Alcohol Policy UK

Latest IAS alcohol alert & alcohol newsletters

The latest Alcohol Alert Issue 3 2014 from the Institute of Alcohol Studies (IAS) is now available.

See here for the cover story Alcohol Duty Escalator Scrapped: Government “has turned its back on public health” , which criticises the Government's failure to stick to the Prime Minister's 2012 commitment of "coming down hard on cheap alcohol."

Other reports in the issue include:

• IAS suggests support for Minimum Pricing of alcohol greater than Government acknowledged

• British Medical Journal lambasts consultation on minimum pricing as a ‘sham’

• Ban on below-cost alcohol sales to come in before World Cup

• Government failure to act on liver disease slammed by MPs

• Harmful consequences of alcohol consumption result in over 21,000 deaths in England each year

• Local Government Association calls for ‘health’ licensing objective

• 24-hour licensing laws fail to deliver promised cut in violence

• Scotland’s Alcohol Strategy Interim Report

• Contradictory claims in regard to Scots ban on multi-buys

• A decade of alcohol strategy: What has been achieved?

• Online marketing threat to young adults

• Nottinghamshire Alliance Against Violence

Other news round ups and reporting

You can see the latest Alcohol Policy UK newsletter here[pdf], or subscribe to the round up or email bulletins.

The latest Drink and Drugs News issue can be found here, including a feature critiquing the 12 step model. See here for the latest Alcohol Concern newsletter or NWPHO alcohol e-shot.

Responsibility deal pledge to remove 1 billion units 'on track' - but no news on labelling pledge

The Department of Health have released a report detailing interim findings on the Public Health Responsibility Deal (PHRD) Alcohol Network pledge to remove 1 billion units of alcohol from the market by the end of 2015. 

The report suggests a reduction in the strength of drinks by alcohol producers removed 253 million units of alcohol from the market between 2011 and 2012. However overall consumption was down by 1.3 billion units (2%), despite a small upward pressure from a growing market share of wine and spirits. The removal of units therefore equates to around one fifth of the overall reduction in unit consumption for the year.

Most of the units removed came from reductions in the Alcohol By Volume (ABV) of beer, most notably Stella Artois, Budweiser and Becks which were changed from 5% to 4.8% ABV by drinks giant AB InBev in 2012. However at the time, AB InBev would not specify the reason, but it is reported to save them up to £8.6 million a year in duty on off-trade sales alone. 

The units pledge is one area which may appear to benefit health and industry interests alike, although there has been widespread dissatisfaction from public health groups with the Government's reliance on industry action and reported influence. There are also questions as to whether the promotion of lower strength drinks can actually deliver public health gains.

In addition other elements of the responsibility deal have be seen to fail; last year Asda pulled its pledge to stop promoting alcohol in its foyers after other supermarkets had not followed suit. An announcement is due this year from the Portman Group who are monitoring the labelling pledge that 80% of drinks labels by December 2013 contained key health information.

There was speculation on Twitter following the report as to whether the industry could remove a further 747 million units by 2015. However Henry Ashworth, Portman Group Chief Executive and Chair of the Responsibility Deal Alcohol Network, said in a press release:

“It is good news that producers and retailers have already removed 253 million units of alcohol from the UK market and are on track to remove 1 billion units by the end of 2015. This report shows the first year results of this four year pledge so it is important that we stay focused on continuing this industry-wide innovation.”

The report also includes individual updates from the companies signed up to the Responsibility Deal.

Could an upward trend in wine and spirits ABV and consumption undermine the units reduction pledge?

More action needed by local authorities, says Alcohol Concern review of JSNAs

Alcohol Concern have assesed the level of priority given to alcohol across 25 local authorities in England in a new report. The audit found that although most key local needs assessment documents recognised alcohol, most did not go far enough to address the full impact of alcohol misuse on the local population. 

