Alcohol - Health Committee Contents

Memorandum by the British Medical Association (AL 06)

  The British Medical Association (BMA) welcomes the opportunity to submit evidence to the Committee's inquiry on "Alcohol".

  The enclosed response focuses on alcohol, and in particular, alcohol misuse, as a major healthcare concern.

  This evidence is supported by the BMA report Alcohol misuse: tackling the UK epidemic (2008) which leads the way in encouraging healthcare professionals to raise awareness of alcohol misuse and makes recommendations for tackling this epidemic.


    —  Alcohol consumption represents an integral part of modern culture. Alcohol is a psychoactive substance and its consumption in moderation can lead to feelings of relaxation and euphoria. It is also an addictive drug and its misuse is associated with a wide range of dose-related adverse sequelae that can lead to significant harm to the individual and society.

    —  The relationship between alcohol consumption and health and social outcomes is complex and multifaceted. In the short term, the acute intoxicating effects of alcohol on cognitive and motor functioning impair an individual's reactions, judgements, coordination, vigilance, vision, hearing and memory. This impairment is associated with many adverse outcomes for the individual and those around them as it can lead people to have accidents, misread situations and act aggressively. Excessive alcohol consumption is linked to long-term health and social consequences through three main causal pathways: intoxication, dependence, and toxic (and beneficial) direct biological effects.[57] These pathways are in turn affected by the volume of consumption and pattern of drinking. Alcohol misuse is also frequently associated with drug abuse and other harmful behaviours such as smoking.

    —  Alcohol consumption is commonplace; however, there is significant variation in the level and pattern of consumption between particular groups. Various estimates have been made for the number of individuals who misuse alcohol. While these estimates do not provide a definitive picture of consumption patterns, it is clear that a significant proportion of individuals misuse alcohol by drinking above recommended UK guidelines.

    —  The cost of alcohol misuse in the UK is substantial, both in terms of direct costs (eg costs to hospital services and the criminal justice service) and indirect costs (eg loss of productivity and the impact on family and social networks). There is substantial evidence demonstrating that targeted and population-wide alcohol control policies can reduce alcohol-related harm. Lessening the burden of alcohol misuse requires strong leadership and the implementation of effective alcohol control policies that reduce overall consumption levels and minimise the harm to the public and the individual. Developing comprehensive alcohol policy requires partnership between governmental agencies and organisations. Emphasis on partnership with the alcohol industry and self-regulation has at its heart a fundamental conflict of interest that does not adequately address individual and public health. The alcohol industry clearly has a vested interest in the development of alcohol control policies. It is essential that Government moves away from partnership with the alcohol industry and looks at effective alternatives to self-regulation that will ensure there is a transparent policy development process that is based on reducing the harm related to alcohol misuse.

    —  The BMA has produced comprehensive policy on alcohol and the 2008 Board of Science report Alcohol misuse: tackling the UK epidemic (enclosed) unifies this work and identifies effective, evidence based policies for reducing the burden of alcohol misuse in the UK. This document is accessible through the BMA website at—promotion—ethics/alcohol/tacklingalcoholmisuse.jsp


  1.  The BMA is an independent trade union and voluntary professional association which represents doctors from all branches of medicine all over the UK. It has a total membership of over 141,000.

  2.  The evidence for this Health Select Committee inquiry originates from the BMA report Alcohol misuse: tackling the UK epidemic (2008).[58]


  3.  A large majority of the individuals in the UK who consume alcohol do so in moderation. Analysis of the patterns of alcohol consumption, however, reveals that a significant proportion misuse alcohol by drinking above the UK recommended guidelines. Of particular concern is the pattern of drinking among adolescents, and the high level of binge drinking and heavy drinking among men and women in the 16 to 24 and 25 to 44 age groups. UK teenagers are among the most likely in Europe to report heavy consumption of alcohol, being intoxicated and experiencing adverse effect from drinking.

  4.  The 2003 Prime Minister's Strategy Unit (PMSU) interim analytical report estimated that in Britain:

    —  6.4 million people consume alcohol at moderate or heavy levels.

    —  1.8 million consume alcohol at very heavy levels.

    —  5.8 million people exceed recommended daily guidelines.

    —  5.9 million people engage in binge drinking.

