Alcohol-use disorders: prevention

The PDG agreed that the state has a duty to look after the welfare of the population as a whole (Nuffield Council on Bioethics 2007). This includes protecting it from the range of problems that may be caused by alcohol. The PDG believes interventions to prevent alcohol-related harm are likely to improve the population's overall wellbeing and productivity. It also believes they will help reduce health inequalities, as alcohol-related problems have a disproprotionate effect on disadvantaged groups.

The PDG believes both population-wide and individual interventions are needed as part of a combined approach to reducing alcohol-related harm that will benefit society as a whole. Population-level approaches are very important because they can help reduce the aggregate level of alcohol consumed and therefore lower the whole population's risk of alcohol-related harm. They can help those not in regular contact with relevant services. They can also help reduce the number of people who start drinking harmful or hazardous amounts in the first place. In addition, they may help those who have been specifically advised to reduce their alcohol intake, by creating an environment that supports lower risk drinking.

The PDG acknowledges that some people drink alcohol as a result of underlying problems. Clearly, these need to be addressed along with any alcohol-related issues.

The PDG recognises that a large percentage (76%) of the population drinks alcohol at a level that is unlikely to cause risk to themselves or others. However, for others, alcohol is associated with many detrimental outcomes. In his 2008 annual report, the Chief Medical Officer highlighted that alcohol can affect not only the person drinking but those around them, including their families and the wider population.

For example, each year, drinking adversely affects up to 1.3 million children and leads to over 7,000 road accident injuries and 17 million lost working days. It may also be a contributory factor in up to 1 million assaults and is associated with 125,000 instances of domestic violence (DH 2009). The PDG therefore believes that interventions to address alcohol-related harm should take these wider consequences into account.

Although there is evidence that alcohol may reduce the risk of certain cardiovascular diseases, these effects are limited to men over the age of 40 and postmenopausal women who drink small amounts. Overall, the evidence suggests that drinking alcohol is never without risk and that, as consumption increases so does the risk of developing an alcohol-related problem. An increase in per capita alcohol consumption is associated with an increase in related deaths.

The PDG believes that most of the recommendations will have a greater impact on those who drink irresponsibly. However, taken together, they are very likely to improve the health of the population as a whole. As indicated by the Rose hypothesis, a small reduction in risk among a large number of people may prevent many more cases, rather than treating a small number at higher risk. A whole-population approach explicitly focuses on changing everyone's exposure to risk (Rose 2008). In this instance, the number of people who drink a heavy or excessive amount in a given population is related to how much the whole population drinks on average. Thus, reducing the average drinking level, via population interventions, is likely to reduce the number of people with severe problems due to alcohol.

The PDG felt that a population-level approach to preventing alcohol-related harm could be as effective as legislation to address drink-driving had been. The latter was based on a much more limited evidence base than the proposals in these recommendations. In this case, there is extensive and consistent evidence in favour of a population-level approach on alcohol.

The PDG has not been able to consider all the population-wide actions needed to reduce alcohol-related harm. For example, it did not consider the provision of information on product labels and at the point-of-sale on the alcoholic content of drinks and the risks related to different levels of consumption. (This is in line with a proposed amendment to the Food Safety Act 1990 [Home Office 2009]). Other issues that have not been considered include: wider dissemination of information on alcohol units and related health information (for example, within the workplace); the provision of non-alcohol related activities for young people; and the introduction of mandatory conditions for the responsible sale of alcohol.

The PDG feels that these are all important areas that need to be tackled, in conjunction with the recommendations made in this guidance.

Making alcohol less affordable is the most effective way of reducing the harm it causes among a population where hazardous drinking is common – such as in the UK (Chisholm et al. 2004). There is extensive evidence (within the published literature and from the economic analysis undertaken to support this guidance) to justify the introduction of a minimum price per unit. For example, the evidence suggests that young people who drink and people (including young people) who drink harmful amounts tend to choose cheaper alcoholic products. Establishing a minimum price per unit would limit the ability of these groups to 'trade down' to cheaper products. The same effect would be more difficult to achieve through alcohol duties, as retailers or producers may absorb the cost of any extra duty levied.

Prohibiting 'below cost' selling would ensure any price increases (for example, through taxation) are passed on in full. However, a large increase in duty would be needed to raise the price of the cheapest products to a level that would reduce alcohol harm. Unlike a minimum price per unit, this would affect all products equally rather than focusing on cheaper and stronger goods.

