Recent research on alcohol and the family James Nicholls Alcohol Research UK

Known knowns Known unknowns Unknown unknowns

What is the scale of the problem (and what is the problem…?) Common prevalence estimates are very out of date (Manning (2009) and APMS (2007) both based on data from 2004. Manning (2009) 3.3 to 3.5 million children ... but this conflates hazardous, harmful and dependent drinking – range from 21 units a week (or on session of 8+ units) to possibly100s of units per week. (NB: health risks not the same as risk of harm in family) Need updated estimates or data (possibly new APMS will help), and clearer view of what constitutes actual or potentially problematic levels of consumption.

Age of first drink is not as important as we used to think Kuntsche et al. (2012). ‘Not early alcohol initiation, but early drunkenness was a risk factor’ Ystrom et al. (2014). ‘The association between early age alcohol initiation and alcohol use disorders in later life does not reflect a causal relationship.’ Percy et al. (2015). ‘Underage drinking per se was not associated with HED in adulthood. When HED was not routine the young people were at no greater risk of transitioning into HED in adulthood than those young people who had more limited engagement with alcohol in their teens.’

Implications for policy? Kuntsche et al. (2015). ‘Rather than recommending delaying the first sip or drink of alcohol, it appears more important to implement theory-driven, evidence-based measures for adolescents, focusing on preventing heavy episodic drinking.’

Parental drinking is a problem at higher levels Rossow et al. (2015). ‘This study has demonstrated that there is currently little strong evidence … of a causal effect of parental drinking on that of their children.’ Haugland et al. (2013). ‘… adolescent hazardous drinking is more prevalent among boys and girls with alcohol misusing parents than those whose parents do not misuse alcohol.’ Kelly et al. (2016). ‘Parental drinking did not appear to be associated with the odds of drunkenness [at age 11]. Associated with higher odds of drunkenness were having friend who drank; having positive expectancies towards alcohol ; ever having smoked cigarettes; the mother-child relationship not being close’

Implications for policy? We need to target interventions, and know what we are targeting. Risk of diminishing returns, target-group disengagement, anxiety-inflation is cut-off level lower than necessary.

Drinking with children: little, and not often? Degenhardt (2015). ‘The onset of risky drinking was more likely among young people who had consumed alcohol with the family on multiple occasions (3+ times in previous six months) than among those who had done so less frequently or not at all.’ Pape et al. (2015). Only frequent drinking with parents (5+ times per year) associated with higher risk drinking in adolescence. But no evidence that early introduction to alcohol was protective either. ‘Hence, the zero-tolerance approach to drinking with parents was not supported. The result did not also support the view that adolescents may learn to drink sensibly by consuming alcohol with their parents.’

Implications for policy? No robust evidence for protective value of ‘continental approach’ … or total avoidance. Complex message: if you drink regularly with your children they are more likely to drink hazardously later on. Simple message: alcohol-free childhood until 15

Parental monitoring does matter … but what is it? Degenhardt et al (2015). ‘Incident risky drinking was even more likely among young people who reported drinking in contexts where they had limited (or no) parental adult supervision.’ Higgins et al. (2013). Parental ‘control’, rather than mere ‘solicitation’ had main effect. Early drinking (pre-11) predicated poor parental monitoring. Which suggests…? Pape et al. (2015). Parental monitoring highly correlated with strong parent-child relationship Kerr et al. (2010). Parental ‘monitoring’ may just be an indicator of strong parent-child relationships

Parenting skills / styles do matter … but aren’t the whole story Velleman et al. (2010). Numerous protective factors (e.g. ‘responsive parenting’) but there is ‘increasing recognition that the influences of families and peers are interdependent’ Cablova et al. (2013). ‘While there is some evidence of a protective effect of an authoritative parenting style there are many other individual, social and environmental factors.’ Visser et al. (2013). ‘…adolescents who perceived more parental overprotection were at increased risk of developing regular alcohol use, even after adjustment for several confounders.’ Leung et al. (2015). ‘Participants who were exposed to parental arguments / fights in childhood were 1.24 times more likely to drink at hazardous levels in midlife after controlling for covariates and other adverse childhood events.’

Won’t somebody think of the parents… Valentine et al. (2010). Parents rely on their own experience, and respond to a range of dynamic situations, rather than applying blanket public health messaging. Eadie at al. (2010). ‘…parents’ expectations of their children’s future alcohol behaviours were often characterised by a sense of helplesness and a limited belief in their ability to teach their children to drink responsibly.’ Velleman et al. (2010). Parental influence wanes passed the age of 13, but remains a key factor in establishing behavioural frameworks.

Implications for policy? Parenting messages are important, but should not be viewed as alternative to supply-side or wider social interventions. Parenting is complex and often difficult – messages should be supportive rather than didactic? Risk of confirmation bias among parents with high social / cultural capital.

What children know Eadie et al. (2010) ‘… children demonstrated a nuanced understanding of alcohol and its effects, and an ability to appraise different consumption styles ... There was some indication that children at this age can already anticipate modelling their own future drinking patterns on that of adult family members.’ Valentine et al. (2010). While social risks are often discussed and well understood, this is less true of health risks.

Implications for policy? Approach parenting messages and interventions as dynamic, multi-directional, culturally situated etc.

Implications for research We need better prevalence estimates Standard data collection methods tend to miss the most problematic drinkers Focus on hard-to-reach high-consuming subgroups or ‘low consuming fruit’ in general population (or both?) Better understanding of how prevention messages are received within the family More support for family interventions – but also recognition that ‘family’ is not a unitary phenomenon.

Implications for Alcohol and Families Alliance? Collective potential to take a lead role in establishing research agenda. Promotion of focus on alcohol harms in the family (as distinct from public disorder or individual-level health impacts) Support for family interventions Developing / disseminating models for co-producing family-oriented research Focusing the target and supporting effective interventions.