Download 'An audit of alcohol-related harm in Joint Strategic Needs Assessments, Joint Health and Well-being Strategies and CCG Commissioning Plans' [pdf]

The report highlights the "unprecedented and wholesale changes to health service" over recent years, impacting on local structures and commissioning. The shift in responsibility means that Joint Strategic Needs Assessments (JSNAs) should now be taking centre stage for local action and decision making by Clinical Commissioning Groups (CCGs) and local authorities. 

However many key alcohol needs assessments gave alcohol only a brief mention – far from the ‘comprehensive section on alcohol harm’ that Public Health England recommends. Local prioritisation to alcohol also appeared less in areas classified as lower need in the NWPHO dataset, but Alcohol Concern warn such areas must not overlook the still significant impact of alcohol misuse. The report raised other specific concerns, including a gap in some areas failing to recognise key evidence based approaches including addressing hospital admissions or delivering Identification and Brief Advice (IBA) or treatment.

The report makes 11 recommendations. In particular, local Directors of Public Health need to ensure alcohol is sufficiently prioritised with attention to the local picture, with needs assessments making use of wider datasets. As one example, the needs of young people should not over-emphasised in comparison with other groups, including older adults.

It also recommends that Public Health England (PHE) should note the positive impact of the alcohol-related hospital admissions indicator on local prioritisation of such work, and consider indicators around IBA or treatment provision to improve local responses. Public Health England have an Alcohol stocktake self-assessment tool to encourage local areas to take a systematic review of their strategy for addressing alcohol-related harm. The report suggest this may not be going far enough to promote widespread local prioritisation.

Last year Alcohol Concern published a Guide to Alcohol for Councillors, which aims to help councillors meet the new commissioning challenges and tackle alcohol abuse in their communities. NICE has a comprehensive set of alcohol guidance and quality standards, including alcohol pathways and further tools. NICE also recently released Public Health Guidance for local authorities.

CBT / MI effective for combined mental health and alcohol problems - implications for 'dual diagnosis'?

Which comes first - alcohol misuse or mental illness?

Dual diagnosis - co-existing substance misuse and mental health problems - has long been a thorny issue for the alcohol field when it comes to treatment. It is acknowledged that

there is a clear association between having a mental illness and increasing risk of alcohol dependence (to quote the Govenment's alcohol strategy),

and that the reverse is also true, i.e.

individuals presenting for treatment with alcohol misuse may also present with features of other psychiatric disorders, most commonly anxiety or depression. For many, these symptoms will be closely linked to their alcohol misuse and lessen when drinking is reduced or stopped (to quote NICE guidance). 

Who treats what and when if the patient has a dual diagnosis?

The problem seems to be knowing which diagnosis to treat first; it all gets a bit chicken and egg. The NHS 2002 Dual Diagnosis Good Practice Guide told substance misuse services and, more pointedly, mental health services to get their act together, stop 'shunting patients between different sets of services', and to 'mainstream' treatment for people with severe mental health problems and co-occuring substance misuse issues within mental health services.

IAPT (Improving Access to Psychological Therapies) - an NHS programme rolling out services across England offering interventions for treating people with depression and anxiety disorders - will be accessable to the whole adult population by April 2015, and is a major plank in the Government's mental health stratety for England No health without mental health. The mainstreaming message of 2002 needed another push ten years on, however, with publication of  IAPT positive practice guide for working with people who use drugs and alcohol, which said:

IAPT services do not provide complex interventions to treat substance use problems but drug and alcohol use should not be an automatic exclusion criterion for accessing psychological therapy

Meanwhile, current NICE guidance CG115 (Alcohol dependence and harmful alcohol use), having reviewed the available evidence, recommends that:

the first step in treating people presenting with alcohol misuse and comorbid depression/anxiety is to treat the alcohol misuse. Given that the presence of a comorbid disorder following a reduction in alcohol consumption is associated with a poorer long-term prognosis, an assessment of the presence and need for treatment for any comorbid depression or anxiety should be considered 3 to 4 weeks after abstinence is achieved

 Treat both at the same time!