A minimum price per unit (unlike a tax increase) would prevent retailers from passing on any increase to producers, or absorbing it themselves. It would also encourage producers to reduce the strength of products. As an example of the effect of minimum pricing, over a 10-year period it is estimated that a 50p minimum price per unit would reduce the cost of alcohol-related problems by £9.7 bn.

The PDG is aware of concerns that introducing a minimum price per unit for alcohol would have an unfair impact on people who are from disadvantaged groups. The reality is, however, that alcohol problems are not evenly distributed throughout society. Evidence shows that people from disadvantaged groups experience more health problems than others as a result of their alcohol use. They are also affected more when others around them consume excessive amounts. The PDG concluded that the overall benefits of introducing and maintaining a minimum price for alcohol would far outweigh any perceived disadvantage to lower income groups.

Although the introduction of a minimum price per unit of alcohol would prevent low cost promotions, it would not affect other types of alcohol promotion. The PDG, therefore, strongly supported the government's mandatory code on retailing which included a ban on irresponsible promotions.

Introducing a minimum price per unit of alcohol might lead to price promotions on other products that could, in turn, offset the impact of any alcohol price increases for many consumers. The PDG also noted that alcohol price increases are factored into the 'Retail prices index' which, in turn, influences the index-linked increases in state benefits and allowances for lower income groups.

International evidence suggests that making it less easy to buy alcohol, by reducing the number of outlets selling it in a given area and the days and hours when it can be sold, is an effective way of reducing alcohol-related harm. Changes to the current licensing provisions will enable members of licensing authorities to be an interested party. However, the Licensing Act does not, as it stands, cover public health considerations. Making this kind of change to the current licensing provisions may result in some initial implementation difficulties. However, the PDG believes that the long-term benefits would outweigh any immediate difficulties.

The PDG noted the recent legislative changes in Scotland, where the protection and improvement of the public's health has been included within the licensing objectives.

Increasing the price of alcohol, or reducing its accessibility, may lead to an increase in the amount of alcohol imported from abroad (both legal and illegal imports). The PDG considered that the current personal alcohol import allowance could undermine the introduction of a minimum price per unit for alcohol.

Evidence from a systematic review of 132 studies finds a clear and consistent relationship between advertising expenditure and alcohol consumption, across the whole population. However, the median effect is very small, possibly due to the limited variation in advertising expenditure, which restricts the range of effects that are available for analysis. A greater variation might have produced larger effects. There is limited evidence relating to a complete ban on advertising. However, there is evidence that bans on tobacco have had an impact on tobacco consumption and the PDG considered that this issue merited further consideration.

There is strong evidence that alcohol advertising affects children and young people. The data show that exposure to alcohol advertising is associated with the onset of drinking and increased consumption among young people who already drink.

The PDG is aware of the role of the Advertising Standards Authority (ASA) in monitoring the self-regulation code for alcohol advertising within the UK. It noted recent positive changes to the advertising code. It also noted the findings from a recent Ofcom and ASA report which assessed the impact of these changes. The report found that young people recalled fewer advertisements and were less likely to say that they were aimed at them. However, they were also more likely to say that the adverts made alcohol look appealing and would encourage people to drink.

The PDG recognised that a complete ban would be needed to fully protect children and young people from alcohol advertising. However, this strategy would also affect adults, for whom there is less evidence of an adverse impact. Hence the PDG concluded that there should be a cost-benefit assessment of the impact of an advertising ban. In the meantime, it felt there was potential for the appropriate bodies to strengthen current regulations. The Group believes that a balanced, realistic portrayal of alcohol by the media (illustrating the negative consequences of excessive alcohol consumption) would be a helpful move.

The PDG noted that product placement (a form of advertisement, where branded goods are placed within television programmes) may soon be allowed on commercial television. In view of the increase in health-related harms from alcohol in recent years, and the need to protect children from alcohol advertising, the PDG did not think it appropriate for alcohol to be included in this.

The PDG acknowledges the importance of 'World class commissioning', 'Vital signs operating frameworks' (VSOF) and commissioning strategic plans (CSP) when developing services. 'World class commissioning' emphasises the importance of ensuring patients' views are taken into account when making commissioing decisions.

