1. Alcohol ‘ A Whole Population Approach’ Insert Names here:
April 2017
Alcohol
‘ A Whole Population Approach’
Insert Names here:

2. Trends in prevalence, affordability and availability
Whole Population – What is covered?
Trends in prevalence, affordability and availability
Alcohol & ill health (alcohol-related deaths)
Attitudes & Values
Social norms
Societal costs
Understanding alcohol units and guidance
Drinking definitions
Problematic Drinking
Alcohol & ill health (wider impact)
Stages of an Alcohol Brief Intervention (ABI)
Screening

3. Attitudes & Values?
Hand out Attitudes and Values Statement Sheet (2 minutes Individuals Complete – into Small Groups Discuss/Compare)
Count no of Agree/Disagree/Unsure
Discuss

4. Litres of pure alcohol consumption per capita in the UK, 1900-2010
Alcohol Consumption UK ( )
Litres of pure alcohol consumption per capita in the UK,
This slide shows alcohol consumption in the UK over the last century*. Having fallen in the beginning of the 20th century, notably during the two world wars, it has more than doubled since 1950, with the rate of increase particularly noticeable since the early 1990s. Consumption has increased by around 20% since 1980.
Industry sales data for Scotland (2005-7) show that enough alcohol was sold in Scotland for every man and woman over 16 to exceed the adult male guidelines every single week #
*These figures are based on HMRC data on alcohol released for sale, which is recognised by the World Health Organisation as an indicator for population consumption.
# The Nielsen Company, 2008, published on Scottish Government website
Slide clearly shows the emergence of wine, ready to drink alcopops and cider.
Beer still has a large hold on the market but is probably now stronger volume.
It is interesting to note that licensing laws changed in the 1970s - contributed to increased consumption levels

5. Consumption – Sales – Impacts
UK has high levels of alcohol consumption in context of Europe. Scotland purchases 20% more alcohol than the rest of the UK (that gap once being as high as 25%) with an increase in sales in MESAS data (2016)
In 2015 alcohol off-sales account for 74% of all sales in Scotland. Average price for off-sales alcohol is £0.52 per unit (with more than half being sold under this. Average price for on-sales is £1.74 per unit. MESAS (2016)
Mismatch between sales and reported consumption (from Scottish Health Survey) so highly likely that actual consumption is under-reported
Cost to Scotland for alcohol-related issues estimated at £3.6 billion* p.a. Costs to Aberdeen estimated to be around £120 million p.a. (2010, based on 2007 data analysis)
Costs calculated incorporate health, lost economic productivity, crime and anti-social behaviour, accidents and premature deaths (taking into account wider effects of alcohol)
This is a broad look at Scottish statistics.
MESAS – (Monitoring & Evaluation of Scotland’s Alcohol Strategy) report that between 2009 and 2013 the average price of alcohol increased and consumption decreased. Since 2013, average price has flattened and consumption has increased in both 2014 and 2015
Difference in UK consumption (to Scotland) explained by spirits (cheap vodka) where off-sales purchases in Scotland are twice as high than in England and Wales
Wine sales in Scotland reached their highest level in 20 years. Sales of spirits actually increased in 2015 for the first time in six years. Beer sales have been in decline in Scotland between 1994 and 2013, but have since stabilised
So, in sum, an increase in sales co-relates with a decrease in price in off-sales retail

6. Hazardous / Harmful Men (SHS 2014)
Little differentiation between 16-24, but increase in consumption and Little significant drop-off until 75+ (Scottish Health Survey 2014)
In 2015 Scottish Health Survey the mean number of units consumed across Scotland was 12.9 units. This has declined since 2003 (16.1 units) but higher than in 2013 (12.2 units) suggesting little recent change in patterns. Grampian consumption on par with Scottish Average in 2015.
*Drinking more than 14 units per week (new guidelines) was reported by 36% of men and 17% of women nationally (Scottish Health Survey 2015)

7. Hazardous / Harmful Women (SHS 2014)
Like Men, little differentiation in earlier age groups excepting showing a decline (pregnancy/children?) unlike Males. The and groups are very similar to Males. Faster decline in women from 55+ than in males.