So, arguably, mental health services can still justifiably bounce dual diagnosis patients back to alcohol services. However, a new meta analysis, reviewed by Prof Matt Field on the excellent Mental Elf blog, suggests a way forward. The analysis found that compared to other psychological therapies, cognitive based therapy (CBT) and/or motivational interviewing (MI) for comorbid alcohol use disorder and major depressive disorder produced small but robust beneficial effects on both depression and alcohol consumption.

In conclusion, Prof Field suggests the following clinical implications:

• Treatment of comorbid alcohol use disorder and major depressive disorder with CBT / MI seems to produce beneficial effects on both outcomes.
• Clinicians don’t need to identify a ‘primary’ diagnosis and treat that in the hope that the other will resolve; both can be treated at once.

Alcohol Research UK 2014 conference presentations

Alcohol Research UK recently held its 2014 annual conference, 'Alcohol Through the Life Course'. The conference brought together some of the world’s leading experts on alcohol to discuss key research and policy issues in this area.

Speakers included Professor Tim Stockwell (University of Victoria Canada), author of over 200 papers on alcohol and advisor to the World Health Organisation. Professor Stockwell is also the world’s leading authority on the impact of minimum unit pricing on health in real-world contexts.

Also speaking, Professor Robin Room (University of Melbourne), author of over 30 books on alcohol and advisor to the World Health Organisation since 1975, and considered one of the most influential figures in global alcohol research and policy.

Available presentations included:

• 'Moderate Alcohol Use in Older Years', Professor Tim Stockwell [PPT 17.24 MB]

• 'Wet and Dry Generations: What happens with social change in drinking', Professor Robin Room [PPT 693 kB]

• 'Young People’s Online Alcohol Behaviours', Professor Harry Sumnall [PPT 4.52 MB]

• 'Parenting and School Level Effects', Dr Mark McCann  [PPT 1.83 MB]

• 'What Alcohol Means for Working Age Home Drinkers', Dr Jonathan Ling [PPT 1.65 MB]

• 'Alcohol Misuse in Older Adults', Dr Sarah Wadd  [PPT 905 kB

See here for a summary of the Alcohol Research UK Postgraduate and Early Career Symposium 2014.

A number of Alcohol Research UK funded projects will be presented at the forthcoming New Directions in the Study of Alcohol Group 2014 conference, taking place in Dundee, Scotland from 23rd April to 26th April.

Videos of the presentations will be made available on Film Exchange on Alcohol and Drugs (FEAD).

Pricing and policy around the UK: Brits love of cheap wine & end of aisle displays as Wales eyes up minimum pricing.. and Scotland waits

British love affair with "cheap" vino?

Some interesting insight into Brit's wine habits was revealed in the press this week, as research showed less than half of Brits will pay more then £6 for a bottle of wine.

Drinks consumer insight specialists Harpers say supermarket price wars are threatending to 'dumb down' British consumer's attitudes to wine. It reveals 80 per cent of all wine sold in the UK sells for less than £6 a bottle, with only 7% willing to pay £10 or more. 

Wine has been the biggest area of UK growth in alcohol sales over the decades of increasing consumption, with the UK still the world's biggest importer of wine. Trends of more regular home drinking since the 1950s, including more women drinking and supermarkets using alcohol as a big draw are likely to be key factors. However with alcohol consumption having dropped since 2004, significant 'growth' in UK any alcohol markets may be unlikely, so alcohol producers have been seeking to drive demand for premium products. 

But should wine drinkers feel any shame by our love of cheap plonk - even if a third of us can't name a single grape type? An anonymous supplier said in the Telegraph "The fact is, it’s hard to make any money in Britain, but it’s a great market if you want to get rid of bin ends or if you’ve got tanks to empty for the next harvest. You chuck it in the UK’s direction because there they’ll suck in cheap wine."

The Daily Mail take says that high tax rates mean once tax and shipping costs are met it leaves little profit. Interestingly though the Goverment's below cost ban, currently delayed, calculates duty + VAT on a 12.5% ABV wine at £2.41. Arguments against minimum pricing included the charge that raising the price would shift significant additional profits to producers and retailers, but presumably retailers choose not to as alcohol promotions are a big draw in the war for market share.

