Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Population versus individual approach

A combination of interventions are needed to reduce alcohol-related harm – to the benefit of society as a whole.

Population-level approaches are 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 who are not in regular contact with the relevant services

  • those who have been specifically advised to reduce their alcohol intake, by creating an environment that supports lower-risk drinking.

They can also help prevent people from drinking harmful or hazardous amounts in the first place.

Interventions aimed at individuals can help make people aware of the potential risks they are taking (or harm they may be doing) at an early stage. This is important, as they are most likely to change their behaviour if it is tackled early. In addition, an early intervention could prevent extensive damage.

The government continues to use both individual and population approaches to address the harm caused by alcohol (for example, in its strategy 'Safe. Sensible. Social.' [Department of Health's Safe. Sensible. Social. The next steps in the national alcohol strategy (2007)]).

This NICE guidance provides authoritative recommendations, based on a robust analysis of the evidence, which support current government activities. The recommendations could form part of a national framework for action.

As highlighted by the House of Commons Public Accounts Committee, national-level action to reduce the population's alcohol consumption requires coordinated government policy. It also needs government, industry and key non-governmental organisations to work together (House of Commons Public Accounts Committee – Reducing alcohol harm: health services in England for alcohol misuse).

Policy and practice

This guidance makes the case that alcohol-related harm is a major public health problem. On the basis of the best available evidence, it also identifies the policy options that are most likely to be successful in combating such harm. The final decision on whether these policies are adopted – and how they are prioritised – will be determined by government and the normal political processes.

The policy recommendations (recommendations 1 to 3) are based on extensive and consistent evidence which suggests that the issues identified deserve close attention. This evidence also suggests that policy change is likely to be a more effective – and more cost-effective – way of reducing alcohol-related harm among the population than actions undertaken by local health professionals. Many of the policy changes considered in this guidance are similar to those proposed by the House of Commons Health Select Committee (House of Commons Health Select Committee – Alcohol first report of session 2009–10).

The recommendations for practice (recommendations 4 to 12) support, complement – and are reinforced by – these policy options. They include the use of screening and brief interventions. The latter includes structured brief advice and extended brief interventions.

For the purposes of this guidance, screening involves identifying people who are not seeking treatment for alcohol problems but who, in the view of the professional, may have an alcohol-use disorder. Practitioners may use any contact with clients to carry out this type of screening. The term is not used here to refer to national screening programmes such as those recommended by the UK National Screening Committee (UK NSC).

Recommendations for policy

Who should take action?

The Chief Medical Officer should coordinate the alcohol harm-reduction strategy for England across government, supported by the Department of Health.

The following departments and national agencies should also be involved:

  • Advertising Standards Authority

  • Department for Business, Innovation and Skills

  • Department for Culture, Media and Sport

  • Department for Education

  • Department for Environment, Food and Rural Affairs

  • Department of Communities and Local Government

  • HM Treasury

  • Home Office

  • Ministry of Justice

  • National Treatment Agency

  • Ofcom

  • Office of Fair Trading

Organisations that should be consulted include:

  • advertisers

  • alcohol producers

  • national non-governmental organisations (for example, Alcohol Concern and the Royal Medical Colleges)

  • off- and on-sale retailers.

Recommendation 1: price

Making alcohol less affordable is the most effective way of reducing alcohol-related harm. The current excise duty varies for different alcoholic products (for historical reasons and under EU legislation). This means that the duty does not always relate directly to the amount of alcohol in the product. In addition, an increase in the duty levied does not necessarily translate into a price increase as retailers or producers may absorb the cost. There is extensive international and national evidence (within the published literature and from economic analyses) to justify reviewing policies on pricing to reduce the affordability of alcohol.

What action could be taken?

  • Consider introducing a minimum price per unit. Set the level by taking into account the health and social costs of alcohol-related harm and its impact on alcohol consumption. Consider initiating a review of the excise duty regime with fellow EU member states. The aim would be to obtain a pan-EU agreement on harmonisation which links alcohol duty to the strength of each product.

