House of Commons - Alcohol - Health Committee

Alcohol - Health Committee Contents

3 The impact of alcohol on health, the NHS and society

35. Over recent years the public have been exposed to mixed messages from the media with some articles promoting the benefits of alcohol, especially wine, in preventing cardiovascular disease, others stressing the harm done in causing cancer and liver disease and others the consequences of binge-drinking.

36. Doctors tend to stress the harm done. The BMA points out that whilst alcohol may indeed have some moderate beneficial cardiovascular effects in older men and women with low intake, 'these are insignificant compared to the dangers of excessive intake'.[42] Sir Liam Donaldson, the Chief Medical Officer informed the committee that there were no safe limits of drinking.[43] and that "alcohol is virtually akin to smoking as one of the biggest public health issues we have to face in this country".[44]

37. The acute intoxicating effects of alcohol are the most visibly shocking to the public. Brian Hayes, a London Ambulance Paramedic, drew our attention to the consequences of binge-drinking:

We are talking about people that because of alcohol have jumped on a wall because they think it is a bravado thing to do with their mates, not realising that the drop on the other side is 60 feet and they have gone down it. Their one massive night has ended up with a family with someone who is deceased….. the injuries we have been faced with have been so horrific, due to a bus driver who had kicked somebody off his bus and his head had been used as a football by about five or six blokes who were all drunk, and he ended up in intensive care. This is happening week in, week out; it does not have to be a Friday or Saturday……….We went to one female who was found staggering down a road in south-east London, completely out of it on alcohol. When we got her into the ambulance we went to remove her jacket to take her blood pressure and she had nothing on underneath, and did not have a clue what had happened to her.[45]

Alcohol also causes accumulating harm to a large sector of society in much more subtle, long term ways. Alcohol contributes to liver cirrhosis, acute and chronic pancreatitis, heart failure, hypertension, depression, strokes and cancer and can harm developing foetuses.

38. Furthermore alcohol is addictive, with 3.5m people in the UK dependent on it.[46] It severely impairs the physical, mental and social well-being of the user, their families and others.

Alcohol harms health through three mechanisms:

acute intoxicating effects, occurring after a single binge.
chronic toxic effects, following years of drinking at harmful levels.
propensity for addiction leading to physical and psychological dependency.

39. Alcohol impacts on the entire range of services the NHS provides, from neonatal care to healthcare for the elderly. Liver disease, a useful marker of alcohol related harm, is soaring in the UK, with a five-fold increase since 1970. There were 863,300 alcohol related hospital admissions per year. Alcohol costs the NHS £2.7 billion per annum.[47]

The impact of alcohol on health

PHYSICAL HEALTH BY AGE

40. Acute intoxication with alcohol following a single 'binge' can cause alcohol poisoning, injuries and accidents, with young people being disproportionately affected. Alcohol is strongly associated with an increased risk of acquiring sexually transmitted infections (STIs). The rates of STIs increased 63% in the UK between 1998 and 2007 and as many as 76% of people in one genitourinary clinic in 2006 reported having unprotected sex as a result of drinking.[48]

41. The figures below show deaths attributable to alcohol consumption.

Figure 4: Percentage of male deaths attributable to alcohol consumption (2005)[49]

Figure 5: Percentage of female deaths attributable to alcohol consumption (2005)[50]

They show how alcohol affects different age groups. Between the ages of 16 and 34, more than 20% of male deaths, and 14% of female deaths are attributable to alcohol consumption. In this age group the main causes are road accidents, injuries and poisoning, including suicides. Overall between one third and one seventh of accidental deaths are alcohol related—amounting to 1,700 deaths each year.[51]

42. In people over 35 the main alcohol related causes of death are firstly liver disease, and then cancer and high blood pressure. Alcohol is the second biggest risk factor for cancer after smoking. Alcohol especially contributes to cancers of the mouth and throat, liver, laryngeal, colon (in men) and breast cancer. It is responsible for many cancer deaths each year; of these perhaps the most worrying is breast cancer—alcohol accounts for 6% of breast cancer in the UK amounting to around 3,000 cases each year.[52]

