Issue 2 2010

Which direction for alcohol policy under the coalition?

The new Coalition Government has immediately courted controversy with the public health community by basing its approach on education rather than regulation, action to improve health being undertaken in close cooperation with the alcohol and food industries as well as public health practitioners and the Third Sector.

While Coalition policy is still being formulated, Government Ministers have already made it clear that, from now on, alcohol policy will be less dominated by the issue of crime and disorder, and less focused on controls on availability. According to new Health Secretary Andrew Lansley, alcohol policy will instead become a key responsibility of a new Public Health Service, and the new Coalition Government’s approach to creating a healthy nation will focus on behaviour change. The idea is that the approach will go beyond constraining the supply of illegal drugs, alcohol and tobacco, and begin to understand and influence the drivers of demand.

Speaking at the UK Faculty of Public Health Conference in July 2010, Mr Lansley criticised the previous Labour Government for failing to get to grips on demand.

Mr Lansley continued:

“Public health efforts which only try to control supply will fail. We have to impact on demand. That people’s relationships with each other and with drugs, alcohol, tobacco and food.

“And where behaviour change has been the aim of recent initiatives, the outcomes have been with the alcohol issue or with other public health problems, such as obesity, all of which had got worse during its term of office. In regard to alcohol, Mr Lansley said that the lack of national leadership under the previous Government could be seen in the sharply rising effects of alcohol consumption, and the pattern of alcohol consumption. Alcohol strategies had failed to go much beyond the public order issue, and the approach had been confined to supply, with little impact means we have to change behaviour, and change patchy at best.

“It seems to me that awareness campaigns have too often sent the wrong messages – when they’re screaming at you to drink less, many people are just having their behaviour reinforced – the message doesn’t come out as ‘drink less’ but as ‘everyone drinks, so don’t worry about it’. It tells people that the norm in society is misuse of alcohol.”

The government’s coalition programme includes the following commitments:

• we will ban the sale of alcohol below cost price
• we will review alcohol taxation and pricing to ensure it tackles binge drinking without unfairly penalising responsible drinkers, pubs and important local industries
• we will overhaul the Licensing Act to give local authorities and the police much stronger powers to remove licences from, or refuse to grant licences to, any premises that are causing problems
• we will allow councils and the police to shut down permanently any shop or bar found persistently selling alcohol to children
• we will double the maximum fine for under-age alcohol sales to £20,000 we will permit local councils to charge more for late-night licences to pay for additional policing.

However, it is clear that this new emphasis on endeavouring to empower the population to live more healthily, rather than seeking to impose solutions from the top down, does not preclude action on licensing controls or on the price of alcohol. Although the Coalition does appear to have rejected the option of a nationwide minimum price per unit of alcohol, the system for which the main alcohol and public health bodies have been campaigning, Prime Minister, David Cameron, has publicly supported local initiatives to establish a minimum price for alcohol. The Coalition also intends to put an end to the 24 hour alcohol licensing introduced by the Labour Government. Instead of minimum pricing, the Coalition promises to ban the sale of alcohol below cost price, and the Coalition has been quick to seek views on this proposal. It has put forward four options to ban below-cost selling of alcohol and is planning to take the proposals to a public consultation in the near future. The issue is what is meant by ‘cost’.

The Grocer magazine reported that the Home Office told industry lobbyists it was working on four possible options, the first of which defined cost as simply duty and VAT. This is the definition used by leading supermarket chains, including Morrisons, which last month called on the Government to ban the sale of alcohol below this figure.

However, many in the industry objected to the definition on the grounds that it would only affect the deepest discounts and attributed no cost to the product itself. Two other options were to add some form of cost for the production, distribution and marketing of the product, or to ban sales below the cost of the invoice sent to retailers.

The fourth option was to allow retailers to work together on fair pricing without fear of prosecution under competition law. The four options would be presented in a consultation document in early August as part of the Police Reform and Social Responsibility Bill.

“End of 24 Hour Licensing in sight”

While the Coalition is still consulting on its plans to reform the Licensing Act, it is clear that it intends to give local authorities greater powers to limit opening hours in their own areas and to control the excesses associated with late night opening. Coalition Ministers have commented on the failure of the Labour Government’s new Licensing Act to bring about the promised Mediterranean-style café culture or to tackle effectively the binge drinking problem.

One unnamed Government source quoted in the Daily Telegraph commented:

“When (the Coalition’s licensing proposals) are implemented, this will be the death knell for 24-hour drinking.

“Labour unleashed 24- hour drinking on our communities, then they said they had abandoned it but the truth was we were still saddled with it.

“The whole point of this move is that unregulated 24-hour drinking is brought to an end.”

The toughening up of licensing controls coincides with returning responsibility for licensing to the Home Office from the Department of Culture, Media and Sport which was widely felt to have mishandled the licensing issue.

Commenting on the transfer of responsibility, Minister for Crime Prevention, James Brokenshire said:

“We continue to be concerned about the number of alcohol-related incidents and the drink fuelled violence and disorder that blights many of our towns and cities.

“The government believes that the power to make licensing decisions needs to be rebalanced in favour of local communities, so that they can decide on the night-time economy they want.

“We have already committed to overhaul the Licensing Act to give local authorities and the police much stronger powers to remove licences from, or refuse to grant licences to, any premises that are causing problems.

“We will toughen the sanctions for those premises found to be persistently selling alcohol to children and will allow local councils to charge more for late-night licences, which in turn will raise money for extra policing. We will also ban the below cost sale of alcohol.

“This move will not only help reduce duplication of effort but will mean just one department is responsible for enforcement and licensing policy, allowing for a more consistent approach to tackling this issue.”

Expert opinion has generally sided with the Coalition on the licensing issue. Professor Jonathan Shepherd, Director of the Cardiff University Violence Research Group and a leading authority on combating alcohol-related violence and disorder, welcomed the Coalition’s proposals which, he said, could turn the tide in Cardiff’s fight against disorder.

Speaking to the Cardiff Echo Professor Shepherd said: “There have been improvements in Cardiff city centre but the levels of drunkenness out there late at night in St Mary Street are still almost epidemic in proportion, so it’s still a really serious problem for the city, the economic health of the city and for individuals. I think this could turn the tide and stem the epidemic.”

He added: “I think a review of current licensing laws and the laws that relate to dealing with and preventing alcohol-related disorder and violence in our cities is welcome. And I would say that a levy on late-night opening is very sensible and likely to be beneficial. It’s clear that the powers that are currently available are not sufficient.”

The new framework will include:

• A new responsibility deal between Government and business built on shared social responsibility and not state regulation
• A new ring-fenced public health budget
• A new ‘Health Premium’ to target public health resources towards the areas with the poorest health
• Clear outcomes and measures to judge progress alongside NHS and social care outcomes
• An enhanced role for Public Health Directors so they have the resources and authority to improve the health of their communities; and
• A new Cabinet Sub- Committee on Public Health, chaired by the Health Secretary, to tackle the drivers of demand on the NHS
• A White Paper, to be published later in the year, will set out in more detail how the Public Health Service will work.

