House of Commons - Health Committee

Alcohol - Health Committee Contents

Supplementary memorandum by the Department of Health (AL 01B)

I. EFFECTIVENESS OF GOVERNMENT CAMPAIGNS

Government campaign strategy

— The Government campaign strategy targets the kinds of harmful drinking that puts health at risk.

— While the programme of campaigns provides information and education for all drinkers, the priority groups are:

— Children and young people under 18 who drink alcohol, many of whom are drinking more than their counterparts did a decade ago.

— 18-24 year old binge drinkers, who are putting their health at risk and a minority of whom who are responsible for the majority of alcohol-related crime and disorder in the night-time economy.

— Harmful/higher-risk drinkers, many of whom do not realise that their drinking patterns damage their physical and mental health and who may also be causing harm to others.

Objectives of the Government campaigns

— In the Government's 2007 strategy, we set ourselves the following objectives:

— Most people will be able to estimate their own alcohol consumption in units;

— Most people will be able to recall the Government's sensible drinking guidelines and will know the personal risks associated with regularly drinking above the sensible limits; and

— Most people will be able to recognise what constitutes their own or others' harmful drinking and will know where to go for advice.

It is against these objectives that the success of the campaigns is measured, and levels of Public knowledge and awareness have increased already.

These objectives recognise that education on its own is not effective in bringing about behaviour change. This is clear from Government and other research. (eg See extract from Review of the evidence base around effective alcohol harm reduction communications, prepared for COI Communications, on behalf of Department of Health and Home Office, September 2005).

Nevertheless, education is effective as part of a wide-ranging programme of policy interventions, as part of the wider Government alcohol strategy.

The four elements of our approach comprise:

(i) Informing and supporting people to make healthier and more responsible choices: eg through our national campaigns and providing education and information.

(ii) Creating an environment in which the healthier and more responsible choice is the easier choice: eg through our licensing and enforcement regimes for alcohol retailing

(iii) Providing advice and support for people most at risk: eg through early identification and treatment of people whose alcohol consumption is damaging their health

(iv) A delivery system that effectively prioritises and delivers action on alcohol misuse: eg through strengthening local commissioning of services and additional central and regional support, alongside local accountability.

Main Government campaigns

— The Government campaign programme comprises two central strands for drinkers:

— a "binge drinking" campaign, starting in 2006, which, from June 2008, is challenging the public acceptability of drunkenness and highlighting the attendant personal and social consequences.

— a "units" campaign, from May 2008, to improve the public's knowledge of alcohol units and the recommended alcohol consumption guidelines and of the link between alcohol consumption and health.

— Alongside national advertising, the campaigns include a helpline and the development of a range of new kinds of information and advice, all available nationally.

Your drinking and you.

Efficacy of Government campaigns—Summary

Know Your Limits

— The campaigns are gaining recognition and increasing people's awareness of units and lower-risk limits

— Early analysis of the campaign awareness KPI is promising with public recall running at 73%.

— Analysis of the recall KPI of the daily units guideline shows improvement, with a rise from 29% to 34% giving the correct answer.

Your drinking and you

Evaluation of the Know your limits—units campaign

Summary of impact

— In line with all campaigns run by the Department, DH carried out pre and post campaign tracking.

— The campaign is performing well, as measured by good campaign awareness levels and increases in knowledge of units.

mid wave

— The tracking research was carried out by TNS from 16 June—7 July 2008. (NB. This evaluation took place before the second wave of the campaign, which addressed the health consequences of drinking).

Level of recall

TV advertising was the key factor in driving unit awareness—69% of respondents claimed it as their source of information. 61% said that, having seen the TV adverts, they had a better idea of the number of units in alcoholic drinks.

— Recognition of DH advertising was 66% (COI average for similar spend campaigns is 64%).—Rising to 73% when prompted.

— Recognition is higher amongst the 25-34 age group, at 85%, C1, C2s and harmful drinkers.

— Radio adverts had low recognition overall at 21% (COI average 34%) although they worked well for the higher risk drinkers audience.

— Printed adverts worked well, with 38% recognition, against a COI average of 22%—with wine and lager doing especially well.

Knowledge of units

— More people are claiming knowledge of units already, but, when tested, this was still lower than claimed. However, there is a definite correlation between improved knowledge and the advertising campaign, for example, there were increases in units knowledge for wine:

pre-wave

— At the pre-wave, only 6% correctly said there were three units in a large glass of wine (250ml at 12.5% ABV) but this rose significantly to 21% at the mid-wave.