    —  2.9 million of the adult population are alcohol dependent.[59]

  5.  The 2004 Alcohol Needs Assessment Research Project (ANARP) estimated that, for adults in England aged 16 to 64:

    —  26% have an alcohol misuse disorder (8.2 million);

    —  of the 26% with an alcohol use disorder, 23% (7.1 million) consume alcohol at hazardous or harmful, and 3.6% (1.1 million) are alcohol dependent; and

    —  21% of men and 9% of women are binge drinkers.[60]

  6.  Alcohol consumption has been shown to be causally related to over 60 different medical conditions and is a significant cause of morbidity and premature death worldwide. In the majority of cases there is a dose-response relationship, with risk increasing with the amount of alcohol consumed. Moderate alcohol consumption is not usually harmful to health. Indeed, consumption at moderate levels or below in older men and women is associated with a lower risk of coronary heart disease (CHD), ischaemic stroke and diabetes mellitus, compared to individuals who abstain from alcohol. While there are some beneficial direct biological effects linked to low-level alcohol intake, these are insignificant compared to the dangers of excessive intake. Drinking heavily, however, can result in significant health problems through either acute or chronic misuse. In the UK, the burden of alcohol-related morbidity and mortality is shifting to younger age groups in both men and women, and toward the most socially deprived groups. The pattern of consumption is important in determining the impact of alcohol misuse on health. Binge drinking is a particularly harmful form of alcohol consumption and significantly increases the risk of alcohol dependence in men and women. The frequency of heavy drinking by the pregnant mother is also associated with the occurrence of a range of preventable mental and physical birth defects, collectively known as fetal alcohol spectrum disorders (FASD).[61]

  7.  Alcohol misuse can lead to harmful consequences for the individual drinker, as well as their family and friends. It significantly impacts on family life and is also a significant contributory factor in domestic violence incidents in about 50% of cases. Parental alcohol misuse is also correlated with child abuse and impacts on a child's environment in many social, psychological and economic ways.

  8.  The levels of alcohol-related crime and disorder may vary with age and pattern of drinking, with alcohol related offences particularly common among binge drinkers in the 18 to 24 age group compared to other regular drinkers. Drinking alcohol, especially frequent drinking, is also a significant factor in criminal and disorderedly behaviour in young people aged under 18.

  9.  Driving under the influence of alcohol is a significant cause of death and serious injury from road traffic crashes in the UK. In 2006, 6% of all road casualties and 17% of road deaths were due to alcohol intoxication. Alcohol consumption by other road users such as cyclists and pedestrians is also associated with fatalities and injuries. Driver impairment resulting from the use of alcohol with other drugs, both prescribed and illegal, is also an important factor in road traffic crashes.

  10.  The BMA recommends:

    —  The legal limit for the level of alcohol permitted while driving, attempting to drive, or being in charge of a vehicle should be reduced from 80mg/100ml to no more than 50 mg/100ml.

    —  Legislation permitting the use of random roadside testing without the need for prior suspicion of intoxication should be introduced. This requires appropriate resourcing and public awareness campaigns.


  11.  The National Social Marketing Centre estimated that the cost of alcohol misuse on public health and care services in the UK to be £2.8 billion.[62] In 2004 the PMSU estimated that the overall annual cost of alcohol-related harm in England to be up to £1.7 billion.[63] In 2002-03, it was estimated that NHS Scotland provided over £110 million worth of healthcare services.


  12.  There is a substantial body of evidence demonstrating that targeted and population-wide alcohol control policies can reduce alcohol related harm.


  13.  This is an important determinant of alcohol use and misuse. This incorporates the implementation of policies that regulate the affordability of alcohol as well as the introduction and enforcement of strict controls on the availability of alcohol to adults and young people. There is strong consistent evidence that increases in price have the effect of reducing consumption levels, as well as rates of alcohol problems including alcohol related violence and crime, deaths from liver cirrhosis and drink driving deaths. Increases in the price of alcohol not only affect consumption at a population level, but there is evidence that particular types of consumers, such as heavy drinkers and young drinkers, are especially responsive to price.

  14.  Licensing interventions are one of the most influential methods for controlling alcohol consumption and misuse through regulation of where, when and to whom alcohol can be sold. There is strong evidence that increased opening hours are associated with increased alcohol consumption and alcohol related problems. Conversely, reductions in opening hours and particularly in the number of outlets are associated with reductions in alcohol use and related problems. A high density of alcohol outlets is associated with increased alcohol sales, drunkenness, violence and other alcohol related problems.

