Supplementary memorandum by the Department
of Health (AL 01B)
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
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
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;
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.
For the pilots for higher-risk drinkers,
there is also a world first in interactive web-based support and
advice and the booklet Your drinking and you.
Efficacy of Government campaignsSummary
The success of Government Know Your
Limits campaigns is assessed and evaluated robustly against
Key Performance Indicators (KPIs) at regular intervals.
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.
Requests for the booklet Your drinking
and you outstripped expectations, prompting an early reprint.
To date, over 30,000 have been requested
Evaluation of the Know your limitsunits
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
There were 522 respondents to tracking
research undertaken at mid wave (ie after the initial burst
The tracking research was carried out
by TNS from 16 June7 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 awareness69% 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:
At the pre-wave (ie before the
campaign) only 7% of drinkers correctly said that there were 10 units
in a bottle of wine (13.5% ABV) but this rose significantly to
13% at the mid-wave (after the initial burst of advertising);
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.
The campaign is reaching a good proportion
of the population:
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
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 200822 October
| (Could include repeat visitors)
| (Those who visited the site once only)
New site visits
Fieldwork was conducted from 16 July8 August
2008, with 613 responses in total. The results are extremely
74% rating the website as excellent or very
good, and most (81%) claiming they would recommend the site
95% found the information easy to understand
38% claimed they will try to keep track of what they
33% will discuss units of alcohol with friends, family
31% will try to stay within the recommended daily
TNS Presentation to DH, HO and COI
The TNS full presentation of the above interim findings from
the TNS evaluation of the Know Your LimitsUnits Campaign
was given to DH, the Home Office and the Central Office for Information
in September 2008.
Know Your LimitsUnits CampaignBackground 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
Some people are still not aware of the links between
alcohol consumption and harm to health.
Context of the campaign:
In October 2006, the Home Office and DH launched the
first ever Know Your Limits campaign aimed at 18-24 year
old binge drinkers. This ran again in October 2007 and January
In May 2008, the Know Your Limits campaign,
included unit awareness. This Units campaign targets all
drinkers over the age of 25.
The Units campaign launched in May 2008 and a
further burst ran from November 2008, through to the end of January
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
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
to increase understanding amongst the adult population
of the health consequences of regularly exceeding the guideline
to highlight sources of support to change drinking
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).
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.
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,
there were 8,724 alcohol-related deaths in 2007,
more than double the 4,144 recorded in 1991;
in 2007 the alcohol-related death rate for all
persons was 13.3 per 100,000 population, compared with
6.9 per 100,000 in 1991; and
ONS DATA ON ALCOHOL-RELATED DEATHS
|Year||Number of deaths
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 North West Public Health Observatory estimates
that the 2006 total for alcohol attributable mortality was
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
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:
|(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.
Excessive alcohol consumption is associated
with between 15,000 and 22,000 deaths per annum.
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.
Antabuse is the trade name for
the drug disulfiram.
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
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
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
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
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.
| 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
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
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
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 2008March 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
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
NATIONAL ALCOHOL TREATMENT MONITORING SYSTEM (NATMS) DATA
WAITING TIMES (FIRST INTERVENTION), CLIENTS WITH ALCOHOL
AS PRIMARY DRUG INTERVENTIONS (01/04/200831/03/2009)
% waiting less
than 3 weeks
% waiting less
than 6 weeks
|Structured Psychosocial Intervention||35,383
|ALCStructured day programme||5,745
|Other structured treatment||40,527
|9,296 records did not specify the treatment entered.
ONS statistics on alcohol-related deaths in the United Kingdom
ONS statistics on alcohol-related deaths in the United Kingdom
NWPHO (www.nwph.net/alcohol/lape/download.htm) Back
Safe Sensible Social The next steps in the National Alcohol
Strategy, 2007. Back