  • Regularly review the minimum price per unit to ensure alcohol does not become more affordable over time.

  • Regularly review alcohol duties to make sure alcohol does not become more affordable over time.

Recommendation 2: availability

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 another effective way of reducing alcohol-related harm. In Scotland, protection of the public's health is part of the licensing objectives.

What action could be taken?

  • Consider revising legislation on licensing to ensure:

    • protection of the public's health is 1 of its objectives

    • health bodies are responsible authorities

    • licensing departments can take into account the links between the availability of alcohol and alcohol-related harm when considering a licence application (that is, they can take into account the number of alcohol outlets in a given area and times when it is on sale and the potential links to local crime and disorder and alcohol-related illnesses and deaths)

    • immediate sanctions can be imposed on any premises in breach of their licence, following review proceedings.

  • Consider reducing personal import allowances to support the introduction of a minimum price per unit of alcohol.

Recommendation 3: marketing

There is evidence that alcohol advertising does affect children and young people. It shows that exposure to alcohol advertising is associated with the onset of drinking among young people and increased consumption among those who already drink. All of the evidence suggests that children and young people should be protected as much as is possible by strengthening the current regulations.

What action could be taken?

  • Ensure children and young people's exposure to alcohol advertising is as low as possible by considering a review of the current advertising codes. This review would ensure:

    • the limits set by the Advertising Standards Authority (ASA) for the proportion of the audience under age 18 are appropriate

    • where alcohol advertising is permitted there is adequate protection for children and young people

    • all alcohol marketing, particularly when it involves new media (for example, web-based channels and mobile phones) and product placement, is covered by a stringent regulatory system which includes ongoing monitoring of practice.

  • Ofcom, the ASA and the government should keep the current regulatory structure under review.

  • Assess the potential costs and benefits of a complete alcohol advertising ban to protect children and young people from exposure to alcohol marketing.

Recommendations for practice

Recommendation 4: licensing

Who is the target population?

Alcohol licence-holders and designated supervisors of licensed premises.

Who should take action?

  • Local authorities.

  • Trading standards officers.

  • The police.

  • Magistrates.

  • Revenue and customs.

What action should they take?

  • Use local crime and related trauma data to map the extent of alcohol-related problems before developing or reviewing a licensing policy. If an area is saturated with licensed premises and the evidence suggests that additional premises may affect the licensing objectives, adopt a 'cumulative impact' policy. If necessary, limit the number of new licensed premises in a given area.

  • Ensure sufficient resources are available to prevent under-age sales, sales to people who are intoxicated, proxy sales (that is, illegal purchases for someone who is under-age or intoxicated), non-compliance with any other alcohol licence condition and illegal imports of alcohol.

  • Work in partnership with the appropriate authorities to identify and take action against premises that regularly sell alcohol to people who are under-age, intoxicated or making illegal purchases for others.

  • Undertake test purchases (using 'mystery' shoppers) to ensure compliance with the law on under-age sales. Test purchases should also be used to identify and take action against premises where sales are made to people who are intoxicated or to those illegally purchasing alcohol for others.

  • Ensure sanctions are fully applied to businesses that break the law on under-age sales, sales to those who are intoxicated and proxy purchases. This includes fixed penalty and closure notices (the latter should be applied to establishments that persistently sell alcohol to children and young people).

Recommendation 5: resources for screening and brief interventions

Who is the target population?

Professionals who have contact with those aged 16 and over.

Who should take action?

  • Chief executives of NHS and local authorities.

  • Commissioners of NHS healthcare services.

  • Commissioners from multi-agency joint commissioning groups.

  • Managers of NHS-commissioned services.

What action should they take?

  • Chief executives of NHS and local authorities should prioritise alcohol-use disorder prevention as an 'invest to save' measure.