  15.  The BMA recommends:

    —  The availability of alcoholic products should be regulated through a reduction in licensing hours for on- and off-licensed trade.

    —  Town planning and licensing authorities should ensure they consider the local density of on-licensed premises and the surrounding infrastructure when evaluating any planning or licensing application. Legislative changes should be introduced where necessary to ensure these factors are considered in planning or licensing applications for licensed premises.


  16.  Numerous factors contribute to the culture of drinking to excess and the rise in underage drinking and alcohol related harm. Key areas are the supply and promotion of alcohol to consumers. Active enforcement of laws regulating licensing hours, and prohibiting the sale of alcohol to individuals who are intoxicated or underage have been shown to be effective at increasing compliance with legislation. The layout, design and internal physical characteristics of licensed premises are also important considerations for strategies to reduce alcohol-related crime and disorder.

  17.  Irresponsible promotional activities are common in licensed premises and off licenses (including supermarkets and local convenience stores). It is essential that these forms of promotional activity are strictly regulated. This can be achieved through prohibiting price promotions on alcoholic beverages, and by establishing minimum price levels. Repeated exposure to high-level alcohol promotion influences young people's perceptions, encourages alcohol consumption and increases the likelihood of heavy drinking. Specific advertising strategies such as sponsorship of sporting and music events, as well as advertisements using celebrity endorsements all serve to reinforce the image of alcohol among young people and predispose them to drinking below the legal age to purchase alcohol. It is essential that there is statutory regulation of the marketing of alcoholic beverages. This includes prohibiting the broadcasting of alcohol advertising at any time that is likely to be viewed by young people, with specific provisions banning alcohol advertising prior to 9pm and in cinemas showing a film with a certificate below age 18. Consideration also must be given to prohibiting alcohol industry sponsorship of sporting and music events aimed mainly at young people.

  18.   The BMA recommends:

    —  Licensing legislation in the UK should be strictly and rigorously enforced. This includes the use of penalties for breach of licence, suspension or removal of licences, the use of test purchases to monitor underage sales, and restrictions on the sale of alcohol to individuals with a history of alcohol-related crime or disorder.

    —  Legislation should be introduced throughout the UK to:

    —  prohibit irresponsible promotional activities in licensed premises and by off-licenses; and

    —  set minimum price levels for the sale of alcoholic beverages.

    —  A statutory code of practice on the marketing of alcoholic beverages should be introduced and rigorously enforced. This should include a ban on:

    —  broadcasting of alcohol advertising at any time that is likely to be viewed by young people, including specific provisions prohibiting advertising prior to 9.00 pm and in cinemas before films with a certificate below age 18;

    —  alcohol industry sponsorship of sporting, music and other entertainment events aimed mainly at young people; and

    —  marketing of alcoholic soft drinks to young people.


  19.  The use of information and educational programmes is a common theme for alcohol control policies. Such approaches are politically attractive but have been found to be largely ineffective at reducing heavy drinking or alcohol-related problems in a population. While education and health promotion may be effective at increasing knowledge and modifying attitudes, they have limited effect on drinking behaviour in the long term. It is essential that the disproportionate focus upon, and funding of, such measures is redressed.

  20.   The BMA recommends:

    —  Public and school based alcohol education programmes should only be used as part of a wider alcohol-related harm reduction strategy to support policies that have been shown to be effective at altering drinking behaviour, to raise awareness of the adverse effects of alcohol misuse, and to promote public support for comprehensive alcohol control measures.

  21.  Much of the strategy to reduce alcohol-related harm in the UK focuses on recommended drinking guidelines. While the majority of people are aware of the existence of these guidelines, few can accurately recall them, understand them or appreciate the relationship between units, glass sizes, and drink strengths. Labelling of alcoholic beverage containers would be a useful method for explaining recommended drinking guidelines and for supporting other alcohol control policies.

  22.   The BMA recommends:

  It should be a legal requirement to:

    (a) prominently display a common standard label on all alcoholic products that clearly states:

    —  alcohol content in units;

    —  recommended daily UK guidelines for alcohol consumption; and

    —  a warning message advising that exceeding these guidelines may cause the individual and others harm.