End of ailse displays increase sales by up to 46%

The Brits love of a drink bargain may also be confirmed by recent University of Cambridge research that found end of aisle displays significantly increased sales of displayed products: 46% for spirits, 34% for wine and 23% for beer.

The researchers suggest restricting end of ailse displayes could be an important area for policy outside of price, and in line with 'nudge' approaches initially favoured by the coalition (but not without criticism). In 2011 Alcohol Concern called for supermarkets and off-licenses to confine displays of alcohol to a single area of their premises, claiming the widespread promotion of alcohol helped fuel a harmful drinking culture.

However the research also confirmed the role of price in influencing purchasing: "lower price was also associated with increased sales for all of the products, with the biggest impact on alcohol. For every 1% decrease in the price (per volume), there was approximately a 5% increase in sales volume."

Wales consults on minimum unit pricing

The Welsh Government has proposed to introduce a 50 pence MUP in its Public Health White Paper. The consultation document says: "Given the link between consumption and harm, and the evidence that affordability is one of the drivers of increased consumption, the Welsh Government’s view is that Minimum Unit Pricing for alcohol is a key policy proposal for tackling the health harms associated with alcohol misuse."

Scotland's health groups call for end of industry led opposition of MUP

Health groups from across the UK have signed an open letter urging the  Scotch Whisky Association (SWA) to drop their legal challenge to MUP. The minimum pricing bill was passed by the Scottish Parliament in May 2012 and planned to come into force last year. However it faces ongoing legal challenges despite finding favour from the Scottish Judiciary that MUP was not in breach of EU competition law.

Scotland is now awaiting the outcome of the SWA appeal to the Court of Session, which is then likely to be followed by hearings at UK Supreme Court and the European Court of Justice. Dr Evelyn Gillan, Chief Executive of Alcohol Focus Scotland warned it could be five years before the case concludes and said: "The SWA has mirrored the tactics of the tobacco industry in delaying life saving legislation. They oppose any measure that might affect their sizeable profits, no matter the obvious benefits to people's health".

The new indicator for alcohol-related hospital admissions - simple?!

As explained in a recent post on Public Health England's blog and our initial report, the all-encompassing alcohol-related hospital admissions indicator we came to know and love now has a new slimline companion, to be published in the Public Health Outcomes Framework. 

This follows a consultation by PHE last year after the PHOF identified a "preferred option" of an indicator "based on just alcohol-related primary diagnoses".

The new headline indicator is simpler than the previous, although it still relies on 'attributable fractions', which are explained here by the Local Alcohol Alcohol Profiles for England (LAPE) boffins. Attributable fractions are just a scientific way of saying that, on average, some hospital admissions are more related to alcohol than others. This allows calculations as to the overall contribution of alcohol to hospital admissions given its wide health impact.

Hospital admissions are coded for the purposes of data collection according to ICD-10, and each admission is assigned a primary code and up to 19 secondary codes for any diagnoses that affect the treatment needed. The secondary codes may include 'external cause' codes such as motor accident or fall - ie describing the circumstance of the patient that lead to admission.

The original indicator searches every hospital admission for a code that is linked to alcohol and applies the attributable fraction to it. Where an admission has more than one alcohol-related code, the code with the highest attributable fraction is used. The sum of all these fractions of admissions is then used to calculate the rate of alcohol-related admissions for a given population.

The new indicator uses a much narrower search: it looks only for primary or external cause codes that relate to alcohol. These are counted in the same way as before, ie by applying attributable fractions.