  • Commissioners should ensure a local joint alcohol needs assessment is carried out in accordance with Public Health England's alcohol, drugs and tobacco: commissioning support pack and local alcohol services and systems improvement tool. They should also ensure locally defined integrated care pathways for alcohol treatment are reviewed.

  • Commissioners should ensure their plans include screening and brief interventions for people at risk of an alcohol-related problem (hazardous drinkers) and those whose health is being damaged by alcohol (harmful drinkers). This includes people from disadvantaged groups.

  • Commissioners should make provision for the likely increase in the number of referrals to services providing tier 2, 3 and 4 structured alcohol treatments as a result of screening. These services should be properly resourced to support the stepped care approach recommended in the Department of Health's Models of care for alcohol misusers.

  • Commissioners should ensure at least 1 in 7 dependent drinkers can get treatment locally, in line with Signs for improvement.

  • Commissioners should include formal evaluation within the commissioning framework so that alcohol interventions and treatment are routinely evaluated and followed up. The aim is to ensure adherence to evidence-based practice and to ensure interventions are cost effective.

  • Managers of NHS-commissioned services must ensure an appropriately trained nurse or medical consultant, with dedicated time, is available to provide strategic direction, governance structures and clinical supervision to alcohol specialist nurses and care givers.

  • Managers of NHS-commissioned services must ensure community and voluntary sector providers have an appropriately trained professional who can provide strategic direction, governance structures and supervision to those providing screening and brief interventions.

  • Managers of NHS-commissioned services must ensure staff have enough time and resources to carry out screening and brief intervention work effectively. Staff should have access to recognised, evidence-based packs. These should include: a short guide on how to deliver a brief intervention, a validated screening questionnaire, a visual presentation (to compare the person's drinking levels with the average), practical advice on how to reduce alcohol consumption, a self-help leaflet and possibly a poster for display in waiting rooms.

  • Managers of NHS-commissioned services must ensure staff are trained to provide alcohol screening and structured brief advice. If there is local demand, staff should also be trained to deliver extended brief interventions.

Recommendation 6: supporting children and young people aged 10 to 15 years

Who is the target population?

Children and young people aged 10 to 15 years who are thought to be at risk from their use of alcohol.

Who should take action?

Any professional with a safeguarding responsibility for children and young people and who regularly comes into contact with this age group.

What action should they take?

  • Use professional judgement to routinely assess the ability of these children and young people to consent to alcohol-related interventions and treatment. Some will require parental or carer involvement.

  • Obtain a detailed history of their alcohol use (for example, using the Common Assessment Framework as a guide). Include background factors such as family problems and instances of child abuse or under-achievement at school.

  • Use professional judgement to decide on the appropriate course of action. In some cases, it may be sufficient to empathise and give an opinion about the significance of their drinking and other related issues that may arise. In other cases, more intensive counselling and support may be needed.

  • If there is a reason to believe that there is a significant risk of alcohol-related harm, consider referral to child and adolescent mental health services, social care or to young people's alcohol services for treatment, as appropriate and available.

  • Ensure discussions are sensitive to the child or young person's age and their ability to understand what is involved, their emotional maturity, culture, faith and beliefs. The discussions (and tools used) should also take into account their particular needs (health and social) and be appropriate to the setting.

Recommendation 7: screening young people aged 16 and 17 years

Who is the target population?

Young people aged 16 and 17 years who are thought to be at risk from their use of alcohol.

Who should take action?

Health and social care, criminal justice and community and voluntary professionals in both NHS and non-NHS settings who regularly come into contact with this group.

What action should they take?

  • Complete a validated alcohol screening questionnaire with these young people. Alternatively, if they are judged to be competent enough, ask them to fill 1 in themselves. In most cases, AUDIT (alcohol use disorders identification test) should be used. If time is limited, use an abbreviated version (such as AUDIT-C, AUDIT-PC, CRAFFT, SASQ or FAST). Screening tools should be appropriate to the setting. For instance, in an emergency department, FAST or the Paddington Alcohol Test (PAT) would be most appropriate. Use professional judgement as to whether to revise the AUDIT scores downwards when screening people under 18.