    (b) Include in all printed and electronic alcohol advertisements information on:

    —  recommended daily UK guidelines for alcohol consumption; and

    —  a warning message advising that exceeding these guidelines may cause the individual and others harm.

  It should be a legal requirement for retailers to prominently display at all points where alcoholic products are for sale:

    —  information on recommended daily UK guidelines for alcohol consumption; and

    —  a warning message advising that exceeding these guidelines may cause the individual and others harm.


  23.  Preventing alcohol-related harm requires the accurate identification of individuals who misuse alcohol and the implementation of evidence-based interventions to reduce alcohol consumption. At present there is no system for routine screening and management of alcohol misuse in primary or secondary care settings in the UK. Screening and management occur opportunistically and where clinically appropriate in both settings. Identification of alcohol misuse among people not seeking treatment for alcohol problems can be achieved via alcohol screening questionnaires, detection of biological markers, and detection of clinical indicators. The use of alcohol screening questionnaires is an efficient and cost effective method for detecting alcohol misuse. Biological markers can be used as adjuncts to questionnaires for the screening process. Primary care, general hospitals and accident and emergency (A&E) settings provide useful opportunities for screening for alcohol misuse and the delivery of brief interventions. It is essential that systems are developed in order to encourage this activity on a regular basis. Effective operation of such systems requires adequate funding and resources, and comprehensive training on the use of validated screening questionnaires as well as the provision of brief interventions. Routine screening in primary care could be facilitated by the introduction of a directed enhanced service (DES).

  24.   The BMA recommends:

  The detection and management of alcohol misuse should be an adequately funded and resourced component of primary and secondary care in the UK to include:

    —  formal screening for alcohol misuse;

    —  referral for brief interventions and specialist alcohol treatment services as appropriate;

    —  follow-up care and assessment at regular intervals;

    —  a system for the detection and management of alcohol misuse in primary care should occur via the implementation of a direct enhanced service by the UK health departments. This must be adequately funded and resourced; and

    —  systems for the detection and management of alcohol misuse should be developed for A&E care and general hospital setting. These must be adequately funded and resourced.

  25.  Comprehensive training and guidance should be provided to all relevant healthcare professionals on the identification and management of alcohol misuse.

  26.  Brief interventions (behaviour modification techniques) provide prophylactic treatment and produce clinically significant effects on drinking behaviour and related problems in non-alcohol dependent individuals. For individuals with more severe alcohol problems and levels of dependence, specialised alcohol treatment services can effect significant reductions in alcohol use and related problems. It is essential that individuals identified as having severe alcohol problems or as being alcohol dependent are offered referral to specialist alcohol treatment services.

  27.  It is also essential that specialised alcohol treatment services are provided consistently, are adequately resourced and funded, and that this funding is ring-fenced. High-level commitment is also required to ensure that the alcohol treatment services are prioritised when commissioning services.

  28.   The BMA recommends:

  Funding for specialist alcohol treatment services should be significantly increased and ring-fenced to ensure all individuals who are identified as having severe alcohol problems or who are alcohol dependent are offered referral to specialised alcohol treatment services at the earliest possible stage.

March 2009

57   Rehm J, Room R, Graham K et al (2003) The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview. Addiction 98: 1209-28. Back

58   British Medical Association (2008) Alcohol misuse: tackling the UK epidemic. London: British Medical Association. Back

59   Prime Minister's Strategy Unit (2003) Interim analytical report for the national alcohol harm reduction strategy. London: Prime Minister's Strategy Unit. Back

60   Department of Health (2005) Alcohol Needs Assessment Research Project (ANARP): the 2004 national alcohol needs assessment for England. London: Department of Health. Back

61   In 2007 the BMA Board of Science published Fetal alcohol spectrum disorders. This report focuses on the adverse health impacts of alcohol consumption during pregnancy and in particular the problem of FASD. This report is accessible at: Back

62   Lister G (2007) Evaluating social marketing for health-the need for consensus. Proceedings of the National Social Marketing Centre, 25-25 September, Oxford. Back

63   Prime Minister's Strategy Unit (2004) Alcohol harm reduction strategy for England. London: Prime Minister's Strategy Unit. Back

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Prepared 23 April 2009