Overhaul of Licensing Act to give communities more power to tackle crime

Proposals for tough new measures to crack down on problem premises and more powers for local communities to influence licensing decisions have been unveiled by the government. Ahead of a major speech on antisocial behaviour, Home Secretary, Theresa May, outlined a range of options to overhaul the Licensing Act. Measures for consultation include:

• making it easier for communities to have their say on local licensing by allowing local authorities to consider the views of the wider community, not just those living close to premises
• taking tough action against underage drinking by doubling the fine to £20,000 for those found persistently selling alcohol to children, extending orders that see premises closed on a voluntary basis to a minimum of seven days and bringing in automatic license reviews for these problem premises – which can see licenses revoked
• charging a fee for latenight licences to pay for the cost of extra policing and scrapping ineffective, bureaucratic and unpopular Alcohol Disorder Zones
• ensuring policing and health concerns are fully considered so that the impact of licensing on crime and disorder or public health can be fully taken into account when assessing license applications
• increasing license fees so that local councils can cover costs linked to enforcement, leaving premises to pay, rather than the local taxpayer tightening up rules for temporary licenses by limiting the number of Temporary Event Notices that can be applied for in any one year – these are often used to get around the restrictions of applying for a permanent license
• introducing a ban on the sale of below cost alcohol and consulting on how this can be achieved.

Home Secretary, Theresa May, said: “The benefits promised by the 24 hour drinking ‘café culture’ have failed to materialise and in its place we have seen an increase in the number of alcohol related incidents and drink-fuelled crime and disorder.

“We know that the majority of pubs and bars are well run businesses but the Government believes that the system needs to be rebalanced in favour of the local communities they serve with tougher action taken to crack down on the small number of premises who cause problems.”

Last year there were almost one million violent crimes that were alcohol related, with a fifth of all violent incidents taking place in or around a pub or club, and almost two-thirds of these happen at night. As well as this, the total cost of alcohol-related crime and disorder to the taxpayer is estimated to be between £8bn and £13bn.

The government’s public consultation will run for six weeks and seeks views on a range of proposals to tackle alcohol related crime and disorder.

The consultation paper, Rebalancing the Licensing Act – a consultation on empowering individuals, families and local communities to shape and determine local licensing, is available at:

http://www.homeoffice.gov.uk/publications/consultations/cons-2010-licensing-act/ 

Labour elder statesman criticizes “Labour’s ghastly mistake”

Some Labour politicians also appear to support the Coalition’s policy of being tougher on alcohol licensing. Writing in the Daily Mail, Lord Hattersley, former Deputy Leader of the Labour Party, described the introduction of 24-hour drinking as New Labour at its silliest. Lord Hattersley added:

“Looking back to 2003, when the new and undeniably disastrous licensing law was passed, it is almost impossible to understand why New Labour ministers expected anything except a rise in alcohol-related crime and nights of misery for honest citizens who lived near pubs, clubs and wine bars. The only answer to the conundrum is that this ghastly error represented New Labour at its silliest, as personified by Tessa Jowell, then the Secretary of State for Culture Media and Sport, who pioneered the legislation and took responsibility for its implementation.”

Police chiefs as well as politicians have also criticised the Labour Government’s licensing reforms. Sir Hugh Orde, President of the Association of Chief Police Officers, agreed with the Coalition government’s view that the new licensing act was a mistake. And Sir Hugh told the BBC that those who benefited from longer licensing hours should help pay for the extra policing required.

Sir Hugh told the Andrew Marr Show: “I think 24-hour drinking frankly was probably a mistake. The culture in the UK is different from other parts of Europe, where it is far less threatening and far more successful. We need to take that legislation away and indeed I would welcome the notion that if we have longer licensing hours the people making the money pay for some of the policing that has to be put in place to keep those people safe when they’re out under the influence of alcohol.”

KENT police agreed. Ian Pointon, Chairman of the Kent Police Federation, said late-night drinking had created more problems than it had solved and had resulted in fewer officers being available to fight crime during the day.

Speaking to local media, Mr Pointon said: “I think the introduction of 24-hour drinking without the requisite change in culture was a mistake.

“The idea was that we would somehow develop a Continental café culture but that hasn’t happened, especially in town centres.

“The feedback from officers is that they’ve had more problems since the 24-hour laws came in.

“They’re also working into the early hours, which means they’re not available at other times of the day when the public would like to see them.

“It’s time to have a long, hard look at the licensing hours coupled with the drinking culture in this country.”

Mr Pointon’s criticism of 24-hour drinking is shared by Kent’s former Chief Constable Mike Fuller, who had warned against its introduction in an interview with local Kent in January, 2005.

Will the Coalition Government lower the drink drive limit?

The Coalition government has chosen to delay making a decision on whether or not to accept the recommendations of the Review of Drink and Drug Driving Law undertaken by Sir Peter North. The Review, commissioned by the previous Labour Government, recommends lowering the present drink drive blood alcohol limit from 80mg% to 50mg% and, in regard to enforcement, amending the law to give police an unrestricted power to require anyone driving a vehicle on the public highway to give a preliminary breath test. At present, while police can stop any driver at random, they can only require the driver to take a breath test if he or she has committed a moving traffic offence, or been involved in an accident or if there is a specific reason that he or she has been drinking.

The North Review considered but rejected the option of lowering the blood alcohol limit to 20mg%. While the Review accepted the evidence that a driver who has a blood alcohol level of between 20mg% and 50mg% is at least three times more likely to die in a road traffic accident than a driver who is completely sober, it concluded that a sudden reduction in the limit from 80mg% to 20mg% could have a detrimental effect on the currently high level of public support for and compliance with drink drive legislation in the UK. Lowering the limit to 20mg% would necessitate drastically reducing the severity of the penalty for the offence of drink driving, and this could dilute the effectiveness of the current approach for little gain in terms of tackling the drink drive problem.

However, the Review concluded that these objections do not apply to the introduction of a 50mg% limit which, the Review estimates, could save tens or even hundreds of lives each year.

The Review also rejected the option of a lower legal alcohol limit for specific groups of drivers such as drivers of Heavy Goods Vehicles (HGV) and novice or young drivers. The main reason for rejecting the idea of a lower limit for HGV, taxi and private hire drivers was the relative lack of propensity of these drivers to drink and drive, compared with the general population, and the fact that such drivers already face higher penalties from the courts and also from their employers. A lower limit for young drivers could appear discriminatory, and in any case, roadside enforcement would be difficult, given that, as there is no statutory requirement for drivers to carry their driving licence with them, police could find it difficult to tell to which age group they belonged.