MENTAL HEALTH

43. Problem drinking is heavily associated with mental illness (from anxiety and depression through to schizophrenia) and personality difficulties, with each driving the other. Heavy drinkers are more than twice as likely to commit suicide as non-drinkers.[53] Between 16 and 45% of suicides are thought to be linked to alcohol and 50% of those 'presenting with self harm' are regular excessive drinkers.[54]

44. The known association between alcohol and cognitive decline has been neglected by most of the recent inquiries into alcohol. Some researchers have recently warned against a possible surge in alcohol-related dementia in the future, compounding the expected boom in dementia due to an ageing population.[55]

THE HEALTH OF OTHERS

45. The Royal College of Physicians provided a dramatic summary:

The passive effects of alcohol misuse are catastrophic—rape, sexual assault, domestic and other violence, drunk driving and street disorder—alcohol affects thousands more innocent victims than passive smoking.[56]

46. According to the British Crime Survey, in 2007, 46% of violent offenders in England and Wales were perceived by their victims to be under the influence of alcohol.[57] During 2002 there were 1.2 million incidents of recorded alcohol-related assault in England and Wales, but it is estimated that only 20% of such assaults were recorded by police as crime[58] 76,000 facial injuries in the UK each year are linked to drunken violence.[59] In 2006 6% of all road casualties and 17% of road deaths and serious injury from road traffic crashes in the UK were due to drivers being under the influence of alcohol.[60]

47. Alcohol harms the developing foetus. The Royal College of Midwives informed us that 6,000 babies are born with Foetal Alcohol Syndrome in the UK each year.[61]

Foetal Alcohol Syndrome (FAS) is the term used to describe the visible birth defects and invisible organ/brain/nervous damage that can result from exposure to alcohol during pregnancy. It is used to describe the most severe form of a wide range of permanent physical, mental and behavioural problems that begin before birth. From malformed faces and limbs to heart problems and diminished intellectual capacity.[62]

48. The National Society for the Prevention of Cruelty to Children (NSPCC) highlighted the alcohol problems which are associated with parental neglect and physical abuse and affect up to 1.3 million children in the UK.[63] In the year ending March 2008 the NSPCC told us they received more than 80 calls per week from children where alcohol misuse by what they described as a 'significant other' (ie a parent or someone close to them) was the main reason for their call. The National Association for the Children of Alcoholics (NACOA) in claimed that alcohol was a factor in 40% of domestic violence cases, 40% of child protection cases, and 74% of child mistreatment cases, and supplied evidence that children of alcohol dependent parents were much more likely to have psychiatric, behavioural and substance misuse problems.[64]

MORTALITY AND DISEASE

49. ONS data (published in January 2009)[65] estimated there were 8724 alcohol related deaths in England and Wales in 2007, double the rate in 1991. However Professor Ian Gilmore, President of the Royal College of Physicians explained that this was almost certainly a gross under-estimate, with better estimates suggesting alcohol-related deaths may be 30-40,000 which is as much as half that of smoking related deaths:

Those 8,000 are the ONS figures and that is where alcohol is named on the death certificate as the cause of death. Nearly all of those are alcohol induced liver cirrhosis. It does not pick up the accidents, the violence and so on. If you include cases where alcohol is named on the death certificate as a contributory cause, then the figures rise to about 15,000, but if you actually take the percentage of oesophageal cancer that can be attributed to alcohol etc, using the attributable fraction (which is a well recognised and scientifically reputable way of doing it) the figure comes out between 30,000 and 40,000.[66]

50. Dr Peter Anderson told us that 'Disability Adjusted Life Years' (DALYs[67]) were a more useful measure of health impact than simple mortality rates since they accounted for morbidity leading to disability as well. Worldwide, alcohol is estimated to cause 3.3% of deaths and 4% of DALYs.[68] However its effect is much more pronounced in developed countries where it causes 9.2% of lost DALYs, not far behind tobacco's 12.2%.