8. Alcohol intake could cause problems due to: Reduced liver metabolism
Alcohol & Older People
Alcohol intake could cause problems due to:
Reduced liver metabolism
Lower ratio of body water to fat
Negative (multiple) medication interactions
Decrease in other activities
Cognitive impairments interfering with self monitoring (under-reporting)
Instability, falls and accidents/injuries
Poorer nutrition
Low mood/depression (80-84 age group has UK’s highest suicide rate) – alcohol a linked factor in self-harm and suicide
Highlight ‘Alcohol and Later Life’ NHSG publication

9. Evidence suggests not drinking more than 1.5 units per day
Alcohol & Older People
RCGP estimate that between 6-7% of over 60 year olds with problems do not get the treatment they require
However, within this age group individuals more likely to have mild dependence – and generally more motivated than younger age groups to change behaviour
Recommendations:
Evidence suggests not drinking more than 1.5 units per day
Focus on whole person and relationship between ageing and alcohol (including role of family/carers)
Use of SMAST-G screening tool
Mental and physical examination
Provision of brief interventions
RC Psych “Substance Misuse in Older People – An Information Guide” (April 2015)
NHSGGC “Alcohol & Later Life” (Autumn 2014). Recent BMJ (London) study (July 2015) suggests a focus on “young older” males with lower levels of socioeconomic deprivation.

10. Affordability & Sales Scotland:
Affordability increased 45% between 1980 and 2007 and only a small drop off since (MESAS 2012)
In sum, sales follow affordability
Graph from:
ONS Real Households Disposable Income UK (2015)
Affordability of alcohol has increased by 45% since 1980 – mainly through rising disposable income.
Interestingly affordability/sales have slowed down somewhat – from economic crisis point – coincidence? 10

11. Alcohol Related Deaths UK Men 1994-2015
In Scotland approx 600 deaths per annum in 1980s rising steadily to 1546 by Deaths ‘peaked’ and some decline overall since. Since 2012 some levelling off on the figures but still higher than in Overall (both sexes) deaths can be averaged out to approximately 22 per week and is slightly higher than the national (Scottish) average (2014).

12. Alcohol Related Deaths UK Women 1994-2015
Women’s deaths peaked at similar time for men, though at a much lower rate overall. However since 2012 we have seen a slow but steady rise in deaths which are lower but closer to male death rate in England.

13. Alcohol Related Deaths UK in Context
Very clear from this 2014 graph that Scotland has a serious problem. Comparisons on unit consumption alone don’t match with death rates. For example compare South West England with Central Scotland, similar consumption but more than twice number of deaths recorded.
Health Scotland (MESAS) 2014

14. The Usual Suspects ‘social norms’ survey with 1545 respondents
Alcohol Awareness Week (2008) Grampian
The Usual Suspects ‘social norms’ survey with 1545 respondents
95% aware of alcohol guidelines, with 26% (??) able to calculate units
Over-estimation of peer drinking 5.2 drinks to 7.9 drinks ‘estimated’
86% believed their alcohol consumption had no effect on work
21% had reported being either late for or missing work
27% reporting being subject to gossip or a loss of dignity
41% experiencing memory loss
48% experiencing regretful conversations or arguments
16% had experienced anti-social behaviour, violence or theft
32% experience of minor injuries
2% had experience of a major accident
19% experiencing regretful sex
12% reported detriment to health
46% under age of 35 with 20% of sample under age of 25 (students)
Broad demographic
Although these are Grampian wide stats, there was no huge differences between City/Shire/Moray.
Interesting to note that 86% of respondents said their alcohol consumption had no effect on work although 21% reporting being either late or missing from work and we have a list of negative experiences as a direct result of alcohol misuse.
Challenge anyone not to be worried about this.
Generally anonymous surveys are quite reliable.
Over-estimation of peer drinking 5.2 drinks to 7.9 drinks ‘estimated’ - kidding ourselves about social norms.
27% reporting being subject to gossip or a loss of dignity – doing something silly
41% experiencing memory loss – gaps
16% had experienced anti-social behaviour, violence or theft – victims of crime.