Industry opposition to a lower limit

It is clear from submissions made to the North Review that the hospitality, entertainment and leisure industries are still opposing any reduction of the present legal blood alcohol limit for drivers on the basis that it would have a detrimental impact, particularly on country pubs. The North Review, however, decided that reducing the limit to 50mg% would, of itself, have a widespread detrimental impact on the sector, and that, indeed, providing further encouragement for people to drink at home could have beneficial consequences for much of the industry. The Review states that a 50mg% limit is not a zero tolerance approach, and that its introduction would not, therefore, deter those customers the trade is most concerned about, those who consume modest amounts of alcohol to accompany a meal in a pub or restaurant.

Government Response

It may well be, however, that commercial and economic, as distinct from road safety, considerations will weigh heavily with the Government. Responding to the Review, The Secretary of State for Transport (Mr Philip Hammond) said:

“This report covers a wide range of issues and makes 51 detailed recommendations, which we need to consider carefully with other Government departments. In doing so, it is important that we fully investigate the economic and public service resource impact of any suggested changes to the law, taking account of the current financial and economic situation.”

Drop in drink drive casualties

The Department for Transport has published provisional statistics on road accidents reported to police involving drinking and driving in Great Britain in 2009, which show a reduction in the numbers of killed and injured as a result of drink driving compared with the previous year. The figures show that:

Fatalities resulting from drink and drive accidents fell by 5% from 400 in 2008 to 380 in 2009, whilst seriously injured casualties fell by 9% from 1, 620 to 1,480. Slight casualties resulting from drink drive accidents fell by 8% from 10,960 to 10,130. Total casualties fell by 8% from 12,990 to 11,990

Fatal accidents remained unchanged from 2008, remaining at 350 for the second year in a row. Overall drink and drive accidents fell by 7% from 8,620 to 8,050

Rise in number of petrol stations selling alcohol

The reduction in drink drive casualties was achieved despite a growth in the number of petrol stations licensed to sell alcohol in England and Wales. Sales of alcohol from petrol stations have been a recurrent issue in the alcohol policy debate for some time. Alcohol control advocates have always argued that such sales are inappropriate given the obvious incompatibility of drinking with driving. While English and Welsh licensing law normally prohibits the granting of alcohol licences to garages and petrol stations, there is a get-out clause in the legislation which permits such premises to sell alcohol so long as their ‘primary purpose’ is not the selling of petrol. The practice of setting up convenience stores at petrol stations has permitted the proprietors to claim that it is the store which is the primary activity, with petrol sales being of secondary importance.

A survey undertaken by Alcohol Concern Wales found that a third of petrol stations in the principality were licensed to sell alcohol, with two of the premises licensed to sell alcohol 24 hours per day.

Alcohol Concern Cymru makes the following recommendations:

• It should be a mandatory requirement that drink-drive warnings be displayed at the point of sale at all petrol stations where alcohol is also available for purchase. Such warnings would serve to support ongoing awareness-raising campaigns concerning the dangers of drinking and driving

• It should be a condition that any petrol station applying for an alcohol license must be able to demonstrate that it will either buy-in, or provide themselves, thorough training for staff on responsible alcohol sales practices

• A review of the effectiveness of bans on alcohol sales from petrol stations, and alternative measures undertaken in other countries, should be undertaken to inform discussions about the appropriateness of equivalent measures being implemented in England and Wales

• In recognition of the growth of alcohol as a public health issue, and in order to enable licensing authorities to properly address this, the protection and improvement of public health must be established as a fifth criterion within the Licensing Act 2003 for assessing license applications, including those from petrol stations

• The drink-driving blood alcohol limit in England and Wales should be reduced from 80mg/100ml to 50mg/100ml, in line with the North Review, on the grounds that drivers are more likely to be involved in an accident the higher their blood alcohol level. This should be accompanied by greater publicity on penalties and highly visible enforcement.

Majority of Britons support better alcohol labelling and higher age limit

A new opinion poll* has found strong support for the improved labelling of alcohol products, with 82% of the public believing that alcohol manufacturers should be required to provide detailed information about the number of alcohol units and calories contained in all alcoholic drinks. This high level of support was closely matched across the UK, across all age groups and across supporters of all political parties, with 85% of Conservative and 82% of Labour and 84% of LibDem voters supporting the measure. Those aged 18-34 and those over 55 years both gave a strong thumbs up to clearer labelling on alcohol.

A smaller majority (57%) of those questioned also favoured raising the legal age at which people can buy alcohol from 18 to 21.

However, there is much less public support for setting a minimum price for each unit of alcohol, opinion being divided 45% in favour, 44% opposed, with 11% undecided.

There was a clear majority against banning supermarket offers on alcohol such as ‘buy one get one free’ and ‘three for the price of two’. The figures were 41% in favour, 51% opposed with 8% undecided.

The opinion poll was carried out by YouGov for the Faculty of Public Health. Other public health policies with strong public support included making two hours of games or sport each week compulsory in all schools, a ‘traffic light’ system of food labelling, banning anyone from smoking in a car carrying children, and banning TV advertisements before 9pm for ‘junk foods’.

The Faculty of Public Health commissioned the survey to help inform the Coalition Government’s new public health strategy, and, in particular, the White Paper on public health expected later in the year.

*Healthy Nudges: when the public wants change and politicians don’t know it

Faculty of Public Health, 2010

People dependent on drugs or alcohol who refuse treatment could lose their welfare benefits

The Home Office is considering withdrawing benefits from people who are dependent on alcohol or other drugs who refuse the offer of treatment, while exempting them from the requirement to seek work if they do undergo a treatment programme.

The idea is one of a range put forward in a consultation paper on the Coalition Government’s Drug Strategy for England, Wales and Scotland.

The same idea was put forward by the previous Labour Government as part of the Welfare Reform Bill, introduced into the House of Commons by the then Work and Pensions Secretary, James Purnell. The rationale of the measure is also essentially the same for both Governments – using the benefits system to provide incentives for people dependent on drugs, including alcohol, to overcome their problems and to re-engage with the labour market.

A strong prompt for such an initiative is provided by the high number of people who receive incapacity benefit, a weekly payment for people who become incapable of work through illness or disability while under State Pension age. Figures from the Department of Work and Pensions show that in 2008, there were over 2.6 million people claiming incapacity benefits, of whom nearly 54,000 were claiming because of alcohol dependence and 51,000 because of drug dependence.

The new consultation document asks people for their views in regard to whether more use should be made of the potential to use the benefit system to offer claimants a choice between:

a) some form of financial benefit sanction, if they do not take action to address their drug or alcohol dependency; or

b) additional support to take such steps, by tailoring the requirements placed upon them as a condition of benefit receipt to assist their recovery (for example temporarily removing the need to seek employment whilst undergoing treatment).

The proposal to withdraw benefits was immediately attacked by Martin Barnes, Chief Executive of DrugScope, who said he “seriously questioned” whether linking benefit sanctions to a requirement to undergo medical treatment was either fair or effective.

He told BBC Radio 4’s Today programme there was no evidence that such an approach would for work for a “particularly vulnerable and marginalised group”.

“Also, we have to bear in mind that under the principles that are enshrined in the NHS Constitution, medical intervention should be therapeutic, consensual, confidential – and I just don’t see that’s compatible with using the benefits system to require people to undergo a complex form of drug treatment intervention,” he added.