51. Professor Gilmore pointed out that alcohol was a source of health inequalities and Dr Anderson explained that people from lower socio-economic groups were more harmed by a given level of alcohol consumption.[69] In the most deprived areas of the UK, men are 5 times more likely and women 3 times more likely to die an alcohol related death than those in the least deprived areas.[70] This is discussed in more detail in the chapter on pricing below.

RISK

52. Most research has examined 'relative risk', i.e. the proportional increased prevalence of illness in drinkers compared to non-drinkers. The 'absolute risk' increases as the relative risk but it also depends on how common the problem is. Data from a large study of 10,000 people in Copenhagen[71] showed that the relative risk of clinically apparent liver disease increased by 50% above 20 units/week, 350% above 40 units/week and 900% above 90 units/week. The increase in relative risk was the same for someone in their thirties as in their fifties, but the absolute risk of being admitted to hospital was much higher for a 50 year old. So for example, for 50 year man drinking more than 90 units per week, the risk of dying or being admitted to hospital with liver disease over the next 10 years was 15-18%, whereas for a 30 year old man it was 4-6%.

53. Similarly with women and breast cancer, because it is very common—110 women in every 1,000 will get breast cancer at some stage in their lives—the absolute risk from alcohol is quite substantial. The World Cancer Research Fund International estimate that for every thousand women drinking a bottle of wine each week throughout their lives, approximately ten i.e. 1% will develop breast cancer as a direct result of the alcohol. If they drank two bottles of wine each week the number increases to 15-20 women per 1,000, i.e. 1.5 -2%.

54. These risks may seem low, but for comparison purposes the Health and Safety executive quote some comparative absolute risks: the risk of dying from a scuba dive is 1 per 100,000 i.e. 0.0001%, from a base jump (jumping off a building with a parachute) is 1 in 2,000, i.e. 0.05%.

55. Dr Anderson explained that "when you look at alcohol the risks in relation to harm are pretty well monotonic or linear meaning that the risk starts at zero and it goes upwards. The more you drink, the greater the risk"..[72] Nevertheless, the Government has thought it useful to provide advice about the risks of drinking. Its latest advice was drawn up in 1995. It is unclear how the recommended units were decided upon, but it seems to be the point at which the benefits of alcohol from reducing cardiovascular disease are outweighed by the risks of cancer, liver disease and other harms. Essentially, drinking at this level can be seen to do harm at a population level, but the risks to an individual are quite low. However, once people drink at double the recommended limits the risks to an individual become more substantial. The following table sets out the Department of Health's different 'risk' categories associated with different levels of drinking

Table 1: categories of drinkers

Category Alcohol consumption in men Alcohol consumption in women

Low risk or 'sensible' 21 units/week 14 units/week

Increasing risk or 'hazardous' 22-50 units/week 15-35 units/week

High risk or 'harmful' >50 units/week >35 units/week

A unit of alcohol is defined as 8g or 10 ml of alcohol

The impact of alcohol on the NHS

PRIMARY CARE

56. GPs are presented with a range of chronic physical, mental and social problems arising from alcohol. Problem drinkers consult their GPs twice as often as the average patient.[73] Dr Paul Cassidy, a GP in Gateshead, told the committee:

Often, when GPs think alcohol they think alcohol dependence. They are the patients who seem to give us the biggest problem, because we have problems getting them into treatment and it is a chronic illness. I see the non-dependent drinkers, of whom there are a lot, in every day practice, and the challenge for me is to pick those people up. The impact is often felt on the more dependent end, but there are the more subtle effects of raising people's blood pressure or leading to small injuries that affect the normal patient who comes through the door. Certainly it is a common and routine part of clinical practice.[74]

ACCIDENT AND EMERGENCY DEPARTMENTS AND THE AMBULANCE SERVICE

57. Estimates of the proportion of alcohol related emergency attendance vary. A national survey of most of the UK's Emergency Departments by Drummond found that 70% of night time attendances and 40% of daytime attendances were caused by alcohol. A study from Cambridge found the lowest proportion of alcohol related attendances was 24% at night and 4% during the day.[75] The College of Emergency Medicine informed us:

Significant numbers of adults and children attend Emergency Departments in the UK as a direct result of alcohol consumption. Short-term harms include serious accidents (some resulting in death and permanent disability, particularly road traffic collisions), assaults, domestic violence, collapse and psychiatric problems. Furthermore, all Emergency Departments also admit, on a daily basis, patients suffering from the longer-term health effects of sustained alcohol use, for example acute withdrawal fits secondary to alcohol dependence, pancreatitis and liver failure.[76]

58. Brian Hayes, a London Ambulance Paramedic, told us about the added costs of treating alcohol intoxication:

The first thing most of them do as we leave the scene is vomit. That then renders the ambulance off the road for an hour once that call has been finished because it has to be deep cleaned because of infection and so on. Hopefully none of the vomit has gone over the ambulance crew because if that happened—shower, change your uniform. So you can be looking at that ambulance being unavailable to deal with anything else for two hours, two and a half hours because of alcohol. Then you will get the ones where the ambulance crews have been assaulted…We have had cases of paramedics being sliced with knives, punched, kicked, ambulances being nicked just as a prank through somebody being drunk and driving it into a row of cars.[77]

HOSPITAL ADMISSIONS

59. When secondary diagnoses of an alcohol related disorder are included, 863,300 alcohol-related admissions occurred in England in 2007/2008.[78] This is more than 6% of all admissions and a 69% increase from 2002/2003 and rising by around 70,000 per year.[79] There has been a two-thirds increase in alcohol-related admissions in over 65s in past 4 years, from 197,584 in 2002 to 323,595 in 2007.[80]

LIVER SERVICES

60. Mortality from liver disease is regarded as one of the best barometers of alcohol related ill health. Between 1970 and 2000 deaths from liver disease in people aged under 65 increased fivefold, while death rates from other diseases have declined, as figure 6 shows.[81][82]

Figure 6: Movements in mortality 1971-2007 (Deaths per million of population)[83]

The British Society of Gastroenterology (BSG) and the British Association for Study of the Liver (BASL) highlighted:

      While the wine drinking countries of Southern Europe always had historically very
      high levels of liver deaths from alcohol relatedcirrhosis (figure 7 below); deaths in
      these countries have been dropping whereas UK deaths are still rising inexorably.
      The UK finally overtook Spain, Italy and France for liver deaths in 2004.[84]

Figure 7: SDR, chronic liver disease and cirrhosis, 0-64 per 100000

Source: WHO, Europe, European HPA Database, January 2009

OVERALL COSTS TO THE NHS

61. Alcohol cost the NHS £2.7 billion in England in the year 2006-2007 according to the Department of Health.[85] The NAO found that:

Most of these costs are borne by the front-line and mainstream NHS: hospital services (inpatient and outpatient) account for 56% of the total. Ambulance services and accident emergency services, taken together, bear almost a third … of these estimated costs, while hospital services account for over a half … of the total. Specialist alcohol treatment services, provided by non-NHS organisations, account for only two per cent of the total estimated costs.[86]

The figure below highlights the huge disparity between the vast indirect costs of alcohol for the NHS and the small amounts spent on services to treat alcohol problems.[87]

Figure 8: Annual estimated costs of alcohol harm to the NHS, 2006-07

Source: Department of Health Improvement Analytical Team report, The cost of alcohol harm to the NHS in England: An update to the Cabinet Office (2003) study, July 2008

NOTES: 'Hospital' includes inpatient visits directly and partly attributable to alcohol misuse and outpatient attendances. 'Other healthcare costs' include alcohol-related counselling, community psychiatric nurse visits and health visits.

The expenditure on Dependency Drugs is estimated to be at least £2.14 million per annum.

