with this vulnerable client group because of my own history I feel this is a really really important topic.  Many local NHS services do not have a specialist child and adolescent substance misuse service (CASUS) which is true for my county here in Suffolk but I know there is one in our neighbouring county Cambridgeshire.  I hope that Liam Byrne’s work within Parliament will start the process to help change that ……

Ministers lobbied 40 times in three months on alcohol issues

lobbying of parliamentSo over the next ten days I’m going to present a story that starts here with the 40 times the drinks industry lobbied the Irish govt over a 3 month period and then over the next 10 days we consider the collateral damage to public health as presented to me in a weeks worth of news stories that I read including drink driving, alcohol and A&E, alcohol and the workplace and then alcohol and families.  We’re approaching Easter so it feels like a good time to reflect before we hit the next high days and bank holiday event.

Government Ministers and their officials were lobbied on alcohol-related issues more than 40 times in a three-month period, an analysis of the new register of lobbying shows.

Most of the lobbying concerned the Government’s planned legislation to counter alcohol abuse but other topics included the importance of Irish drink exports and the campaign to allow pubs open on Good Friday.

The Minister for Health was the most frequently lobbied Minister on the alcohol issue, followed by Minister for Sport and Tourism Paschal Donohoe. Taoiseach Enda Kenny was also lobbied in face-to-face meetings on several occasions.

Along with drinks companies and their representative bodies, sports organisations such as the Irish Rugby Football Union and its Munster branch were also active in lobbying against any attempt to ban sports sponsorship by the sector.

Alexandre Ricard, chief executive of drinks multinational Pernod Ricard, met the Taoiseach at an event in Paris, where he impressed on Mr Kenny “the importance of supportive domestic policies as underpinning export success,” according to the register.

Irish Distillers, which is owned by Pernod Ricard, invited Tánaiste Joan Burton to speak at the opening of a micro-distillery in Midleton, Co Cork. Informal discussions took place on the “global success” of Jameson whiskey and the economic impact of the indigenous distilling industry.

Public relations

Among the public relations firms actively lobbying in relation to alcohol issues were Q4 PR, Hume Brophy and MKC Communications.

Industry group Ibec made its views known to a wide variety of Ministers, including the Taoiseach and Ministers Leo Varadkar, Paschal Donohoe, Michael Noonan, Alex White and Simon Coveney.

The IRFU wrote to Mr Varadkar and Mr Donohoe to underline its concerns about the Public Health (Alcohol) Bill and to seek a meeting.

The rugby organisation’s Munster branch appealed in an email to Mr Coveney and Mr Noonan not to change the legislation as it would have “a major adverse impact on our ability to continue as a professional sporting organisation”. A meeting was sought with the Ministers but never took place.

So busy behind the scenes lobbying by the drinks industry as the Irish govt were preparing the Public Health (Alcohol) Bill that I talked about here.  Bit like the behind the scenes discussions that took place here about minimum unit pricing ……..

Harmful drinking and dependence: PHE release resource

PHE 2016 harmful drinking resourcesAlcohol Policy UK wrote an excellent summary of the new PHE resources launched in January to support harmful drinking and dependence.  So good that I’m going to share in their entirety 😉

Public Health England (PHE) have released a new resource Health matters: harmful drinking and alcohol dependence – see PDF and links here.

The resource aims to support the ‘commissioning and delivery of evidence based treatment interventions to address harmful drinking and alcohol dependence in adults’, and includes infographics, video, a commissioning toolkit and a local service case study.

PHE say around 1.6 million adults in England have some level of alcohol dependence, many of whom may be suitable for treatment, although this question and much of the content are not explored in detail. As such the resource mainly sets out a broad level overview of the impacts of harmful drinking and main treatment response to addressing dependency. Key stats and issues associated with harmful and dependent drinking are highlighted, including mental health, employment, hospital admissions, health inequalities, key groups, and resources for developing treatment services.

Answering the tough questions?

Certainly championing investment in alcohol services may be considered valid; treatment is an ‘invest to save’ measure for which it can be argued that greater numbers should be receiving it, with alcohol services historically having played second fiddle to the drug treatment agenda. However local commissioners may feel there are many ongoing challenging and complex questions in the development of local systems that meet the needs of a range of harmful or dependent drinkers.