  • Focus on key groups that may be at an increased risk of alcohol-related harm. This includes those:

    • who have had an accident or a minor injury

    • who regularly attend genito-urinary medicine (GUM) clinics or repeatedly seek emergency contraception

    • involved in crime or other antisocial behaviour

    • who truant on a regular basis

    • at risk of self-harm

    • who are looked after

    • involved with child safeguarding agencies.

  • When broaching the subject of alcohol and screening, ensure discussions are sensitive to the young person's age and their ability to understand what is involved, their emotional maturity, culture, faith and beliefs. The discussions should also take into account their particular needs (health and social) and be appropriate to the setting.

  • Routinely assess the young person's ability to consent to alcohol-related interventions and treatment. If there is doubt, encourage them to consider involving their parents in any alcohol counselling they receive.

Recommendation 8: extended brief interventions with young people aged 16 and 17 years

Who is the target population?

Young people aged 16 and 17 years who have been identified via screening as drinking hazardously or harmfully.

Who should take action?

Health and social care, criminal justice and community and voluntary sector professionals in both NHS and non-NHS settings who regularly come into contact with this group.

What action should they take?

  • Ask the young person's permission to arrange an extended brief intervention for them.

  • Appropriately trained staff should offer the young person an extended brief intervention.

  • Provide information on local specialist addiction services to those who do not respond well to discussion but who want further help. Refer them to these services if this is what they want. Referral must be made to services that deal with young people.

  • Give those who are actively seeking treatment for an alcohol problem a physical and mental assessment and offer, or refer them for, appropriate treatment and care.

Recommendation 9: screening adults

Who is the target population?

Adults.

Who should take action?

Health and social care, criminal justice and community and voluntary sector professionals in both NHS and non-NHS settings who regularly come into contact with people who may be at risk of harm from the amount of alcohol they drink.

What action should they take?

  • NHS professionals should routinely carry out alcohol screening as an integral part of practice. For instance, discussions should take place during new patient registrations, when screening for other conditions and when managing chronic disease or carrying out a medicine review. These discussions should also take place when promoting sexual health, when seeing someone for an antenatal appointment and when treating minor injuries.

  • Where screening everyone is not feasible or practicable, NHS professionals should focus on groups that may be at an increased risk of harm from alcohol and those with an alcohol-related condition. This includes people:

    • with relevant physical conditions (such as hypertension and gastrointestinal or liver disorders)

    • with relevant mental health problems (such as anxiety, depression or other mood disorders)

    • who have been assaulted

    • at risk of self-harm

    • who regularly experience accidents or minor traumas

    • who regularly attend GUM clinics or repeatedly seek emergency contraception.

  • Non-NHS professionals should focus on groups that may be at an increased risk of harm from alcohol and people who have alcohol-related problems. For example, this could include those:

    • at risk of self-harm

    • involved in crime or other antisocial behaviour

    • who have been assaulted

    • at risk of domestic abuse

    • whose children are involved with child safeguarding agencies

    • with drug problems.

  • When broaching the subject of alcohol and screening, ensure the discussions are sensitive to people's culture and faith and tailored to their needs.

  • Complete a validated alcohol questionnaire with the adults being screened. Alternatively, if they are competent enough, ask them to fill 1 in themselves. Use AUDIT to decide whether to offer them a brief intervention (and, if so, what type) or whether to make a referral. If time is limited, use an abbreviated version (such as AUDIT-C, AUDIT-PC, SASQ or FAST). Screening tools should be appropriate to the setting. For instance, in an emergency department FAST or PAT would be most appropriate.