Some examples that illustrate the difference between the old and new indicators are highlighted below:

• Patient admitted with a broken leg but also has hypertension (and no alcohol-attributable external cause codes) - IN OLD INDICATOR BUT NOT IN NEW INDICATOR
• Patient admitted with hypertension and various other conditions but hypertension is recorded as the primary code (or reason for admission) - IN OLD INDICATOR, AND IN NEW INDICATOR
• Patient admitted for head injury (primary code) and acute intoxication (secondary code) but no external cause codes -  IN OLD INDICATOR BUT NOT IN NEW INDICATOR (comment: an unfortunate anomaly in the new methodology)
• Patient admitted for head injury (primary code) and a car accident (secondary <external cause> code) - IN OLD INDICATOR AND IN NEW INDICATOR
• Patient admitted for acute intoxication (primary code) - IN OLD INDICATOR AND IN NEW INDICATOR

Pros and Cons?

Clearly the new indicator will produce a much smaller headline figure of alcohol-related admissions. As we highlighted last year, this revised annual figure is likely to come in under 300,000 - way down from the previous annual headline figure of well over one million. This could result in far less press attention to the issue of alcohol-related admissions, which may please critics of the previous one.

PHE argue that the new methodology will be more sensitive to local action on alcohol-related harm (by including a higher proportion of acute admissions due to alcohol), and less influenced by changes in coding practice. However, others fear that the impact of excessive drinking on chronic conditions will be sidelined by the new indicator. See the PHE blog Understanding alcohol-related hospital admissions and associated comments for more on this.

Findings bank alcohol 'matrix bites': The talking road to recovery

The fourth series of 'matrix bites' from the Drug and Alcohol Effectiveness Bank looks at 'therapies in which interaction is intended to be the main active ingredient': 

Psychosocial or ‘talking’ therapies are the mainstay of alcohol dependence treatment. If they are not up to scratch or misunderstood, we risk the bulk of patients doing less well than they could. 

Cell A4. Therapies; effectiveness and general principles
Asks whether therapists really can make things worse, points out that while research has to package interventions, real-world therapy does not, and invites you to critique the American Psychological Association’s list of the most important elements of addiction therapy.

Cell B4. Impact of practitioners on psychosocial therapies
Highlights the seminal study which seemed to prove the importance of Carl Rogers’ classic formulation of therapeutic essentials such as empathy, and asks: Are they really all that is needed? And can being genuine mean breaking other therapy ‘rules’?

Cell C4. Impact of management on psychosocial therapies
Whether alcoholics be taught to control their drinking was the issue in the bitterest series of disputes in the history of alcohol treatment research. You are also invited to consider if good counsellors are found, can be taught by classes, or have to coached.

Cell D4. Organisational influences on psychosocial therapies
Money or vocation; does it matter? Is change driven by money just as good for patients as change motivated by the desire to improve their lives? Students are invited to try a mind experiment to see whether it would matter to them.

Cell E4. Psychosocial approaches in treatment systems
At the heart of this bite is guidance from the UK’s official health advisory body (NICE) on how to organise and procure treatment systems. Why did they recommend 12-week therapy packages? And why no evidence for the core care coordination role?

These 'bites' form the fourth row of the Alcohol Matrix. Round ups of the previous rows below:

• Row 1 covering brief interventions 
• Row 2 covering fundamental issues to treatment.
• Row 3 covering treatment in a medical context

See here for NICE guidance, standards and tools for alcohol treatment.

News & updates March 2014: liver disease warning; Vaportini; boozey school fetes; E-cigarettes and alcohol; trade news

Some selected media stories since the February round-up:

Alcohol and health

The all-party Parliamentary Hepatology Group says deaths from liver diseasee in England have risen 40% between 2001-2012, and that the lack of Government action to tackle it is 'scandalous', reports the BBC and the Guardian.

Research by the University of Leeds suggests drinking alcohol during the first three months of pregnancy is linked to a higher risk of having a premature or unexpectedly small baby.

Hidden levels of sugar in alcohol revealed, says the Telegraph. It suggests one pint of cider contains almost as much sugar as the WHO recommended average daily intake.

New alcohol 'craze'?

Experts have warned against a new 'Vaportini' drinking craze, suggesting the inhalation of alcohol "has the potential to be a very dangerous phenomenon", says the Express.  See a review of the Vaportini in Cosmopolitan.