One such area may be how the needs of harmful drinkers with no or low severity of dependence might be better engaged. As part of NICE CG115 released in 2011, it identified that 84% of those with a level of dependency are only ‘mildly’ dependent, yet only 1.13% of this population receive specialist treatment, versus 33.69% with moderate or severe dependence. However such drinkers are unlikely to seek or access specialist treatment, in part because they may be unlikely to consider their drinking problematic, or at least not enough to warrant treatment. Whilst ‘extended brief interventions’ or ‘brief treatment’ approaches in non-specialist settings may be most appropriate, there still remains limited examples or guidance on this issue.

It should be noted that in 2011 NICE CG115 released an exhaustive review of the evidence and a comprehensive series of supporting tools and resources. NICE Quality Standard 11 also directly set out the expectations for local treatment provision. PHE too have since released other resources, most notably self-assessment tools, hospital guidance and JSNA support packs. However numbers in treatment have not climbed significantly, and assessing the impact of such guidance on commissioning practice may be questionable.

On a broader level, the effects of changes to the commissioning landscape and indeed ongoing cuts are still to be navigated. Last year Alcohol Concern’s review of alcohol treatment in England revealed a mixed picture; services may be holding steady for the time being, but challenges were by no means limited. PHE state they will be releasing further resources to help local areas identify and target drinking population needs. On how the picture develops, only one thing may be called with a degree of certainty – it will probably vary depending on where you look.

Thank you James (and Libby!) for a great summary and this video does a great job of explaining it all clearly and succinctly.  I was really struck by the numbers in the top featured image so I’m going to re-iterate them here:

Millennials and drinking

MillennialsSo there’s an interesting dichotomy I’m noticing as these two news stories that appeared on the same day and relating to millennials show.

Online music videos ‘expose teens to smoking and drinking’

Online music videos are heavily exposing teenagers to positive depictions of smoking and drinking alcohol, research suggests.

Such portrayals posed a “significant health hazard that requires appropriate regulatory control”, researchers said.

YouTube videos of songs in the top 40 singles chart were examined by the University of Nottingham study.

The British Board of Film Classification started putting age ratings on online pop videos last year.

The research, in the Journal of Epidemiology and Community Health, said girls between the ages of 13 and 15 were the most exposed to cigarettes and alcohol in videos.

Using pollsters YouGov, researchers asked 2,068 11- to 18-year-olds and 2,232 over-19s whether they had seen the videos, taken from the chart between 3 November 2013 to 19 January 2014.

The average viewing percentage across the 32 music videos was 22% for the younger group and 6% for the elder.

“It is well established that young people exposed to depictions of tobacco and alcohol content in films are more likely to start smoking or to consume alcohol, but the effect of imagery in other media, including new online media such as YouTube music videos, has received relatively little attention,” research author Dr Jo Cranwell said.

Her research calculated the number of “impressions” – any verbal or visual reference – of alcohol or tobacco imagery in the videos.

When Dr Cranwell extrapolated the data to estimate the overall affect on the British population, she concluded the 32 videos were responsible for 1,006 million impressions of alcohol and a further 203 million of tobacco.

“If these levels of exposure were typical, then in one year, music videos would be expected to deliver over four billion impressions of alcohol, and nearly one billion of tobacco, in Britain alone,” she said.

“Further, the number of impressions has been calculated on the basis of one viewing only, however, many of the videos had been watched multiple times, so this number is likely to be much bigger.”

And yet:

Generation Abstemious: More and more young people are shunning alcohol

According to a report last year from the Office for National Statistics, Britain’s young people are turning away from alcohol in droves. The proportion of 16-24-year-olds who do not drink increased by more than 40 per cent between 2005 and 2013. Today, one in five is teetotal. Binge drinking has fallen by more than a third and just one in 50 young adults describe themselves as a frequent drinker.

In reality, a number of factors – less disposable income, a reaction to the overindulgence of the previous generation, the prominence of social media – have apparently converged to call time at the bar for Britain’s young people.