  • Do not offer simple brief advice to anyone who may be dependent on alcohol. Instead, refer them for specialist treatment (see recommendation 12). If someone is reluctant to accept a referral, offer an extended brief intervention (see recommendation 11).

  • Use professional judgement as to whether to revise the AUDIT scores downwards when screening:

    • women, including those who are, or are planning to become, pregnant

    • people aged 65 and over

    • people from some black and minority ethnic groups.

      If in doubt, consult relevant specialists. Work on the basis that offering an intervention is less likely to cause harm than failing to act where there are concerns.

  • Consult relevant specialists when it is not appropriate to use an English language-based screening questionnaire. (For example, when dealing with people whose first language is not English or who have a learning disability.)

  • Biochemical measures should not be used as a matter of routine to screen someone to see if they are drinking hazardously or harmfully. (This includes measures of blood alcohol concentration [BAC].) Biochemical measures may be used to assess the severity and progress of an established alcohol-related problem, or as part of a hospital assessment (including assessments carried out in emergency departments).

Recommendation 10: brief advice for adults

Who is the target population?

Adults who have been identified via screening as drinking a hazardous or harmful amount of alcohol and who are attending NHS or NHS-commissioned services or services offered by other public institutions.

Who should take action?

Professionals who have received the necessary training and work in:

  • primary healthcare

  • emergency departments

  • other healthcare services (hospital wards, outpatient departments, occupational health, sexual health, needle and syringe exchange programmes, pharmacies, dental surgeries, antenatal clinics and those commissioned from the voluntary, community and private sector)

  • the criminal justice system

  • social services

  • higher education

  • other public services.

What action should they take?

  • Offer a session of structured brief advice on alcohol. If this cannot be offered immediately, offer an appointment as soon as possible thereafter.

  • Use a recognised, evidence-based resource that is based on FRAMES principles (feedback, responsibility, advice, menu, empathy, self-efficacy). It should take 5–15 minutes and should:

    • cover the potential harm caused by their level of drinking and reasons for changing the behaviour, including the health and wellbeing benefits

    • cover the barriers to change

    • outline practical strategies to help reduce alcohol consumption (to address the 'menu' component of FRAMES)

    • lead to a set of goals.

  • Where there is an ongoing relationship with the patient or client, routinely monitor their progress in reducing their alcohol consumption to a low-risk level. Where required, offer an additional session of structured brief advice or, if there has been no response, offer an extended brief intervention.

Recommendation 11: extended brief interventions for adults

Who is the target population?

Adults who have not responded to brief structured advice on alcohol and require an extended brief intervention or would benefit from an extended brief intervention for other reasons.

Who should take action?

NHS and other professionals in the public, private, community and voluntary sector who are in contact with adults and have received training in extended brief intervention techniques.

What action should they take?

  • Offer an extended brief intervention to help people address their alcohol use. This could take the form of motivational interviewing or motivational-enhancement therapy. Sessions should last from 20 to 30 minutes. They should aim to help people to reduce the amount they drink to low risk levels, reduce risk-taking behaviour as a result of drinking alcohol or to consider abstinence.

  • Follow up and assess people who have received an extended brief intervention. Where necessary, offer up to 4 additional sessions or referral to a specialist alcohol treatment service (see recommendation 12).

Recommendation 12: referral

Who is the target population?

Those aged 16 years and over who attend NHS or other public services and may be alcohol-dependent. (For those under 16 see recommendation 6.)

Who should take action?

NHS and other professionals in the public, private, community and voluntary sector who have contact with anyone aged 16 and over.

What action should they take?

Consider making a referral for specialist treatment if 1 or more of the following has occurred. They:

  • show signs of moderate or severe alcohol dependence

  • have failed to benefit from structured brief advice and an extended brief intervention and wish to receive further help for an alcohol problem

  • show signs of severe alcohol-related impairment or have a related co-morbid condition (for example, liver disease or alcohol-related mental health problems).