Simon Antrobus, Chief Executive of Addaction, was also critical. He said that while getting more people into drug treatment was always a good thing, attempting to force them into that process by taking away their benefits would be a mistake as it could increase their chances of turning to crime to find an alternative income.

The previous Labour Government’s similar proposals were attacked on the same basis. Then, the Royal College of Psychiatrists and the civil rights lobby group ‘Liberty’ protested that the proposals amounted to a gross intrusion into privacy and jeopardised patient confidentiality, as well as being based on a “fundamentally flawed” understanding of the nature of drug dependence.

In a briefing on the Welfare Reform Bill to the House of Lords, the Royal College and Liberty stated that the proposals would “discourage many problem drug users from applying for benefits and may mean a number of people will withdraw from the system to ensure that their dependency does not become public. Many people dependent on drugs hide the problem from their friends and family and, indeed, do not even admit their addiction to themselves. Imposing what, in effect, amounts to forced treatment also shows a failure to understand the fundamental nature of addiction and the method by which it is treated. These provisions are likely to act as a further barrier to employment; may increase the risk of social exclusion; and risk increasing crime rates and entrenching the cycle of dependency.”

However, these views were themselves regarded as questionable by others in the field. This journal commented that arguments about patient confidentiality and alcohol and drug dependents being in denial were strange ones, given that the question arose in relation to people claiming benefi ts precisely on the basis of a medical diagnosis of alcohol or drug dependence. And forcing people to confront their dependence on alcohol and other drugs and to do something constructive to overcome the problem was normally accepted as a legitimate, indeed indispensable, element of the social response to alcohol and drug dependence.

In the criminal justice system, for example, the return of the driving licence to drink drive offenders with a serious alcohol problem was conditional upon their providing convincing evidence to the authorities that they had overcome their problem and were fit to drive.

The same principle of conditionality applied in workplace alcohol and drug programmes, which normally offered alcohol or drug dependent employees a hobson’s choice between agreeing to overcome their dependence by, for example, undergoing a treatment programme, or accepting normal discipline, which would often mean being fired. Far from being attacked as counterproductive intrusions into privacy, likely to entrench dependence and bring about relapse, workplace programmes were actively promoted as highly desirable responses to alcohol and drug problems. Indeed, in one of its major reports on alcohol, the Royal College of Psychiatrists itself claimed that “in companies where such policies exist and are genuinely operated, the extra motivation provided by the opportunity to remain employed greatly enhanced treatment outcome.”

On the face of it, it was difficult to see why the proper approach to treatment for dependence should take not just different, but exactly opposite forms in the employed compared with the unemployed.

Alcohol: No Ordinary Commodity – New edition

Seven years after the original publication of the book that has come to be regarded by many in the public health community as the standard manual for alcohol policy interventions at the local, national and international levels, an international group of alcohol experts has just published a revised and expanded edition of Alcohol: No Ordinary Commodity – Research and Public Policy.

The 15 alcohol scientists who compiled the book’s findings represent the world’s leading authorities on how evidence informed alcohol policy can better serve the public good by reducing the burden of disease and disability caused by the misuse of beverage alcohol.

The second edition of the book was officially launched in July at a meeting at the Royal College of Physicians, sponsored by the Society for the Study of Addiction.

According to lead author Professor Thomas Babor from the United States, alcohol is one of the most prominent causes of health problems in the European Union, accounting for more death and disability than tobacco, obesity, high blood pressure, illicit drugs and a variety of other health risk factors. In England, it is estimated that 10 million adults drink above safe limits. Alcohol-related admissions in the UK between 2004 and 2009 increased from 644,000 to 945,000, and liver disease deaths have increased by 12% in the last three years.

Babor argues that two things need to happen to reduce alcohol’s adverse impact, both locally and globally. “First, we need to recognize that alcohol is no ordinary commodity. Second, we need to look at effective alcohol policies supported by scientific evidence. Our book reviews the scientific literature on 42 strategies and interventions used around the world to prevent alcohol problems,” he said.

“Interventions with the most empirical support include alcohol taxes, drunk driving laws, age restrictions on alcohol purchases, and limits on the physical availability of alcohol.”

In the revised version of the book, the global alcohol industry is singled out for its role in promoting alcohol availability in developing countries and its aggressive marketing tactics targeting young adults throughout the world. According to co-author Professor Sally Casswell from New Zealand, “The major players in the alcohol industry consistently oppose effective policies, and then take credit for supporting ineffective policies like voluntary self-regulation of advertising and alcohol education programs.”

Alcohol No Ordinary Commodity research and public policy, Second edition Babor, T et al 2010, Oxford University Press, ISBN – 978-0-19-955114-9

Government ‘health watchdog’ calls for minimum price of alcohol

A minimum price for a unit of alcohol should be introduced to help tackle the rise in problem drinking in Britain. This is one of the main recommendations of the Guidance issued by the National Institute for Health and Clinical Excellence (NICE) on preventing hazardous and harmful drinking. The guidance is intended for the NHS but also for government as a whole, industry and commerce and all those whose actions influence the population’s attitude to, and use of, alcohol.

The Guidance was welcomed by the Alcohol Health Alliance, the British Medical Association and other public health practitioners and advocates, but criticised by representatives of the alcohol industry. Simon Litherland of Diageo GB said: “Yet again it is disappointing to see continued support for minimum pricing despite no credible empirical evidence that it would be an effective measure in reducing alcohol-related harm.”

Andrew Opie, Food Policy Director at the British Retail Consortium, said: “It’s too simplistic to say the UK’s alcohol problems are down to price. Irresponsible alcohol consumption is primarily a cultural issue that needs to be addressed through education and information.”

However, the month before the publication of the NICE Guidance, Sir Terry Leahy, the boss of Tesco, came out in favour of minimum pricing.

Health Secretary Andrew Lansley also distanced the Government from the NICE recommendation, saying that ministers instead favoured banning supermarkets and off-licences from selling alcohol “below cost price”. Mr Lansley said: “It is not clear that [Nice’s] research examines specifically the regressive effect on low income families [of a minimum price], or proves conclusively that it is the best way to impact price in order to impact demand.”

The NICE Guidance is based on the findings that one in 4 men and women are currently drinking dangerous amounts of alcohol that are causing, or have the potential to cause, physical and mental damage, and that the number of alcohol-related deaths has more than doubled in the past 16 years, with over 8,000 people dying of conditions such as alcohol poisoning and liver cirrhosis every year.

NICE argues that introducing a minimum price for alcohol alongside other measures that make it harder to buy alcohol, like reducing the number of outlets selling alcohol in a given area or the days and hours that it can be purchased, will help to save thousands of lives each year.

Professor Anne Ludbrook, a health economist from the University of Aberdeen who helped develop the NICE guidance on alcohol-use disorders, said: “Alcohol is much more affordable now than it ever has been, and the price people pay does not reflect the cost of the health and social harms that arise.