— There has also been an improvement in the proportion of people giving the correct daily units guideline figures, from 29% to 34% saying that the recommended maximum number of units per day for men is 3-4, and 37% (up from 34%) giving the correct answer of 2-3 for women.

Campaign reach

— The campaign is reaching a good proportion of the population:

— 85% 25-34

— 78% 35-54

— 72% 55-64

— 55% 65+

— The campaign is doing particularly well with higher-risk drinkers; with 81% reach (73% lower-risk drinkers and 70% increasing-risk drinkers).

— Respondents' emotional engagement was low, but in line with the results received on the binge drinking campaign, and good, considering the units message is one that people do not want to take on board. (The "brick wall of refutability" is highlighted as a key challenge in the strategy).

— General impressions of the advertising are generally positive, with 3/4 of people saying it offers good advice.

— Relevance hovers at around 50%, where people believe the adverts are for "people like me" but varies for different groups. It is higher for 25-34s (67%) and harmful drinkers (57%) and lower for 65+s (22%).

At this stage of the campaign, shifts in attitudes are not really to be expected. Nonetheless, there has been an acceptance of the situation in the UK, with an increased agreement that we "tend to drink more than is good for us"; from 77-82%. (This has clearly been influenced by the campaign; for those aware of the campaign it rises to 85%, and for those not aware the figure is 72%).

However, again as expected at this stage, there is work to be done to maximise the campaign's relevance across different groups in society and to motivate people to address the amount that they drink. (When asked if they should cut down on the amount that they drink, 66% of higher-risk drinkers and 54% of increasing-risk drinkers agreed they should).

Know your limits Website tracking survey

Use and usefulness of Units Website

Topline results on website use (19 May 2008—22 October 2008)

Visits 345,400

(Could include repeat visitors)

Unique visitors 312,990

(Those who visited the site once only)

Page views 1,122,895

New site visits 90.57%

Fieldwork

Fieldwork was conducted from 16 July—8 August 2008, with 613 responses in total. The results are extremely promising with:

excellent

very good

— 95% found the information easy to understand

— 38% claimed they will try to keep track of what they drink

— 33% will discuss units of alcohol with friends, family or colleagues

— 31% will try to stay within the recommended daily limits.

TNS Presentation to DH, HO and COI

The TNS full presentation of the above interim findings from the TNS evaluation of the Know Your Limits—Units Campaign was given to DH, the Home Office and the Central Office for Information in September 2008.

Know Your Limits—Units Campaign—Background information

Reasons for the campaign:

— There are people of all ages who do not know their units or the guideline daily amounts for sensible drinking.

— Over the years, glass sizes and measures have increased, and so has the alcoholic content of many drinks. This makes judging units harder.

— Some people are still not aware of the links between alcohol consumption and harm to health.

Context of the campaign:

Know Your Limits campaign

Know Your Limits

Units

— The Units campaign launched in May 2008 and a further burst ran from November 2008, through to the end of January 2009.

Content of the campaign:

The campaign had two phases. Phase one focused on helping people (25+) to understand how many units there are in the alcohol they drink. Phase two promoted an understanding of the link between drinking alcohol and ill health.

The first burst of the campaign in May 2008 featured TV, outdoor, radio, press and online activity (including a new website nhs.uk/units). The campaign also included the provision of information and educational materials aimed at GPs and NHS staff.

Overall objectives of the campaign:

— to increase awareness of the units of alcohol in the most common drinks amongst the adult population aged 25+;

— to increase awareness of the recommended guideline daily amounts for sensible drinking (2-3 for women/3-4 for men);

— to increase understanding amongst the adult population of the health consequences of regularly exceeding the guideline daily amounts;

— to highlight sources of support to change drinking habits.

Note on the social marketing approach

Social marketing: The systematic application of marketing concepts and techniques to achieve specific behavioural goals for social or public good.

It's our health published by the independent National Consumer Council in 2006 recommended a move away from advertising-led public health communications focusing largely on awareness-raising, toward a social marketing approach, based on evidence, customer insight, and ultimately measured against behaviour change. (Evidence to support the efficacy of social marketing is set out in It's our health[2]).

The Government's social marketing programme for alcohol began in 2007 and has been built into its campaign work. Since May 2009, the programme has been featured as World Class Practice by the National Social Marketing Centre.[3]

II. ALCOHOL-RELATED MORTALITY

The Office for National Statistics ONS tracks the deaths directly attributable to alcohol. Death statistics for alcohol, published on 27 January 2009 for the UK show that:

— the trend in the rate of alcohol-related deaths is now levelling out, following rapid increases from the early 1990s, but;

ONS DATA ON ALCOHOL-RELATED DEATHS

Year	Number of deaths
2000	6,884
2001	7,499
2002	7,701
2003	8,164
2004	8,221
2005	8,386
2006	8,758
2007	8,724

— the Department aims to work with ONS to establish a broader estimate, which may well give higher figures than those published to date.