Many people attending health and other public and voluntary sector services will benefit from the recommendations on screening and brief alcohol interventions –not just those who are seeking treatment for alcohol-related problems. The benefits of using a brief intervention are most clearly seen when it is used with people who are unaware that alcohol is compromising their mental or physical wellbeing. This approach may also help those people who may be aware that their drinking is harming either themselves or others, but are ambivalent about cutting down. NICE is producing 2 complementary pieces of guidance which, in conjunction with this publication, will provide advice on how to support these groups.

Healthcare professionals are well placed to identify and help people with alcohol-related problems. There is strong evidence to show that many people benefit from brief advice provided by healthcare professionals who are not alcohol specialists.

The PDG noted the benefits of local area agreements that identify and tackle the wider determinants of health within local communities.

The PDG acknowledges the important role of the voluntary sector in helping to deliver the recommendations made in this NICE guidance.

Research on alcohol screening and brief interventions in primary healthcare and emergency departments has not been widely replicated in other health or social care settings. Nevertheless, the PDG believes evidence from other areas (such as educational settings) clearly shows that it is worthwhile for healthcare professionals outside primary care – and non-healthcare professionals – to carry out these interventions.

Many of those working in public services (such as social care, criminal justice, higher education, occupational health and children's services) have contact with people who are drinking a hazardous or harmful amount. The PDG believes these professionals are well-placed to help – and that many of their clients would benefit.

The PDG is aware of the importance of ensuring service delivery is coordinated (for screening, brief interventions and referrals) so that people can receive the appropriate level of care.

Where possible, the recommendations for practice refer to explicit and easily available intervention protocols. The aim has been to maintain standards by encouraging the use of interventions that have been evaluated and have been shown to be effective.

A number of intervention packages offer a coordinated collection of evidence-based materials for use when screening and carrying out a brief intervention. They usually consist of:

• a short guide on delivery

• a screening questionnaire

• visual material (clarifying the risks or harm caused by alcohol consumption and showing people how their drinking compares with the rest of the population)

• practical suggestions on how to reduce alcohol consumption

• a self-help leaflet

• an optional poster for display in waiting rooms.
  
  An example is the 'Drink-less pack', which was used and evaluated in the WHO series of studies on brief interventions (Centre for Drug and Alcohol Studies 1993). Another is the 'How much is too much?' pack, which was based on the Drink-less pack but is specifically tailored for the UK (Institute of Health and Society 2006), and has been used by the DH for training.

The PDG acknowledges that public finances, especially NHS and local authority funding, may be subject to constraints. However, it concluded that the public sector savings realised in the long term by investing in alcohol misuse prevention and intervention will be significant.

The PDG noted that the Chief Medical Officer has called for an alcohol-free childhood up to the age of 15. Young people are particularly vulnerable to alcohol and the harm it causes, because they are still developing both physically and emotionally. They may also be drinking in unsupervised situations and in 'unsafe' environments (parks and street corners) where problems are more likely to occur. The PDG noted that young people may have underlying problems which may cause them to drink alcohol and that these need to be addressed. For example, their behaviour in relation to alcohol may be indicative of underlying difficulties within the family, school or elsewhere.

Inevitably some children and young people will drink alcohol and the PDG felt it was necessary to provide guidance on how to help this group. While developing the recommendations, the PDG took into account other NICE guidance that addresses alcohol use among this age group.

The problems young people aged under 16 may face and their susceptibility to alcohol will vary greatly. For example, a young person aged 10 is different, both physically and emotionally, to someone aged 15. In addition, young girls and boys develop at a different rate (girls often experience puberty earlier than boys). Girls who drink at an earlier age may be more likely to take risks with their sexual health, while boys may be more likely to have accidents or experience a trauma. Thus, it takes professional judgement to decide how to deal with children and young people who drink early in life.

The PDG noted that, in keeping with Gillick and Fraser principles (see below) it is important for professionals to encourage vulnerable young people to include their parents or guardians in any professional intervention. It is also important that professionals are aware of child safeguarding, consent and confidentiality issues. It is likely that a proportion of young people will have intellectual or other developmental difficulties that will require parental or carer involvement.