“When it is sold at a very low price, people often buy and then consume more than they otherwise would have done. It is a dangerous pattern which many people have unknowingly fallen into.”

Professor Ludbrook, who was speaking at the guidance launch in London, added that there are over 100 studies showing that increasing the price of alcohol will reduce levels of drinking and the harms associated with drinking.

“Increasing the price is likely to be the most cost-effective way of reducing drinking,” she said.

Economic modelling work for the guidance was carried out at the University of Sheffield, where researchers found that introducing a minimum price of 50p per unit reduced levels of alcohol consumption by 10.3 % among harmful drinkers and 3.8 % among moderate drinkers.

But Professor Mike Kelly, Director of Public Health at NICE, stressed that it was not down to the Institute to set a price for a unit of alcohol.

“What we do is review the evidence not specify a minimum price. The decision is one for Parliament and for ministers to take,” he said.

Professor Kelly added: “Alcohol misuse is a major public health concern which kills thousands of people every year and causes a multitude of physical, behavioural and mental health problems.

“What’s more, it costs the NHS over £2 billion annually to treat the chronic and acute effects of alcohol – this is money that could be spent elsewhere to treat conditions that are not so easily preventable.

“This is a big-ticket issue and the recommendations on minimum pricing chime very well with those made by the Conservatives in their working paper. The Chief Medical Officer and the Scottish Government have all been moving in this direction, and the signals from the Department of Health look quite promising.” Professor Sir Ian Gilmore, President of the Royal College of Physicians and Chair of the Alcohol Health Alliance UK, has long been an advocate of minimum pricing and welcomed NICE’s careful and systematic review of the evidence for minimum pricing.

‘It is reassuring to hear these recommendations from NICE. Week in, week out I see the burden of alcohol misuse in my clinics. There is not a family out there that has not been affected by it. “

Elsewhere, the guidance addresses the problem of alcohol-misuse from an individual level with recommendations to screen young people aged 16 and 17 and adults for alcohol problems.

Professor Eileen Kaner, Chair of the Development Group and a public health researcher at the University of Newcastle, said: “The guidance calls for GPs and other public service workers to ask some simple questions about people’s drinking habits as early as possible if they ever suspect that there may be a problem.

“Just 5-10 minutes of brief structured lifestyle advice is sufficient to make changes in drinking behaviour. This can help make people aware of the potential risks they are taking or harm they may be doing at an early stage.”

Alcohol and obesity mix to create deadly liver disease cocktail

Drinkers who are overweight are much more likely to develop deadly liver disease, according to scientists from the University of Glasgow. In a study conducted by Dr Carole Hart of the Section of Public Health and Health Policy, scientists examined whether a raised Body Mass Index (BMI) and alcohol consumption acted together to increase the risk of liver disease. They found that the combination of drinking and being overweight or obese led to a much greater risk of liver disease than either alcohol consumption or overweight/ obesity alone.

Meanwhile, another Glasgow University research team found that virtually the entire adult population of Scotland are dangerously at risk of illness or premature death as a result of unhealthy lifestyles.

Obesity and alcohol

Overweight (BMI of 25 to <30) men had higher death rates than normal weight men while obese men (BMI of 30 or more) had a five-fold increase in the risk of dying of liver disease.

Drinkers of 15 or more units a week of alcohol in any BMI category, and obese drinkers had higher risks of liver disease mortality than normal weight non-drinkers. Risks increased as BMI and alcohol levels increased. Obese men drinking 15 or more units a week had almost 19 times higher risk of dying of liver disease.

Dr Hart added: “We may need to consider recommending lower ‘safe’ limits of alcohol consumption for people who are overweight.”

The study was published in the British Medical Journal. Hart, C et al – Effect of body mass index and alcohol consumption on liver disease: analysis of data from two prospective cohort studies. BMJ, 2010, doi – 10.1136/bmj. c1240

Scots living dangerously

In the second study, researchers examined the Scottish Health Survey and found that nearly the whole adult population (97.5%) reported to have at least one of five main behavioural risk factors for ill-health – tobacco use, alcohol consumption, poor diet, physical inactivity, overweight and obesity. 55% of the sample reported having three or more risk factors, and nearly 20% reported having four or all five risk factors. The most important determinants for having four or five multiple risk factors were low educational attainment which conferred over a 3-fold increased risk compared to high education, and residence in the most deprived communities (relative to least deprived) which had greater than 3-fold increased risk.

The study was led by Dr David Conway, who commented that the true picture could be even worse, due to respondents putting a positive spin on their behaviour.

The Scottish results are similar to those in a recent survey of English behaviour, and suggest both nations are more unhealthy than many European countries, and North America.

Scotland has earned a reputation as the ‘sick man’ of Europe in recent years. The country has higher death rates from cancer, heart disease and stroke than anywhere else in the UK, and among men, Scotland has more than twice as many alcohol-related deaths than England.

Scots Drink 24% more than English and Welsh

The reason alcohol features so large in the unusually high mortality rate in Scotland is that the Scots drink almost a quarter as much again as the English and Welsh. Figures based on alcohol sales data and analysed by NHS Scotland show that the drinking Scots population aged over 16 consume 13.5 litres of pure alcohol per annum, compared with 11.1 litres in England and Wales. Expressed in terms of alcohol units, Scots aged 16 and over purchased 1190 units in 2009, equivalent to 22.9 units per person per week. When the proportion of Scots who do not drink alcohol are taken into account, consumption per drinker increases to 25.9 units per week, almost five units per week more than the recommended weekly maximum for men. The equivalent English figures are 18.4 and 21.4 units.

Other highlights from the report are that:

• More than twice as much alcohol was purchased in Scotland from the off trade as from the on trade, with off sales continuing to increase and on sales to decline
• The price per unit of alcohol was between two and three times as high in the on-trade as in the off trade
• The average price per unit of alcohol in 2009 was 72 pence in Scotland, compared with 71 pence in England and WalesHowever, in Scotland 77% of all drink was sold from shops and supermarkets at less than 50p a unit, 51% at 40p or less and 16% at 30p or less
• A quarter of cider was sold for less than 20p per unit, 48% at less than 30p per unit and three-quarters at less than 40p per unit
• More than half (5%) of beer was sold at 40p per unit and 59% of vodka was sold for less than 35p per unit.

The study was published in the online journal BMC Public Health Conway, D et al – Is the Scottish population living dangerously? Prevalence of multiple risk factors: the Scottish Health Survey 2003; BMC Public Health 2010, doi: 10.1186/1471- 2458-10-330

 

Free NHS treatment to be pared back by 2020, says new report

The continued unhealthy lifestyles of the British population, including the over -consumption of alcohol, mean that the NHS may have no choice other than to pare back some of the free treatment that we currently receive and penalise unhealthy behaviours, according to a new report commissioned by the Friends Provident, a company originally founded in 1832 to alleviate the hardship of Quaker families facing misfortune.