Similarly, says Dr James Nicholls, director of research and policy development at Alcohol Research UK, children of hedonistic generations often turn away from alcohol.

People just don’t want to look like their parents. It happened in the 1930s, it happened in the 1980s and it’s possibly happening again now.”

Generation X (which was my generation) and the X could so easily have stood for eXcess has been replaced by Generation Y, or whY bother drinking?  Curiouser and curiouser and good news to boot 🙂

How many drinkers should be in treatment?

alcohol treatment referral sourcesThis was a Drug and Alcohol Findings hot topic in January looking at drinkers and treatment numbers and follows on nicely from the recent post about blocking of FOI data requests regarding MP’s & treatment!

How well are we doing in getting people who need this help into treatment for their drinking problems? It’s a question whose importance was signified by an estimate for 2004 that there would have been 794 fewer deaths had one in five dependent drinkers been treated with medications versus a zero treatment rate. Numbers avoiding illness would have been considerably greater. As we’ll see, depending on where you draw the line, England’s performance in ensuring needy drinkers enter treatment can look anywhere from an abysmal 7% to an excellent 44%. Line-drawing is a matter of judgement and perhaps too of motivation – of how you want to portray performance, and in turn whether you want to argue for more services or that need is already largely being met. But at least we can be as clear as possible about the facts on which these judgements are made.

The following analysis focuses on England which has both the best figures and dominates the UK population; Scotland seems to doing much better at meeting treatment need. The analysis also glosses over complicating factors including trends in dependent and harmful drinking since 2007, conflating estimates for different years. It is presented as a ball-park indication not necessarily of absolute numbers and proportions, but of the degree to which these alter under different assumptions of what counts as being ‘in need of treatment’.

How many in need of treatment?

Let’s start with how many are in treatment, using England as our example. There about 115,000 adults were in specialist alcohol treatment during 2013/14. Based on a 2007 survey which still seems the latest source, this amounts to about 7% of all 1.6 million drinkers experiencing harm from their drinking.

We can narrow this down further to the approximately 1 million adults who according to NICE, Britain’s official authority on health interventions, also score as at least mildly dependent on alcohol. On this basis, numbers in treatment represent about 11% of dependent drinkers who might need this help. One serious concern over this estimate is that by design, the questionnaire used to assess dependence was not based on clinical criteria.

Putting that concern to one side, results from this questionnaire can be used to narrow down further to the numbers who perhaps really ought to be in treatment. In 2011 NICE calculated that in England 260,000 adults were not just ‘mildly’ dependent or drinking in ways which were harming them, but were moderately dependent or worse. Accepting this figure as the in-need population suggests that numbers in treatment represent 44% of those whose condition ‘really’ justifies intensive help.

Now we have a range from treatment capturing numbers equivalent to just 7% of harmful drinkers to capturing nearly half of those also at least moderately dependent. The lower figure can be justified as the percentage of all those who might need help, the higher as perhaps closer to those who really do need treatment to overcome their dependence. That higher figure gains support from US findings that three-quarters of dependent drinkers remit without treatment and just 10% most clearly need and most often access this kind of help. NICE also appears to draw the line nearer to (and perhaps even above) the moderate dependence level, which would imply that England has the capacity to treat over 40% of the in-need population.

We might further constrict the population in need of treatment if we accepted the view that diagnosing an alcohol use disorder requires not just harm from drinking, but evidence that rather than having freely chosen this penalty, the individual is pathologically impaired in their ability to control their drinking. Compared to standard clinical criteria for dependence, applying this ‘harmful dysfunction’ diagnosis to US figures slashed the numbers calculated as potentially in need of treatment, and the proportion whose need had not yet been met by treatment services – the latter from 34% over their lifetimes to just 4%.

All these estimates of unmet need are based on access to specialised treatment for drinking problems. One reason why unmet need is not necessarily as large as it appears is that structured specialist treatment is not the totality of support available to problem or dependent drinkers nor the only way out of even severe drinking problems.

What is a reasonable target?

Fortunately we have specific guidance on what counts for Britain as good record for getting in-need drinkers into treatment; less fortunately, its provenance makes it of doubtful validity.