The Gillick principle is: "As a matter of law the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to understand fully what is proposed" per Lord Scarman. In terms of determining the competence of a young person to consent to treatment, a clinician needs to apply the Fraser guidelines. These were laid down by Lord Fraser and require the professional to be satisfied that:

• the young person will understand the professional's advice

• the young person cannot be persuaded to inform their parents

• the young person is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment

• unless the young person receives contraceptive treatment, their physical or mental health, or both, are likely to suffer

• the young person's best interests require them to receive contraceptive advice or treatment with or without parental consent.

Although the Fraser guidelines specifically refer to contraception, the principles are deemed to apply to other treatments. In addition, although the judgment in the House of Lords referred specifically to medical practitioners, it is considered to apply to other health professionals, including nurses.

The Advisory Council on the Misuse of Drugs (ACMD) 'Hidden harm' report provides strong evidence of the impact of parental drug misuse on children and the steps required to address this. There has been no equivalent study of the impact of parental alcohol misuse on children (ACMD 2003).

Screening is a systematic process of identifying people whose alcohol consumption places them at increased risk of physical, psychological or social problems and who would benefit from a preventive intervention. Questionnaire-based screening is accurate, minimally intrusive and has been found to be acceptable to recipients. It is also considerably cheaper than using physiological tests to detect alcohol-related problems (Wallace 2001).

The 'Alcohol-use disorders identification test' (AUDIT) was the first screening tool designed specifically to detect hazardous and harmful drinking (Saunders et al. 1993). It has been validated in a number of health and social care settings and across a range of drinking cultures (Reinert and Allen 2007). This 10-question screening tool asks about drinking frequency and intensity and covers experience of alcohol-related problems and signs of possible dependence. AUDIT can detect 92% of genuinely hazardous and harmful drinkers and excludes 93% of those who are not. It is regarded as the 'gold standard' screening questionnaire for detecting hazardous and harmful drinking.

'Hazardous' and 'harmful' drinking are medically defined terms that have been used extensively in the scientific literature and in many recommended tools. 'Harmful use of a psychoactive substance' is an official term in the World Health Organization's (WHO) 'International classification of diseases' (10th revision). 'Hazardous use of a psychoactive substance', while not an alcohol-use disorder in itself, is included in WHO's 'Lexicon of alcohol and drug terms' (1994).

It is also useful to define drinking behaviour in terms of the types of risk associated with it. The DH has recently used the terms lower risk, increasing risk and higher risk drinking. This unit-based approach complements the medically-defined terms described above. For the purposes of this guidance, 'increasing risk' equates with 'hazardous drinking' and 'higher risk' equates with 'harmful drinking'.

In addition, categories of risk in relation to alcohol consumption may be defined by scores used in the 'Alcohol use disorders identification test' (AUDIT). These are as follows: 1–7: low-risk drinking; 8–15: hazardous drinking; 16–19: harmful drinking; 20+: possible dependence. For simplicity and convenience, the terms 'hazardous' and 'harmful' are used in this guidance (Room et al. 2005).

Even with just 10 questions, the full AUDIT questionnaire has been considered too lengthy for use in routine practice. Thus several shorter versions of AUDIT have been developed. These comprise between 1 and 4 questions. Generally, they are less accurate than the full AUDIT and do not clearly differentiate between hazardous, harmful and possibly dependent drinking.

Different factors may make some people more vulnerable to alcohol than others and this can affect the precision of some screening tools. These factors can include lower body weight, inexperience in handling the psychological effects of alcohol being less able to metabolise it or being more susceptible to its adverse effects.

Women are more vulnerable to the effects of alcohol than men and younger and older people tend to be more vulnerable than those who are middle-aged. In addition, some black and minority ethnic groups are less able to metabolise alcohol than caucasians. In such cases, lower cut-off points on screening tools may need to be applied.

Reducing the cut-off point on a screening tool will increase its sensitivity (that is, the ability to identify truly positive cases of hazardous or harmful drinking). However, this can be at the expense of specificity (the ability to accurately exclude those who are not drinking a hazardous or harmful amount). Thus, professional judgement may be needed before screening cut-off points can be altered. It is for this reason that the PDG has not recommended specific (lowered) cut-off points on various screening tools.

Professional judgement is needed to decide on any additional support that should be offered to vulnerable groups who are identified as being hazardous or harmful drinkers. This includes:

• women (in particular those who are, or are thinking of becoming, pregnant)

• younger people

• people aged 65 and over

• people from some black and minority ethnic groups.