15. A “Continental” style of drinking?
Wine drinking on steady decrease in France
Fall in consumption of wine is mirrored in other countries such as Spain and Italy
In France - at dinner, wine is now the third most popular drink behind tap and bottled water with other non-alcoholic drinks catching up
Change in policy France – higher value wines compared to cheap table wines
Proportion of people who never drink wine at all has doubled to 38%
Stronger enforcement of drink-driving rules in recent years – now must carry breathalyser kits in cars
Overall consumption down over last 50 yrs but rise of “beuverie express” in younger age groups
Like for like comparison difficult, we do drink in a different ‘culture’, however stereotypes often obscure the complexities and reality, that we drink to excess in comparison to a number of EU countries, however there are different issues in different localities e.g. younger age groups in France and Spain. 15

16. Low Risk Drinking Guidelines? Units Exercise!
What is a unit of alcohol – handouts (blank examples) – 5 minutes complete
Clarity – Mixed messages and confusion around units/drinks
1 unit = 10ml of pure alcohol
Explain – talk through full guidance
People need information
We need to benchmark – identify the sensible drinking guidelines so that people have something to work on and professionals can identify problem and hazardous drinking.
Can you identify the sensible drinking guidelines.
Calculation – Volume (mls) x strength (%ABV)
/ 1,000

17. Unit guideline is now emphasising ‘low risk’ i. e
Unit guideline is now emphasising ‘low risk’ i.e. no more than 14 Units per week for men/women (CMO, England, Scotland, Wales and Northern Ireland) from August 2016
No daily recommendations are in force, although suggestion of spreading any consumption across a number of days, keeping several alcohol-free days.
Risk increases as consumption increases – there is no ‘safe’ limit of alcohol consumption.

18. Drinking Definitions:
Hazardous
Level of consumption above the sensible limit increasing the risk of harms
Men & > Units
Women:
Harmful
Level of consumption causing actual damage to health and wellbeing
Men: > Units
Women: 35> Units
Dependent
Physical and psychological dependence present
High tolerance and presence of withdrawal syndrome
Binge Drinking
More than double recommended daily unit intake and/or drinking to get drunk
Could include any of above as a regular pattern of drinking (including problematic drinking) 18

19. Education, Education, Education !
SHS Knowledge Attitudes & Motivations
Education, Education, Education !
Nationally 23% of men and 17% of women drink hazardously / harmfully (SHS 2015)
Only 20% of men and 11% of women can accurately describe sensible drinking guidance. Those in older age groups had poorer recall of limits (SHS KAM 2011)
Only 1 in 6 (17%) of both sexes could accurately describe daily guidance and upper limits (SHS KAM 2011)
Only 38% of both sexes could recall familiarity with keeping alcohol-free days each week (SHS KAM 2011)
Stats have dropped since 2003 – 33% and 23% hazardous/harmful men and women respectively. Though in recent years no significant change
In 2014, 31% and 22% of men and women in the highest income households drank hazardous/harmfully compared with 18% of men and 13% of women in the lowest income households. Consumption has declined for both groups over time – but the income gap has remained significant
Statistics are taken from the Scottish Health Survey – and Knowledge Attitudes and Motivations report.

20. Thornley Model – Problem Drinking
Excessive regular
consumption
Dependence
Intoxication
These tend to be the most common terms used to describe problem drinking.
Someone who is alcohol dependent will probably have health related problems, could have been involved in accidents, criminality – as either a perpetrator or victim
Excessive regular consumption and intoxication can both be present without any dependence issues
A problem drinker falls within the perimeter of the circles. It is worth noting that problems, risks & harms can arise from intoxication alone.