The report, Visions of Britain 2020, conducted with the Future Foundation, condemns Government health campaigns as failing to persuade individuals to live healthier lifestyles. However, in contrast, legislation to curb smoking has been hugely successful. As a result, Visions of Britain argues that penalties are a likely solution to help relieve the current strain that unhealthy behaviours place on the NHS. The report predicts that it is only a matter of time before similar legislation to the smoking ban will be imposed to curb obesity. It also suggests that minimum pricing of alcohol is also on the way. The main conclusion of the report is that the rising cost of the NHS will necessitate a focus on preventative treatment. Given the failure of persuasion the government is more likely to legislate – curbing a range of behaviours to force healthier outcomes and reduce demand on the NHS. A voluble ‘New Puritan’ group will support these measures, something that will encourage legislators. Secondly, private companies will become more involved in the NHS than they are now. Their role may be in creating greater competition to reduce costs (for example through out-sourcing treatments). Thirdly, citizens will have to take greater responsibility for their own health as less treatment is provided. This may take the form of paying for treatments that are currently offered for free, or greater take-up of private medical insurance. It may also mean the provision of individualised preventative measures.

That the NHS will be reduced in terms of scope is almost inevitable. One of the experts consulted for the report, Dr Sarah Brewer said:

“Something has to give. One scenario is that people may well end up being charged for certain treatments or denied certain non-essential treatment, particularly if their unhealthy lifestyle was a contributory factor. The other scenario is the withdrawal of many free treatments.”

The report says that experts and consumers agree that unhealthy lifestyles should be penalised when it comes to treatment, with almost half (44%) supporting the introduction of a ‘fat tax’ and over a third (38%) agreeing that the NHS should not prioritise people who fail to look after their health. But, despite this apparent support for penalties, we still readily admit that we aren’t leading healthy lifestyles. Less than one in five claim to adhere to Government guidelines on calorie intake (18%) and exercise (19%). Just one in three (34%) follow official guidelines on alcohol consumption. Experts claim this apparent ambivalence to today’s guidelines will force Government to take a new, prescriptive approach.

Trevor Matthews, Chief Executive Officer of Friends Provident, said:

“Our report reveals that there will be a fundamental and permanent change in the provision of free healthcare in the next decade. The study identifies a disconnect between our aspirations for healthcare, and our behaviour.

We all need to adopt healthier lifestyles or else risk being faced with penalties in the years ahead.”

“We all know that we should follow a healthy low fat diet, eat at least 5-a day etc. But how many actually do anything about it? Unless an unhealthy diet and lifestyle is penalised in some way no-one will change.”

As well as penalties, experts consulted for the report predict that a range of treatments will no longer be free in 2020, including:

• IVF and fertility treatment
• Subsidised dental treatment
• Obesity surgery and drugs
• Dementia treatment
• Complementary therapies

Dr Patricia Macnair, a medical practitioner consulted for the report said:

“There will be less and less money coming from the state to help people maintain their health, so something needs to give, and increasingly it will be up to us to take responsibility for our own health. In addition there will be endless paring away in subtle degrees at the funding for all sorts of different treatments – although this may be subtle the changes will be profound.”

Scottish doctors say ‘Minimum pricing for alcohol only credible option available’

Commenting in advance of a cross party meeting of Scottish politicians to discuss areas of consensus on alcohol policy, Dr Brian Keighley, Chairman of the BMA in Scotland, said:

“I am pleased that the political parties are coming together to discuss alcohol policy but it will not be possible to reach consensus until public health is put before party politics.

“So far, none of the major opposition parties have brought forward credible alternatives to minimum pricing, which modelling has shown could save hundreds of lives, reduce alcohol related illness and harm and cut alcohol consumption by around 5%.

“The NHS is buckling under the pressure of having to pick up the pieces of Scotland’s drinking culture which has largely been driven by cheap, strong alcohol.

“Consensus must be based on evidence-based policies and the BMA calls on the political parties to support minimum pricing or present an equally effective policy.”

Source: BMA Scotland Public Affairs Office

More than 100 children a week contact Childline with worries about their parents’ drinking or drug use

Worries about parental alcohol or drug use account for just under one third of all calls from children to Childline, the helpline provided by the NSPCC, concerning parental behaviour. Some of the calls are from children as young as five years old.

The figures are derived from an analysis of the calls made to the helpline in the year between April 2008 and March 2009. In the year, 4,028 children (21% of all callers [18,983] with a concern about a significant other) were counselled by ChildLine with concerns about their parents’ alcohol misuse. This number consisted of 2,867 girls and 1,161 boys. Alcohol problems were the largest concern mentioned regarding parents.

In addition, 2,284 children (12% of all callers about a parental drug misuse concern) were counselled by ChildLine with concerns about their parents’ drug misuse. This number consisted of 1,639 girls and 645 boys.

Calls to ChildLine from children who talked about parental alcohol and drug misuse represent 4 per cent of all (156,729) children counselled by ChildLine. Alcohol and drug concerns make up 33% of the total concerns given by children for their parents.

Altogether, the NSPCC helpline received more than 150,000 calls during the year. Although concerns about parental drug and alcohol use made up only a small percentage of them, the head of ChildLine, Sue Minto, said: “The fall-out from parental drug and alcohol abuse is a ticking timebomb in many children’s lives. It is vital these children are helped before lasting damage occurs.”

Ms Minto said that some children told ChildLine about their parents’ severe mood swings, episodes of violence and emotional instability.

Some said their parents were regularly sick and that caring for them had affected their schooling, or prevented them forming friendships with other children.

Ms Minto added that children affected by parental alcohol and drug problems were at more risk of harm than other children and ways needed to be found of helping them sooner.

“But we must also remember they can be fiercely protective of their parents,” she added.

“One young girl’s first comment to the ChildLine counsellor was: ‘I don’t want anything to happen to my mother’.”

Key findings

Children who were counselled by ChildLine about their parents’ alcohol and drug misuse often also talked about their experiences of physical abuse, family relationship problems, neglect and sexual abuse.

Children talked about being worried, frightened and confused by their parents’ alcohol and drug misuse.

Children often took on a caring role and saw it as their responsibility to solve their parents’ alcohol and drug misuse problems.

Throughout this report we use the terms “parents” and “parental” interchangeably to mean either/both parent(s), carers and others with parental responsibility. This person is usually the child’s mother or father.

Almost twice the number of children were counselled by ChildLine about their parents’ alcohol misuse than about drug misuse.

Children who were cared for by habitual alcohol or drug users could be inducted to rely on alcohol and drugs in order to cope with life’s challenges.

Children talking to ChildLine about parental alcohol and drug misuse.