In 2009 the UK Department of Health estimated that provision should be made for 15% of dependent drinkers to access specialist treatment, a figure accepted by NICE. The origin of this figure was a Canadian model of treatment demand based on a model published in 1976 and developed for the US state of Nebraska.

Though perhaps of local applicability, this model does not seem to warrant elevation to an international guide. Its denominator for the population in need of specialised alcohol treatment was derived not from an assessment of harm or dependence, but purely of consumption – the number aged 15 or over who drank at least 475g of alcohol a week, about 59 UK units. The top part of the fraction – the target number for treatment during a year – was not based on an assessment of the proportion of these drinkers who might profit from treatment, but on the relapse rate (defined as return to drinking) after treatment and the annual increase in the prevalence of alcohol dependence, in the source study estimated respectively as two-thirds and 10%. To keep pace with relapse of treated alcoholics and the expanding population of newly dependent drinkers, it was estimated that 15% of the population in need of treatment would have to be treated each year.

‘Need’ is not the same as ‘demand’

So while we may suspect that capturing 115,000 of England’s problem drinkers in treatment is not enough, there is no clear way to determine whether and the degree to which this is the case. Good waiting time figures have (in respect of drug addiction treatment) been used as an indicator that treatment supply is keeping up with demand. Good waiting times for alcohol treatment may mean the same, but perhaps only because need is not reflected in demand because dependent drinkers are divorced from routes to treatment – much as a hungry population may not result in demand for bread if they can’t find their ways to the bakers or don’t like the bread they bake.

That this is at least partly the case was suggested by a report on alcohol treatment in England in 2011/12. It expressed concern at how few people had successfully been referred to specialist treatment by GPs or accident and emergency departments, despite the fact that around one in five people seeing a GP is drinking at risky levels, and an estimated 35% of emergency attendances are alcohol-related: “An aim for the coming years is that these two key routes will become more active in identifying and referring people who need treatment for harmful drinking and alcohol dependency”.

If there was cause for concern then, there was even more cause in subsequent years. Referrals from GPs fell from 14,330 in 2011/12 to bottom at 13,541 the following year, only partially recovering to 13,864 in 2013/14 chart. From 22%, since 2008/09 the proportion of all treatment entrants accounted for by GPs seems to have fallen each year, ending at 17% in 2013/14. Accident and emergency department numbers and proportions are both up, but from a very low base, peaking in 2013/14 at 1268 patients, equating to 1.6% of all referrals – still a small proportion of the potential. From a peak of 15,900 in 2009/10, in 2013/14 these two sources accounted for 15,132 treatment starts in 2013/14; as a proportion of all treatment starts, the trend has consistently been down from 23% in 2008/09 to 19% in 2013/14.

The bit of this that really jumped out at me I’ve bolded.  Assessment criteria was based on consumption of approx 60 units a week!  That seems a really low ball number when I know many who regularly drink a bottle a night which would be 70 + units particularly if we are depending on self-reporting where people are prone to under-estimate their consumption.

Prim sent me this link when the new drinking guidelines came out in January and seems pretty apt here 😉

Men to tell doctors they now drink just 14 units a week

What do you think?

Three in four people in A&E at weekend are there because of alcohol

A+E hospital visitsThis is not the first time I’ve written about alcohol and its impact on A&E and to me that means both paramedics and A&E staff (read more here & here).

This was featured by the BBC & The Telegraph in December.

Three in four people in accident and emergency units at the weekend have been admitted because of alcohol, new figures have shown.

The new research, which was carried out at an A&E unit in the North East of England shows the huge burden that excess drinking places on the NHS.

Young men aged between 18 and 24 made up the bulk of the admissions, with most there because they have been injured in fights or falls, alcohol poisoning or because they were suffering mental health problems.

Dr Jim Connolly of the Department of Emergency Medicine at the Royal Victoria Infirmary in Newcastle carried out breath testing of A&E attendees during four weeks in 2012-13.

The alcohol-related attendance rate varied substantially from four per cent to 60 per cent on weekdays, but rose to 70 per cent at the weekend. Based on the figures, researchers calculated that it costs each emergency unit around £1 million a year just to treat drink related problems and injuries.