22. Health Issues – Body Map Exercise
Blank Body-Map handouts

23. Body Map Exercise:
Premature aging

24. Medical Presentations
Hand out A3 Colour Prints for reference

25. Drinking above daily benchmarks:
Summary of Specific Health Risks
Drinking above daily benchmarks:
Raises blood pressure, risk of coronary heart disease
Leads to incremental increase in risks of cancer (oral, breast, liver), liver disease
Risk of psychological/emotional problems/depression, dementia (early on-set) and detrimental to mental wellbeing overall
Increases risk of increased tolerance and dependency
Poorer sleep patterns
Increases calorific intake and resultant weight gain
Increases risky sexual health behaviours
Increases risk of hospital admission

26. Alcohol & Hypertension
Regularly drinking alcohol progressively (dose dependent) increases the risk of developing hypertension
Drinking more than 3 alcohol drinks a day can increase the chance of developing hypertension in later life by up to 75%
Hypertension untreated significantly increases risk of stroke, heart disease and vascular dementia and chronic kidney disease
Most prevalent alcohol-related condition and most prevalent in over 35 age group
It is not the type but rather the volume of alcohol consumed that affects blood pressure
Alcohol is therefore one of the most preventable risk factors related to hypertension
In a controlled study, where one group switched from normal strength beer to low-alcohol beer for a six week period systolic blood pressure fell between 3.8mmHG and 4.4mmHG and diastolic blood pressure between 1.4mmHG and 2.5mmHG. No change in physical activity, smoking habits or diet and many reporting weight loss which underlines the strength of the link between alcohol and blood pressure.

27. Alcohol & Cancer – Emerging Risks
Drinking alcohol, even within the limits of current advice on sensible drinking, may increase the risks of alcohol-attributable oral and pharyngeal cancers and cancer of the female breast
Drinking alcohol at levels higher than the guidelines for sensible consumption can increase the risk of cancer within the larynx, oesophagus, liver, colon and rectum
In 2010, alcohol was an attributable risk factor in approximately 7%, or 1948 new cases, of cancer in Scotland. Globally 21% of cancer deaths alcohol related
In the UK, 6% of breast cancer cases were directly attributable to alcohol consumption – 3,000 cases ( )
There are evidently more risks for women – wider range of risk/issues

28. Dose/Response – Alcohol & Cancer Type
No safe level of alcohol consumption when seeking to reduce risk of alcohol-related cancers. The ‘type’ of alcohol has no effect on risk only strength/volume.
Alcohol breaks down into the carcinogenic compound ‘acetaldehyde’ inside the body. This substance causes genetic mutations and permanently damages DNA leading to development of cancerous cells (Boffetta & Hashibe (Lancet Oncology 2006))

29. Alcohol & Mental Wellbeing
Research shows alcohol misuse is related to the development of mental health problems – e.g. depression
Alcohol can actually increase stress and anxiety rather than reduce it through disturbing sleep, inducing feelings of lethargy and low mood and increasing anxiety in situations where someone would normally feel comfortable
Drinking often encourages risk-taking and is linked with self-harm and suicide (ideation and attempts)
It is common for people with a severe mental illness to also have alcohol problems. This may be due to issues around ‘self-medication’
In Scotland 27% of men and 19% of women cited alcohol as the key factor in self-harming behaviours

30. Alcohol & Dementia
Emerging evidence shows that frequent drinking in earlier adulthood increases risk of developing early-onset dementia such as Alzheimer’s (before age 65)*
This can outweigh considerations regarding family history, use of other drug types and wider health conditions
Brain capacity naturally diminishes with age but in men who regularly drink alcohol – their brains appear between 1.5 to 5.7 years older than healthier peers
In individuals with severe alcohol problems – a type of alcohol-related dementia – ‘Wernicke-Korsakoff’s Syndrome’ can present. This is often termed alcohol-related brain damage (ARBD)
Partial recovery is possible with abstention from alcohol and a healthier diet (including vitamin B1 doses)
*Alcohol Concern – evidence is still emerging about the exact relationship of alcohol consumption and dementia but what is clear is that long terms alcohol use can damage the brain and lead to cognitive impairment

31. Alcohol & Calorific Value
Strong correlation between alcohol and weight gain and contributor towards obesity. Weight maintenance in adulthood also strongly associated with reduced incidence of diabetes risk
Alcohol is very high in sugar and therefore contains significant calorie content (7.1 kilocalories per gram) with only fat holding a higher energy value per gram.
For adult consumers, alcohol provided on average –
8.7% and 6.9% of energy intake
(19-64 years and 65 years and over respectively).*
*National Diet and Nutrition Survey (2008/ /11) conducted by the Department of Health and Food Standards Agency 
Particularly important is the role between weight management in adulthood. Furthermore if we consider the age-correlation between type 2 diabetes and middle-age and that we know middle-aged men currently drink at highest level in population, we can see therefore a higher risk of T2 Diabetes.