How children describe the problems:

“My mum drinks all the time and leaves me alone lots of times. I feel scared and lonely. I look after my mum when she drinks. I put her to bed. Mum shouts and hits me; she is worse on a Friday. I don’t want to feel pain. I want to die.” (Angel, aged 10)

“My mum and dad don’t feed me. I have to steal money from people so I can get food. When I cry, Mum and Dad hit me. They are drinking all the time. I can’t tell anyone because I am scared my mum and dad might do something and hit me.” (Jonathan, aged 10)

“I live with my mum and her boyfriend. They both take drugs. I am worried they might die. My mum makes tea and then smokes drugs. She shouts at me. I feed my baby sister. I see my dad every two months and he takes drugs.” (Sarah, age unknown)

“I want to run away from home. Both my parents use drugs and alcohol and they fight. My mum brings men home all the time. I really hate their way of living and would like to get away. I did try to get away with my sister but my sister is partly disabled so she couldn’t keep up and we came back home. I am really unhappy to be left alone in the house all night.” (Sanjay, aged 14)

The alcoholic beverage industry’s use of new media ‘a cause for concern’

The alcohol industry’s use of new media channels to market alcohol is a clear cause of concern due to their youth appeal, relative lack of regulation and the sheer volume of promotional messages.

This is the main conclusion of an investigation into the use of new digital media undertaken by the Institute for Social Marketing at Glasgow University for Scottish Health Action on Alcohol Problems (SHAAP), the body established by the Scottish Medical Royal Colleges and Faculties to raise awareness about the high levels of alcohol harm in Scotland and to advocate for evidence based solutions to reduce this harm.

New media are digital forms of communication such as the internet, mobile devices, electronic games, blogs and podcasting. These media are fast-growing and rapidly evolving channels for marketing communications, which represent a departure from traditional forms of media (e.g. print, radio and television). New media offer advertisers a range of innovative and powerful channels to interact with consumers.

These channels (e.g. text messages, social networking or blogging sites) are recognised as having particular appeal to young people. These channels also include e-mail newsletters and promotions, online competitions and downloadable features such as branded MSN icons, wallpapers, cocktail recipes, barfinders and nightlife guides. The report examines the ways in which alcohol producers can use these diverse and increasingly sophisticated new media channels as a powerful means to interact and engage with consumers.

However, the report comments that a key point to note is that new media marketing is not simply replacing traditional alcohol marketing channels; rather it is an extension of alcohol marketing activities. Alcohol brand websites, for example, allow alcohol producers to extend the reach of expensive television advertising campaigns by providing a facility for these adverts to be viewed online. These television adverts can then also be found on video sharing sites such as YouTube, even if they have been banned by the ASA from television broadcast. While alcohol producers may not upload these video clips to YouTube, there is no need for them to do so since users do this for them. It is a matter of concern that television adverts streamed on YouTube for alcohol brands are frequently cited as being most popular with those who are underage (ie. 13-17 years).

Viral marketing campaigns are used by alcohol producers to facilitate the adoption of brand values by consumers who will, in turn, distribute these messages within their social networks. Consumers are encouraged to upload their own photographs, stories and comments to alcohol brand websites and social networking sites. There is considerable evidence of consumers developing their own alcohol brand-related pages and groups on social networking sites, using branded images, and doing so in a way which celebrates irresponsible, excessive and underage consumption.

Further, much of the material contained within alcohol brand websites and social networking sites contravenes the spirit of the CAP Codes on alcohol advertising by appealing to youth, social success, masculinity and femininity. Indeed, viral marketing campaigns are inherently linked to social success and social acceptance since they thrive upon the existence and development of social networks. The 2008 Alcoholic Drinks Advertisements Compliance Survey by the ASA reported that alcohol advertising was 100% compliant with the regulations. However, this may say more about the regulations than alcohol advertising using new media channels; brand websites and pages on social networking sites are not currently covered by CAP Codes.

The extensive use of new media to market alcohol represents a proliferation of alcohol branded messages directed towards consumers. The cumulative impact of such an extensive range of marketing communications has the potential to contribute to the normalisation of alcohol consumption, while responsible drinking messages are lost in amongst the volume of exposure to other messages. Thus, both the volume and content of alcohol advertising must be addressed. The current system of regulation continues to rely upon self-regulatory codes, which focus primarily on content rather than volume and exposure to alcohol advertising.

Recommendations

• Based on the ISM report, SHAAP calls on the four governments of the UK to:

• Subject alcohol brand websites to CAP Codes and all online alcohol adverts to a pre-vetting process in keeping with broadcast adverts with immediate effect.

• Move towards ending self-regulation – regulation should be independent of the alcohol and advertising industries.

• Move towards a complete ban on alcohol promotion on social networking sites.

• Involve young people in the process of regulation given the rapidly evolving nature of new media.

Brooks, O, 2010: ‘“Routes to Magic” – The Alcoholic Beverage Industry’s use of new media in alcohol Marketing’; Institute for Social Marketing, University of Stirling and The Open University

Rowntree reviews ethnicity and alcohol

Individuals from certain minority ethnic groups have historically reported lower rates of drinking and fewer people from minority ethnic groups present to alcohol services for problems related to alcohol misuse.

However, some research has shown that patterns of drinking in second generation minority ethnic groups may alter, becoming similar to the drinking habits of the general population, whilst the drinking patterns of the first generation minority ethnic groups continue to resemble those from their country of origin. A new report from the Joseph Rowntree Foundation, ‘Ethnicity and alcohol: a review of the UK literature’, looks at whether rates of alcohol use are actually changing among ethnic groups, and examines the possible impact of changes in drinking behaviour on the nature and level of support services required.

Key points arising from the report are:

• Most minority ethnic groups have higher rates of abstinence and lower levels of drinking compared to people from white backgrounds.

• Abstinence is high amongst South Asians, particularly those from Pakistani, Bangladeshi and Muslim backgrounds. But Pakistani and Muslim men who do drink do so more heavily than other non-white minority ethnic and religious groups.

• People from mixed ethnic backgrounds are less likely to abstain and more likely to drink heavily compared to other non-white minority ethnic groups.

• People from Indian, Chinese, Irish and Pakistani backgrounds on higher incomes tend to drink above recommended limits.

Over time generational differences may emerge:

• Frequent and heavy drinking has increased for Indian women and Chinese men.

• Drinking among Sikh girls has increased whilst second generation Sikh men drink less than first generations.

• People from some ethnic groups are more at risk of alcohol-related harm:
  • Irish, Scottish, and Indian men, and Irish and Scottish women have higher than national average alcohol-related deaths in England and Wales.
  • Sikh men are over-represented for liver cirrhosis.
  • People from minority ethnic groups have similar levels of alcohol dependence compared to the general population, despite drinking less.

• Services are reportedly not responsive enough:
  • Minority ethnic groups are under-represented in seeking treatment and advice for drinking problems.
  • Problem drinking may be hidden among women and young people from South Asian ethnic groups in which drinking is proscribed.
  • Greater understanding of cultural issues is needed in developing mainstream and specialist alcohol services.

A copy of the report can be downloaded from: http://alcoholreports.blogspot.com/

St Mary’s Alcohol Health Work Project named HubCAPP project of the year

The Alcohol Health Work Project at St Mary’s Hospital, Paddington, has been named as the winner of the inaugural ‘HubCAPP Project of the Year’ 2009, an award which ‘recognised the project that has had an impact on the health and wellbeing of the community’.