“This indicates a significant NHS burden if all such emergency departments in the UK are sustaining similar demands associated with alcohol related attendance,” said Dr Connolly.

“Although older people may cost more per patient, younger people as a group are more costly to the NHS because they have more alcohol related attendances.

“Our results suggest that emergency departments would benefit from routinely providing staff to cover the night and early morning shifts, particularly at weekends, to cope with the high proportion of alcohol related attendances at these times.”

Dr Connolly also found people who didn’t live in the city twice as likely to test positive than local residents, suggesting that city centres attract revellers from elsewhere, while hospitals and other public services in city centres pick up the tab.

Hospital admissions for disease and injuries associated with alcohol has risen 100 per cent between 2003 and 2013 and 21,000 deaths each year are directly caused by alcohol.

Dr Clifford Mann, President of the College of Emergency Medicine, warned that alcohol was currently cheaper than bottled water and said that many young people were risking their health by ‘preloading’ on cheap drink before going out to bars and clubs. He has called for a minimum pricing of 50p per unit

“The pattern of alcohol intoxication has changed significantly in the past 10 years. No longer do people set out sober, in the early evening, to attend licensed establishments where they consume alcohol.

“Instead the phenomenon of ‘preloading’ has become endemic. In consequence, people, especially young people, purchase relatively cheap but potent forms of alcohol and drink large quantities at home, either alone or with friends, before setting out much later in the evening to continue imbibing alcohol in pubs and clubs into the early hours.

“The economic, social, and medical consequences of current alcohol strategies create a compelling argument for improved legislation and regulation of alcohol sales. Currently it is perfectly feasible to purchase a volume of alcohol that represents a safe weekly maximum for less than £10. Alcohol at this price is cheaper than bottled water.

“The financial burden of alcohol is dramatic, yet the response of governments has been woefully inadequate.”

The team carried out breath testing of A&E attendees during the same 4 weeks in 2012-13 to find out who had been drinking.

The research was published in the Emergency Medicine Journal.

And this was the BBC headline (read more by clicking link)

A&E visits for alcohol poisoning ‘double in six years’

Half of all A&E attendances likely to be due to alcohol poisoning – when a person drinks a toxic amount of alcohol, usually over a short period of time – took place on a Friday, Saturday or Sunday, peaking between midnight and 2am.

Three in four arrived by ambulance – putting a strain on already stretched resources, said the Nuffield Trust.

Further coverage:

Report warns over growing burden of alcohol on hospitals

So the NHS is invariably on it’s knee’s at this time of year because of the winter bed crises and as the lack of finances pinches further due to the approach of the end of the fiscal year & yet it has to continue to manage the added pressure of the impact of booze …… The service and its staff are only human – we are not miracle workers!!

Edited to add 5th May 2016:

Frequent attenders to accident and emergency departments: a qualitative study of individuals who repeatedly present with alcohol-related health conditions

The central aim of this study was to provide detailed insights into the characteristics, views and experiences of individuals who repeatedly present to A&E with alcohol-related health conditions in order to optimise the development, implementation and evaluation of interventions for them | Alcohol Research UK, UK

The 3rd national emergency department survey of alcohol identification and intervention activity

This survey followed up on the preceding National Surveys (Patton & O’Hara 2013, Patton et al., 2007) exploring the implementation of alcohol screening activity for adult and adolescent patients, with additional focus on older drinkers and people frequently attending EDs for alcohol-related reasons | Alcohol Research UK, UK

Edited to add 18th July 2016:

Preventing violence-related injuries in England and Wales: a panel study examining the impact of on-trade and off-trade alcohol prices

To examine the influence of real on-trade and off-trade alcohol prices and socioeconomic and environmental factors on rates of violence-related emergency department (ED) attendances in England and Wales over an 8-year period. | Injury Prevention, UK

Edited to add: 6th Feb 2017

The NHS chief executive Simon Stevens said binge-drinkers are “selfish to get so blotto” they end up in an ambulance or A&E.  “More than a third of A&E attendances at peak times are caused by drunkenness – casualty nurses and doctors are understandably frustrated about the NHS being used as a national hangover service,” he added. Telegraph