Estimated number of alcohol-related deaths per annum: NWPHO

— The NWPHO uses a more comprehensive method for calculating the number of alcohol-related deaths, which is broadly consistent with the alcohol-related admissions data in terms of the causes of alcohol-related ill health and death.

— The data published in the local alcohol profiles by the North West Health Observatory use a larger set of conditions (45) than ONS, including those that are partially attributable to alcohol.

— These figures remain an estimate (as with the alcohol-related hospital admissions figures) and NWPHO have estimated the proportion of deaths attributable to alcohol using information from medical research and survey data.

— The latest figures returned show alcohol-related death figures of 10,922 for males and 5,314 for females.

— Although these figures may still be an underestimate, they do provide a reliable indication of trends and point to a slight fall among males and a fairly constant rates among females.

NWPHO has published the rates (but not the underlying numbers) for 2003-2006. These show:

2003 2004 2005 2006

Males 41.10 40.16 40.17 39.75

Females 16.20 16.22 16.03 16.17

(These rates are direct standardised rates per 100,000 population).

Deaths from liver disease

— Chronic liver disease is the fifth most common cause of death in the UK. (Its primary causes are alcohol, hepatitis B or C infection and obesity).

— For men, the number of deaths per million from liver disease has more than doubled from 76 million in 1991 to 162 million in 2007.

— Between 1993 and 2006, the number of deaths from chronic liver disease in England more than doubled, from 2,774 to 5,852 and in 2007 it had reached 5,881.

— Increasing numbers of younger people are contracting and dying from liver disease the average age at death from chronic liver disease is 59.

Alcohol consumption

— In 1991 alcohol related deaths peaked at age 70 for both men and women. By 2005, the peak age for these was between 55 and 59.

— HM Revenue and Customs (HMRC) excise data on duty paid clearance for the domestic market showed a sustained rise in overall consumption up to 2004.

— HMRC data show a 24% increase in consumption between 1995 and 2004 with a fall of 2% in 2005 to 11.54 litres followed by a levelling out.

— HMRC data on clearances for 2007-08 suggested that the average adult in the UK purchased the equivalent of 11.53 litres of pure alcohol over the year. Self reported figures produced by GHS are very considerably lower, indicating that people are drinking far more than they think.

III. ANTABUSE

Antabuse

— It is a sensitising agent that produces an unpleasant reaction when taken with alcohol.

— It is one of the medications that can be used as an adjunct to the treatment of alcohol dependence

— It is used for relapse prevention in recovering alcoholics, after they have undergone detoxification and achieved abstinence.

— When taken under supervision to ensure compliance, it can be an effective component of relapse prevention strategies.

— However, there are unresolved research questions about its long-term effectiveness and there is no clinical consensus on its use.

How Antabuse works for the patient

The dependent drinker experiences unpleasant, negative consequences from drinking alcohol or anticipates this reaction.

These expectations may help stop them drinking. However, this effect may only persist while the drug continues to be taken. For this reason, provision of Antabuse may be more effective alongside a care plan involving additional psychosocial interventions.

How Antabuse works

Disulfiram inhibits the liver enzymes which would otherwise breakdown acetaldehyde, which is the principle metabolite of alcohol. Acetaldehyde is toxic and if the patient drinks alcohol while taking the drug he or she can experience flushing, sweating, tachycardia, nausea, vomiting and throbbing headache.

Use and Contraindications

The British National Formulary (BNF) advises that disulfiram is indicated for use only under specialist supervision, and details the contra-indications of use and potential side-effects.

Antabuse is contraindicated for patients with a number of health problems, including some associated with alcohol misuse, like cardiac failure, coronary artery disease, hypertension, and psychosis. (It is also contraindicated in pregnancy).

In addition, small amounts of alcohol included in many oral medications, even in mouthwash, used inadvertently, can precipitate an unpleasant reaction.

Current use and usefulness in England

Information on the use of Antabuse is not collected centrally other than in prescribing data. The table below shows the number of prescription items of Disulfiram (Antabuse) prescribed and dispensed in the community in England.

Year Disulfiram
items (000s)

2004 42.1

2005 42.3

2006 45.7

2007 47.0

2008 50.5

Source: NHS Business Services Authority

Antabuse is known to be used only in a small minority of cases of alcohol dependence in the UK. In the absence of a wide consensus on its use, Current provision is based on professional clinical judgement including discussion with particular patients about suitability in each individual case.