The HubCAPP (Hub of Commissioned Alcohol Projects and Policies) awards, launched in 2009, were shortlisted and voted on by members of the public and professionals working in the field. The Hub focuses on identifying and sharing local and regional practice regarding alcohol harm reduction and also collects information on needs analysis and strategic planning.

Alcohol Health work at St Mary’s hospital began in 1988 and has developed through extensive research and practice, leading to the appointment of a full-time Alcohol Nurse Specialist (ANS) at St Mary’s Hospital Trust in 2005.

The team developed the Paddington Alcohol Test (PAT) (available to view here – www.sips.iop.kcl.ac.uk/download.php?id=132), a clinical tool used to screen patients who present with the top 10 reasons associated with alcohol misuse (including areas such as falls, collapse, head injury and other medical the relationship between attendance at A & E and drinking. They refer to this conditions) and which asks questions about their levels of alcohol consumption.

The Paddington Alcohol Test (PAT) is at the heart of the Alcohol Health Work Project. Doctors and nurses use PAT to highlight to the patient as the ‘teachable moment’ (Patton et al, 2004) and aim to use it advantageously to combat hazardous and binge drinking.

Patients who screen as positive on the PAT are referred on to an A & E Alcohol Health Work session run by the Alcohol Nurse Specialist, who sees patients from across the wards as well as A & E and who has developed alcohol withdrawal management protocols for the hospital. At this session, the ANS provides a patientcentred assessment of alcohol issues, discusses the impact of alcohol use with the patient and provides further information or referral in order to encourage the patient to reduce their consumption, where appropriate. The ANS can also give brief advice about drinking and provide alcohol information leaflets. For every two patients who accept such an appointment, it has been found that there is one fewer re-attendance at A & E over the next year.

The Alcohol Nurse Specialist also accepts direct referrals from other wards in the hospital and provides several key services, including:

• Alcohol withdrawal management
• A review of St Mary’s alcohol guidelines and protocols
• Advice and support for ward staff
• Psychiatric liaison where dual diagnosis is an issue
• Brief assessment of substance misuse
• Referral to community alcohol services

The St Mary’s team have published their findings extensively and have also helped to replicate the system in other hospitals across England

‘The St Mary’s team demonstrate leadership in the field and provide high quality patient care’

‘St Mary’s was the first hospital to do this work and it has been used as a model for the development of similar services in other areas’

Professor Robin Touquet, Consultant in A & E Medicine, St Mary’s Hospital

‘We are delighted that St Mary’s work has been recognised. This highlights the investment happening countrywide with the roll out of Alcohol Nurse Specialists, many duplicating the St Mary’s model, and incorporating the Paddington Alcohol Test.’

Don Shenker, Alcohol Concern

‘This project has shown how a moment of crisis can be turned into an opportunity to help people change their lives for the better. Every day the work of St Mary’s is making a difference to the lives of people up and down the country’

HubCAPP, an online resource of local alcohol initiatives throughout England was commissioned by the Department of Health and is managed by Alcohol Concern. HubCAPP is also part of the Department of Health’s Alcohol Improvement Programme and is a sister site of the Alcohol Learning Centre.

Book Review – Tackling Addiction, Pathways to recovery – edited by Rowdy Yates and Margaret S Malloch

Reveiwed by By Dr Amul Patel, Specialty Registrar (ST5) in Addictions Psychiatry, Royal Edinburgh Hospital

‘Recovery’ is currently a topical and debated subject in the field of addiction. The Scottish Government has embraced recovery in its latest drug strategy: The Road to Recovery: A New Approach to Tackling Scotland’s Drug Problem. We may also see a similar move in the UK’s drug policy following recent change of government. This book’s stated aim is to contribute to the ongoing debate on recovery with an intention to inform the way forward for policy and practice in this area.

This is an edited book authored by experienced academics, researchers, professionals, clinicians, and service users with a broad range of expertise in addiction, criminal justice, psychology, psychiatry, service development and management, and sociology. It is a compilation of themes which emerged from a seminar series at the University of Stirling which brought together experts to examine various approaches to recovery and consider the relationship of these approaches to the broader policy context. Although the content of the book has a Scottish flavour, the themes discussed are relevant to the UK. The book is relevant for practitioners, researchers, policy makers and students in the fields of addiction, social care, psychology, and criminal justice.

The concept of recovery may have different connotations for the public, professionals and policy makers. The book begins with a discussion of various definitions of recovery and emphasises the importance of individual meaning and the holistic process. It moves on to describe a brief history of recovery, the new recovery movement and the emerging evidence base for the approach. It describes a recovery model by William White in the United States who has suggested three critical elements: sobriety, improvement in global health, and citizenship. The model acknowledges the place of treatment in the early phase of the recovery journey but emphasises much more the social location of the process. It underscores the need for a paradigm shift from an acute care model to the long-term approach.

The middle section of the book explores themes on recovery within projects, women and recovery, and the therapeutic community as a recovery-oriented treatment pathway. The chapters on recovery-oriented integrated systems in North West England and the Ley community, an addiction therapeutic community in Oxfordshire, give a useful insight in to how such systems can be commissioned and provided. The later chapters highlight implications for practitioners and also discuss the concept of recovery in the context of UK drug policies and criminal justice system. The book argues that in recent years, evidence has been used selectively to explain drug use as a crime problem rather than public health problem. It also examines the extent to which drug treatment and testing orders contribute towards promoting recovery. The longest chapter of the book explores the experiences of individuals ‘in recovery’, which I found fascinating. It instils optimism that individuals do recover from chronic and relapsing nature of addiction. This, along with its inclusion of hard-to-come-by information on women in recovery, makes the book unique.

Though the book covers disparate themes, its repeated emphasis on the definition of recovery is evident throughout. It is concise and does not intend to be comprehensive. It provides a starting point on the subject of recovery in addiction. It is easy to read but the style and content of chapters vary according to the theme and the background of the author. The discussion on the limitations of the recovery approach is sketchy and it does not appear to adequately acknowledge the process of recovery in non-abstinence based models.

The book does appear to succeed in its critique of current UK drug policies and criminal justice system which are described as somewhat less than favourable to the recovery oriented approach. It contrasts policies based on the public health (harm reduction) perspective with the person-centred approach of the recovery model and succeeds in stimulating thoughts on that subject. It is useful in understanding the recovery standpoint but the reader would have been benefitted by case examples from professionals’ perspectives depicting how the process of recovery could be facilitated at grassroot level and how service users could be helped to be ‘on top’ of the process.

The book aspires researchers to be creative in finding academically credible ways of studying pathways and models of recovery, as described by one of its authors: ‘We are riding on a wave of enthusiasm and optimism at present – it is essential that this is translated into meaningful change and evidence’.

Tackling Addiction: Pathways to Recovery – Edited by Rowdy Yates & Margaret S. Malloch, Jessica Kingsley Publishers, 2010. £22.99 (pb). 192pp. ISBN: 9781849050173