The PDG recognises that a language-based screening questionnaire may not be the most appropriate tool for certain groups. This includes those whose first language is not English and people with learning disabilities or cognitive impairment. How best to establish whether people in these groups are at risk from alcohol or are experiencing alcohol-related harm will be a matter of professional judgement.

There are 2 main types of brief intervention: structured brief advice or extended brief intervention. Nearly all of the latter are based on the principles and practice of 'motivational interviewing' (Miller and Rollnick 2002).

Evidence shows that brief advice is effective where time is tight – even when there is only 5 minutes available. The evidence is mixed on the additional benefit of providing extended brief interventions in healthcare settings. Thus brief advice is recommended as a first step for adults (aged 18 and over) who have been identified as drinking at hazardous or harmful levels. If brief advice does not lead to a reduction in hazardous or harmful drinking (or if an individuals wishes further input) then an extended brief intervention, including motivational interviewing, has been recommended (see recommendations 8 and 11).

Most extended brief interventions that have been evaluated in research are short versions of motivational interviewing. Examples include the 'Drinker's check-up' (Miller et al. 1988), consisting of 1 assessment session and 1 feedback and counselling session. Another example is 'motivational enhancement therapy', which was developed as a four-session intervention in 'Project MATCH' in the USA (Miller et al. 1992). It was then adapted as a three-session intervention in the 'United Kingdom alcohol treatment trial' (UKATT Research Team 2005).

Some extended brief interventions, perhaps consisting of a single session lasting 30–40 minutes, are based on motivational interviewing principles but would not qualify as full motivational interviewing.

While the distinctions between motivationally-based interventions should be borne in mind, for the purposes of this guidance, all motivationally-based interventions are referred to as extended brief interventions.

There is limited evidence on the effectiveness of brief interventions for young people under the age of 16, with some data suggesting there could be adverse outcomes. Most of the research has been carried out among adults in healthcare settings. However, there is broadly positive evidence from educational settings (such as colleges and universities). Generally, the interventions have taken the form of motivational interviews with young people aged over 16. As a result, the PDG has recommended the use of extended brief interventions for people aged 16–17. However, it is not clear from current evidence if this type of brief intervention can be adapted for younger people.

In motivational interviewing, the practitioner establishes the client's readiness to change and it helps them to make their own decisions with regard to their alcohol use. Some young people may not have the language skills to partake in a motivational interview. In addition, it may not be appropriate to emphasise to those who may need external direction and indeed, safeguarding, that they have a choice. For more mature young people (that is, those who are 'Gillick-competent'), however, the PDG judges that it is appropriate to extrapolate the evidence from educational settings to health and social care settings, especially as part of a response to meeting their identified needs. But as noted elsewhere, intervening with those below 16 years generally requires efforts to include parents or carers.

A brief intervention will address many people's alcohol-related problems. However, those who are moderately or severely alcohol-dependent are likely to need specialist help. This is also true of people who experience physical harm, such as liver damage or mental health problems, as a result of drinking alcohol. In such cases, the recommendations in this guidance should be read in conjunction with 2 complementary pieces of NICE guidance: 'Alcohol use disorders in adults and young people: clinical management' and 'Alcohol-use disorders: diagnosis, assessment and management in young people and adults'.

The PDG recognises that its recommendation to carry out formal evaluations (see recommendation 5) and routine follow-ups of alcohol interventions will change established commissioning practice. Commissioning bodies may seek partnerships with academic institutions to help design evaluation protocols. It may also be that government will provide guidance on minimum standards for comprehensive, routine evaluation and research into local alcohol treatment systems.

Although some aspects of evaluation may be cost neutral, robust evaluation and research will need specified resources. However, the PDG takes the view that evaluation will be essential in ensuring value for money in reconfigured local alcohol treatment systems.

The PDG recognised that empirical data alone, even from the best conducted investigation, seldom provides a sufficient basis for making recommendations. This data requires interpretation and analysis, using prior knowledge and understanding and existing models and theories. Therefore, the PDG developed its recommendations using the best available empirical data and inductive and deductive reasoning.

The PDG acknowledged that the traditional hierarchy of evidence does not resolve all the problems associated with empirical data. For example, while it explicates the degree of bias attributable to poor internal validity, it does not answer it completely. Nor does it deal with external validity, that is, the degree to which findings are transferable to other experimental settings or to practice. The PDG therefore looked at a broad range of evidence.