Currently, there is no consensus on the appropriate circumstances and extent of its use in the clinical management of alcohol dependence, nor on the duration of its use. Research reports suggest it has been widely used in the US in the past, despite limitations of the research evidence, but the extent of that use is not clear.

Action to improve knowledge

Following a referral by the Department of Health, the National Institute for Health and Clinical Excellence (NICE), is developing a clinical guideline on alcohol dependence and harmful alcohol use for England and Wales. As part of their review of the evidence on alcohol dependence treatment, NICE will be looking explicitly at Antabuse.

The NICE guidance will provide recommendations for good practice based on the best available evidence of clinical and cost effectiveness. NICE will identify any credible recommendations for re-positioning any interventions for optimal use, or changing the approach to care to make more efficient use of resources. The NICE guidance is due in January 2011.

Source of further information

Review of the effectiveness of treatment for alcohol problems National Treatment Agency for Substance Misuse, 2006. Inter alia, this document examines the research evidence on the use of Antabuse and notes that methodological problems make interpretation of the research data difficult.

Potential for further research

The MRC has identified addiction as a priority area for funding and developing the quality and extent of alcohol research will form a part of this. While we are not aware of any plans for further research specifically into disulfiram at this time, bids can be made to bodies such as the National Institute for Health Research for research in the NHS.

VI. NATIONAL ALCOHOL TREATMENT MONITORING SYSTEM (NATMS)

— Local health commissioners, in planning how they respond to alcohol problems in their area, need to consider whether current levels of provision for higher-risk and dependent drinkers are sufficient when deciding their priorities for future investment.

— Until recently, data was not routinely collected on individuals receiving specialist alcohol treatment services.

— From April 2008, all providers of specialist alcohol treatment have been asked to submit data to the National Alcohol Treatment Monitoring Service (NATMS) about clients receiving specialist treatment.

— The data will support the reduction of alcohol related hospital admissions and the wider Government strategy to reduce harm, and will provide information for commissioners on the provision of specialist alcohol services at a local level.

The NATMS process

Data is collected routinely and monthly updates are published on the NDTMS website. All or all most all providers of structured alcohol treatment are now reporting their data to the NATMS. Treatment and discharge data are updated each month and are provided at national level, SHA, PCT and service provider level.

"Year to Date" figures from NATMS indicate that 104,207 primary alcohol clients were treated in the year April 2008—March 2009 (around 10%, or 1 in 10, of the 1.1 million dependent drinkers). As these are new data, it is not possible to make a direct comparison with any previous year.

Nevertheless, these NATMS figures are heartening as they are higher than previous estimates of the numbers in specialist treatment. They indicate considerable movement towards the suggested objective of at least 15% that DH set for PCTs in its Commissioning Guidance in July 2009. For example, in 2005, the Alcohol Needs Assessment Research Report estimated that 63,000 (around 5.6%, or one in 18) of dependent drinkers in the country were treated for an alcohol problem in 2003-04.

The NTA make waiting times on alcohol treatment available to alcohol commissioners as part of their restricted access site. Nationally, there were 16,022 valid waits for a first alcohol intervention starting and 91% of these were within 6 weeks of referral.

NATIONAL ALCOHOL TREATMENT MONITORING SYSTEM (NATMS) DATA

WAITING TIMES (FIRST INTERVENTION), CLIENTS WITH ALCOHOL AS PRIMARY DRUG INTERVENTIONS (01/04/2008—31/03/2009)

Treatment modality	Numbers entering treatment	% waiting less than 3 weeks	% waiting less than 6 weeks	Average Waiting Times (weeks)
Total	104,207	80	91	2.1
Tier 3
Community Prescribing	5,597	77	93	2.1
Structured Psychosocial Intervention	35,383	79	90	2.3
ALC—Structured day programme	5,745	88	96	1.4
Other structured treatment	40,527	81	91	1.9
Tier 4
Inpatient detoxification	5,223	66	83	3.3
Residential rehabilitation	2,436	81	92	2.0
9,296 records did not specify the treatment entered.
September 2009

2 http://www.nsms.org.uk/public/default.aspx?PageID=48 Back

3 http://www.nsms.org.uk/public/CSView.aspx?casestudy=98 Back

4 ONS statistics on alcohol-related deaths in the United Kingdom 2007. Back

5 ONS statistics on alcohol-related deaths in the United Kingdom 2007. Back

6 NWPHO (www.nwph.net/alcohol/lape/download.htm) Back

7 Safe Sensible Social The next steps in the National Alcohol Strategy, 2007. Back



© Parliamentary copyright 2010	Prepared 8 April 2010