The overall cost of alcohol to society

62. Health is just one of many Government departments which foot the bill for alcohol-related harm. The total cost to society including costs to the criminal justice system, the economy and social care were estimated by the Cabinet Office in 2003 to be £20 billion.[88] This estimate was composed of £1.7 billion in health costs, £7.3 billion for crime and public disorder[89] plus an estimated £4.7 billion for additional human and social costs of crime, and £6.4 billion from loss of productivity and profitability in the workplace.

63. However, in 2007 the National Social Marketing Centre produced a much higher estimate of £55.1 billion.[90] This estimate was composed of £21 billion cost to individuals and families/households, £2.8 billion cost to public health and care services, £2.1 billion cost to the Criminal Justice System, Education and Social Services, £7.3 billion cost to employers and £21.9 billion in human cost (reduced quality of life adjusted years). The box below shows the different estimates for the costs.

Estimated annual costs of alcohol-related harm in England

The National Social Marketing Centre estimated that the total annual societal cost of alcohol misuse in England to be £55.1 billion including:

£21 billion cost to individuals and families/households (eg loss of income, informal care costs)
£2.8 billion cost to public health services/care services
£2.1 billion cost to other public services (eg criminal justice system costs, education and social services costs)
£7.3 billion cost to employers (eg absenteeism)
£21.9 billion in human costs (DALYs).

The 2004 PMSU report estimated the overall annual cost of alcohol-related harm in England to be £20 billion including:

Up to £1.7 billion for the healthcare service
Up to £7.3 billion from alcohol-related crime and public disorder (£3.5 billion to services as a consequence of alcohol-related crime, £1.7-2.1 billion to services in anticipation of alcohol-related crime, £1.8 billion to the criminal justice system, £0.5 billion from drink-driving)
Up to £6.4 billion from loss of productivity and profitability in the workplace (£1.2-1.8 from alcohol-related absenteeism, £2.3-2.5 billion from alcohol-related deaths, £1.7-2.1 billion from lost working days).

Conclusions

64. The fact that alcohol has been enjoyed by humans since the dawn of civilization has tended to obscure the fact that it is also a toxic, dependence inducing teratogenic and carcinogenic drug to which more than three million people in the UK are addicted. The ill effects of alcohol misuse affect the young and middle aged. For men aged between 16 and 55 between 10% and 27% of deaths are alcohol related, for women the figures are 6% and 15%.

65. Alcohol has a massive impact on the families and children of heavy drinkers, and on innocent bystanders caught up in the damage inflicted by binge drinking. Nearly half of all violent offences are alcohol related and more than 1.3 million children suffer alcohol related abuse or neglect.

66. The costs to the NHS are huge, but the costs to society as a whole are even higher, all of these harms are increasing and all are directly related to the overall levels of alcohol consumption within society.

42 Ev 20 Back

43 Q 1018 Back

44 Q 1029 Back

45 Q 200 Back

46 Psychiatric morbidity among adults living in private households, 2000, ONS. http://www.statistics.gov.uk/downloads/theme_health/psychmorb.pdf Back

47 The NHS Information Centre, Statistics on Alcohol: England, 2009, 2009, p 8. Back

48 Ev 62: Standerwick K, et al. 2007. Binge drinking, sexual behaviour and sexually transmitted infection in the UK. International Journal of STD and AIDS, no. 18, 810-813. Back

49 Jones L, Bellis MA, Dedman D, Sumnall H, Tocque K. Alcohol attributable fractions for England; alcohol attributable mortality and hospital admissions. North-West Public Health Observatory and Dept of Health; 2008, p 26.. Back

50 Ibid., p 27. Back

51 Prime Ministers Strategy Unit. Interim Analytical Report. 2003. Back

52 Key J, Hodgson S, Omar RZ, Jensen TK, Thompson SG, Boobis AR, et al. Meta-analysis of studies of alcohol and breast cancer with consideration of the methodological issues. Cancer Causes Control 2006 Aug;17(6):759-70. Back

53 Tatsuo A, Iwasaki M, Uchitomi Y, et al, Alcohol consumption and suicide among middle-aged men in Japan, British Journal of Psychiatry, 2006, 188: 231-236 Back