1. ALCOHOL MONITORING SYSTEMS Professor Colin Drummond St George’s University of London

2. What is the point of alcohol monitoring systems? Burden of preventable alcohol related harm Economic impact of alcohol related harm Monitoring the impact of alcohol policy Alcohol treatment needs assessment Developing theory/evidence base to inform alcohol policy Persuading governments to take action

3. Top 10 risk factors for ill-health in the European Union Anderson et al., in preparation

5. What causes problems? Acute effects Impaired judgement Disinhibition Aggressiveness Loss of coordination Drowsiness Coma Alcohol poisoning

7. What causes problems? Chronic effects Tissue damage Chronic effects on the brain Psychiatric comorbidity Relationships (inc. marital and parenting) Loss of employment Financial problems Alcohol dependence

10. Source: WHO, 2004

11. Methods of monitoring alcohol consumption and related harm Per capita alcohol consumption General population surveys Indicators of alcohol related harm –Hospital admissions –Morbidity –Mortality –Social and criminal justice –Treatment access Alcohol needs assessment

12. Per capita alcohol consumption Alcohol production+imports-exports Population >15yrs Pros Closely linked to alcohol related harm Based on national statistics Time series Inexpensive to collect Single distribution theory Cons Unrecorded consumption Overseas Duty free Illicit consumption Assumptions % abstainers

14. General population surveys Pros Measure subgroups Individual level data - associations Greater detail – unrecorded/illicit Harmful patterns & quanitites Harmful consequences Diagnostic categories Cons Cost Under-represented groups Recall Attribution Response bias Response rate Recency

15. Alcohol survey measures Quantity/frequency Patterns (binge, regular) Last week/month/year Alcohol related adverse consequences –AUDIT questionnaire –Alcohol dependence –Alcohol-related health consequences –Alcohol-related consultations/help seeking

16. Different questions – different information 90% males, 80% females drink alcohol (16 and over) 30% males, 19% females drink above “safe” weekly level (ONS, 2003) 26% males, 15% females “binge drinkers” 6.4M 32% males, 15% females “hazardous/harmful drinkers” AUDIT 8-15 (Drummond et al., 2005) 7M 7% males, 3% females drink above 50/35 units/wk (ONS, 2003) 6% males, 2% females “alcohol dependent” 16+ AUDIT (Drummond et al., 2005) 1M

18. Indicators of alcohol related harm Pros Official statistics (e.g. ICD) Consequences rather than causes Not reliant on recall/bias Relatively stable methods over time Strong relationship with consumption Cons AAF Alcohol rarely recorded as cause Reliability of coroner’s verdicts/data collection Variation in bias e.g. policing over time/between countries

19. Source: WHO, 2004

20. Indicators of alcohol related harm Alcohol specific measures better Hospital admissions –E.g. alcohol dependence, alcoholic cirrhosis, alcoholic gastritis A&E departments –E.g. alcohol related attendances, recent alcohol use, hazardous/harmful drinking, alcohol poisoning Ambulance statistics –E.g. alcohol related attendances Coroner’s verdicts –E.g. Alcoholic liver disease, alcohol dependence, alcohol related road accidents Health surveys –E.g. alcohol related consequences, injuries, consultations Crime surveys –E.g. alcohol related violence Primary care databases Police statistics –E.g. drink driving, alcohol related road accidents, drunk and disorderly

21. Source: ONS 2001

22. National A&E study Drummond et al., 2005 Funded by Strategy Unit/Dept of Health Maximum burden of alcohol on A&E departments Regional variations & relationship to general population measures 36 randomly selected A&Es in England (18%) stratified by region and urban/rural 116 researchers, 25 regional coordinators All A&E attenders between 0900 and 0859hr Saturday/Sunday 28/29 June 2003

23. National A&E study- Results Eligible1789 Consented1083 (61%) ETOH+41% Intoxicated14% FAST+43% After midnight ETOH+ 70%

25. National A&E Study. Drummond et al., 2005 National means: ETOH+ = 42% FAST+ = 43%

26. National A&E study Predictors of ETOH+ –Young, white, males, single/divorced, unemployed, living with parents or NFA, frequent attenders (1.6x) –More often brought by police/ambulance Reasons for attendance –Violent assaults involving weapons, RTA, psychiatric emergency, DSH –Weapons: fists, knives, shoes, glasses –Locations: clubs, pubs, public transport Correlations with general population data –Male binge drinking r=0.83, p<0.001 –Female binge drinking (ns) –Male weekly alcohol consumption r=0.90, p<0.001 –Female weekly alcohol consumption r=0.93, p<0.001

27. Needs assessment: Definitions NARP - Drummond et al., 2005 Purpose: to estimate the level of need, demand and access to alcohol treatment Need: number of individuals in the general population with alcohol dependence who could benefit from an alcohol intervention Demand: –“potential demand for health service” the estimated number of individuals in England with alcohol dependence who have consulted their GP in a year –“potential demand for specialist alcohol services” (PDSA) the number of individuals who demanded some form of alcohol intervention, which is the number who accessed secondary care services (including general and mental heath hospitals) not necessarily with alcohol as the presenting problem –“actual demand for specialist alcohol services” (ADSA) as the number of dependent drinkers referred to alcohol services. Service utilisation or access: the number of individuals with alcohol dependence that access specialist alcohol treatment in a year Gap or Prevalence-service utilisation ratio (PSUR): the number in need of interventions divided by the number of people accessing specialist alcohol interventions.

28. NARP methodology Drummond et al., 2005 Need: Psychiatric Morbidity Survey –Hazardous Drinking: people drinking above recognised safe levels but not yet experiencing harm (>21/14U <50/35U) –Harmful Drinking: people drinking above safe levels and experiencing harm. (AUDIT 8-15) –Alcohol Dependence: people drinking above safe levels and experiencing harm and symptoms of alcohol dependence (AUDIT 16+) Demand: –PDSA: General Practice Research Database –ADSA: Referrals to specialist agencies Access: National specialist alcohol treatment agency survey PSUR: Alcohol dependence/Access

29. Conclusions Alcohol monitoring essential part of an effective response to alcohol problems in society Data gathering is a government responsibility No one methodology answers all questions: triangulation Different methods, different costs, information Indirect indicators are useful if bias constant over time (control indicators) Measures should be scientifically validated and independently researched Level of data relies on level of resources

30. References Anderson et al., Health Social and Economic Impact of Alcohol, forthcoming WHO, 2004, International Guide for Monitoring Alcohol Consumption and Related Harm Drummond et al., National Alcohol Research Project, forthcoming