32. Sexual Health Impact STI transmission Unintended pregnancy
Regretted sex
76% of those aged under 30 attending Aberdeen City Clinic rated as hazardous drinkers using the FAST screening tool
In 40% of all rape and attempted rape offences it is assumed that alcohol is a key factor. (Scotland)
Many victims of sexual assault have been drinking prior to the event – leaving them in a very vulnerable situation.
76% taken from study on Texting or Talking by Steve Baguley, GUM Consultant, carried out during September 2010 to July 2012.

33. Directly Attributable Hospital Admissions in Context
Men are more than twice as likely as women to be admitted 45% of alcohol admissions were in those aged between 40 and 59 years
Aberdeen City has one of the highest wholly-attributable alcohol-related admission rates in Scotland, significantly higher than Aberdeenshire and Moray.

34. Trauma, Hospitals & Inequalities
Alcohol is associated with 1 in 5 incidents of minor and moderate trauma, rising to 1 in 3 of all major traumas cases recorded in Scotland in
There has been no significant change in the overall rate of alcohol involvement for all trauma patients between 2011 and 2012 (25%).
(Scottish Trauma Audit Group STAG 2015)
Men account for 59% of all trauma incidents, and 70% of all major trauma incidents (assaults, falls, road traffic accidents)
Alcohol is a key factor as it is “ingested by the patient or indeed another involved in the incident itself”
25% of minor trauma incidents involve alcohol as above. It is important to remember that even ‘minor’ trauma is categorised as severe enough to sustain injuries requiring a minimum of three days in hospital or have died as a consequence of injury. Some 6% of all trauma victims die and 22% of major trauma cases end in fatality.
Population from most deprived areas more at risk in terms of alcohol-related admissions
People in deprived areas not necessarily always drinking more than those in less deprived areas, but more likely to have health issues, not just related to alcohol consumption – lack of protective factors?

35. Hospital Admissions & Inequalities
Admissions are more than five times as common in the most deprived areas of Scotland compared to the least (503.5 compared to 97.7 cases per 100,000). This had peaked as high as 7.6 times in the last 10 years.
Figure 9.1 Alcohol related hospital admissions amongst those aged <75y by Income-Employment Index, Scotland 2013 (European Age-Standardised Rates per 100,000)
Alcohol - first hospital admission aged under 75 years[6]
Long Term Monitoring of Health Inequalities: Headline Indicators – October 2015
Trends in alcohol-related admissions
The hospital admission rate for alcohol-related conditions amongst those aged under 75 years has fallen over time, with an 18% decrease between 1996 and 2013 (289.8 and cases per 100,000 respectively).

36. Social Impact Alcohol Misuse
Physical violence – assault, serious assault, domestic abuse, sexual assault
Vandalism
Antisocial behaviour
Littering, noise and associated issues – perceived fear of above
Drink-driving – around 15% of all deaths in RTAs involve at least one driver over the limit. 4% of all RTAs involve at least one driver over the limit (5,710 in 2013) – now lowest UK figure on record (DfT 2015)
Impacts on mental health and wellbeing of others
AFS estimate 1 in 2 of Scots are affected by someone else’s drinking in some way
Not just impacts on the individual – but to others (noise, ASB, domestic violence in all forms, cumulative effect)
Drink Driving still an issue – increases in numbers caught overall in festive period – even taking into account a larger sample size.
Alcohol Focus Scotland report Unrecognised and under-reported: the impact of alcohol on people other than the drinker in Scotland (2013)
70% of assaults presenting at A&E are potentially alcohol related.
22% report being a victim of an incident where the offender was believed to be under the influence of alcohol (some cited alcohol & drugs) with this rising to 63% for violent crimes and assault.
Alcohol is recorded as a factor in 16.8% of accidental domestic fires, resulting in 14 fatal and 292 non fatal casualties.