Should school events allow alcohol to be served? A warning has been issued by the charity Swanswell over the example being set at around 8,000 school events and fetes granted alcohol licenses each year, reports the Guardian.

E-cigarettes and alcohol

Welcoming a consultation on the rules governing how their products should be advertised, e-cigarette makers will fight proposals to ban linking them with alcohol, reports The Grocer.  Meanwhile, anti-smoking campaigners are urging pub operators to keep their policies on e-cigarettes under review as controversy grows around the device, reports The Morning Advertiser.

Trade news

The rise of 'dry' bars has been explored in a PRI reports article on Sobar in Nottingham and a Guardian piece which asks 'is England sobering up?' - perhaps rather simplistically.

New research from the Campaign for Real Ale (CAMRA) has shown how communities are banding together to take over their local pub under the Community Right to Bid, which allows residents to nominate pubs as Assets of Community Value, reports the Morning Advertiser.

The Daily Mail has proclaimed the death of alcopops, quoting health minister Earl Howe: ‘Sales of alcopops are in marked decline, to such an extent that the market for these products looks like disappearing in the next few years’.

Police chiefs claim they are on the verge of winning major supermarket backing for a national clampdown on super-strength beer and cider, reports The Grocer, as Ipswich's Reducing the Strength scheme gains traction across the country.

Cheltenham's late night levy (LNL) came into force on April 1st, see the BBC. This is only the second such levy in operation (after Newcastle), although Islington council recently voted to implement a LNL after September 1st this year, with more expected to follow (see previous APUK update).

Running a pub is amongst the toughest jobs, as explored in a Guardian piece 'Why are pub landlords in low spirits?. Indeed a bid to better protect bar workers by introducing a specific offence of assaulting aworker selling alcohol was put forward, however it was blocked as MPs thought it wouldn't help.

Alcohol Concern warn over 'brand stretching' to non-alcoholic products

A new Alcohol Concern briefing paper has warned over 'brand stretching', a marketing strategy which links alcohol brands to non-alcoholic products. Alcohol Concern suggest the strategy allows alcohol companies to keep their products in consumers’ minds at times when they’re not ordinarily drinking.

'Brand stretch: How alcohol brands are pushing marketing boundaries' [pdf] warns that whilst alcohol brand stretching is currently limited to just a few companies in the UK, it seems to be a growing global trend. It warns that brand stretching - or 'catergory extensions' - may be seen by the industry as a further way to increase reach, particularly should tougher marketing restrictions come about in future. 

In the UK, alcohol category extensions are permitted provided they are not in breach of the Portman Group’s Code of Practice of the Naming, Packaging and Promotion of Alcoholic Drinks. However concerns are highlighted that brand stretching still involves products that are typically appealing to children, such as crisps, chocolates and ice cream. This risks introducing children to familiarity and potentially loyalty to alcohol brands.

Mark Leyshon, Research and Policy Officer at Alcohol Concern said:

“Previous research by Alcohol Concern has shown that children as young as 10 and 11 recognise some alcohol brands better than popular brands of snacks. If they’re seeing big drinks brands on the foods in the fridge and the mugs in the cupboard, that’s an extra dose of alcohol advertising right under their noses.”

Alcohol Concern continue to call for tougher restrictions on alcohol marketing in the UK, including an end to alcohol sponsorship of cultural and sporting events, and that alcohol messages be restricted to adult audiences and contain only factual information about products.

In 2009 the BMA published 'Under the influence: The damaging effect of alcohol marketing on young people'. A report in 2009 highlighted how alcohol advertising linked alcoholic drinks with fun, humour and as a "social glue". In 2011 Alcohol Concern warned how children and young people are at risk of being exposed to alcohol marketing and pro-drinking messages via the internet, and presentations from its 2012 Wales conference on marketing are here.

An insightful exploration of alcohol marketing and some of the complex research and policy issues are analysed in this ADHS blog 'The drip feed'.