37. Evidence Based Interventions? Strategy : WHO review Measure Effect
Price Controls
Taxation graduated by strength
Controlling cheapest price
High
Treatment
Brief Interventions
Intensive treatment for dependence
High/Mid
Availability
Enforced age limits
Restricted hours
Retail monopolies
Outlet Density
Mid
Safer Environment
Enforcement of licensing codes
Server Training
Marketing
Limiting exposure to advertising
Low
Education and Information
Integrated campaigns
Classroom Education Only
Public Campaigns / Warning Labels
Nil
Best approach is a blend of all measures. Education and Information can be effective when presented in a context that explains price control, treatment, availability safety and marketing. Not effective on its own, but when presented within a wider framework evidence indicates it is.

38. A Case for Minimum Unit Pricing?
Impact on heaviest drinkers
50p per unit = £5.00 per bottle of wine
£14 per bottle of spirits (70cl)
Cider – 3 litres of Frosty Jack (7.5%%ABV) is £2.99 = 22.5 units x 50p = £11.25
Cheap ciders, beers and spirits will be hit hardest as these are the ones causing most harm. Only the heaviest drinkers will be affected.
Attitudes towards alcohol in Scotland =- results from the 2013 Scottish Social Attitudes survey
51% thought the MUP would punish everyone
This is not he case and we need to stress that the impact on the moderate/responsible drinker is expected to be minimal.

39. Basic Education, Information & Advice Resources & Tools Screening
Alcohol – My Role? Intervention Pathway
Basic Education, Information & Advice
Resources & Tools
Screening
Brief (Motivational) Intervention
Signposting
Referral
Assessment
Treatment
This is where you could be contributing. If you are not screening – you are missing an opportunity.
If you are not comfortable with any of these you could still signpost clients to someone they can talk to.
All staff can be involved in the first 6 steps above. Voluntary sector / Medical professionals have a lot of crediblity and there is an expectation that you will ask these questions.
Assessment and Treatment will be the remit of a professional service.
Introduce the ABI pack

40. AUDIT – Alcohol Use Disorders Identification Test
Screening Tools
Screening tools depend on self-reporting but many have been well validated:
AUDIT – Alcohol Use Disorders Identification Test
Developed by the World Health Organisation and is the gold standard for sensitivity and specificity
Contains 10 questions – for some too long and/or too difficult to memorise – so a shortened version available:
FAST – abbreviated version of AUDIT contains 4 questions for use in Primary Care, A&E without significantly degrading validity
Often felt to be too long – this is sometimes a complaint about AUDIT but ideal for your setting. Many health professionals use FAST but AUDIT certainly more appropriate.

41. Purpose: to judge when to discuss alcohol further with a patient
Screening in Practice
Purpose: to judge when to discuss alcohol further with a patient
If you already know that there is an alcohol-related problem, you may not need to use a screening tool. However use of a screening tool can be part of assessing the severity of problem
Screening tools are designed to be highly sensitive to identifying risk and have been designed specifically for use in health settings
Some discussion regarding screening opportunities – initial contact, before any service delivery,visits/appointment.
At meetings with keyworkers?

42. The “prevention paradox”
Poikolainen et al (2007) identified the top 10% heaviest drinkers in their national sample...
...and then compared their outcomes to the remaining 90% of drinkers...
A small risk multiplied by a larger population can produce more cases than a greater risk multiplied by a much smaller population
The heaviest drinkers experienced 33% of hospital admissions, 22% of deaths, and 19% of life years lost before the age of 65
This group experienced 67% of hospital admissions, 78% of deaths, and 81% of life years lost before the age of 65
The WPA approach works, because targeting the larger number of smaller risks is more effective in reducing consumption and harms than simply targeting the smaller population with the greater risk 42

43. Support & Information Alcohol & Drugs Action (ADA)
7 Hadden Street, AB11 6NU
Helpline Tel: / Text: (7 Days)
Office Tel:
Alcoholics Anonymous:
Al-Anon Family Groups:
My Drinkaware (Alcohol Diary):
Aberdeen City Alcohol & Drug Partnership:
Alcohol Information Scotland:
Healthy Working Lives/Alcohol:
NHS Alcohol & Units, Local Support:
NHS Health Information Resources: Tel: (01224)