Health CommitteeWritten evidence from the Department of Health (GAS 01)

1. Our response below to the specific points in the terms of reference for the Committee’s inquiry is supplemented by a background paper1 which considers briefly:

the nature and seriousness of harm from alcohol in England (and the UK in some instances) today, along with some issues on alcohol and wellbeing;

trends in alcohol consumption and harm; and

a brief summary of which policy interventions work to change which drinking behaviours.

Establishing who is responsible within Government for alcohol policy in general, policy coordination across Whitehall and the extent to which the Department of Health should take a leading role

2. Alcohol policy particularly affects or is affected by a large number of different policy areas, for which other Government Departments are responsible, for example, the Department for Education, HM Treasury, the Department for Business, Innovation and Skills, the Department for the Environment, Food and Rural Affairs, the Department for Culture, Media and Sport, the Ministry of Justice, the Department for Communities and Local Government, the Department for Work and Pensions, the Scotland Office, the Wales Office, and the Northern Ireland Office.

3. Cross-Government policy coordination is vital. The Cabinet Office has worked closely with other Departments in development of the new Alcohol Strategy. The Cabinet sub-Committee on Public Health has a role in considering key public health policy issues such as alcohol, where a coordinated approach is essential to achieving shared and interdependent outcomes.

4. This coordination is equally important at a local level, as is made clear in the White Paper Healthy Lives Health People, which sets out the Government’s overall strategy for public health. Health and Wellbeing Boards will bring together councils, the NHS and local communities to understand local needs and priorities. The boards will be able to promote integration of health and social care services with health related services like criminal justice services, education or housing to meet these needs.

5. Within central Government, the Department of Health and the Home Office jointly have lead responsibility for alcohol policy within Government. This has been the case for a number of years and has not changed. We believe that joint responsibility by the two Departments is right, as alcohol misuse in the UK has major social impacts as well as major health impacts.

6. Responsibility for alcohol licensing policy was transferred from DCMS to the Home Office in June 2010. Because of this, the Home Office also has lead responsibility for policies impacting on the pricing of alcohol.

Coordination of policy across the UK with the devolved administrations, and the impact of pursuing different approaches to alcohol

7. Health and education are devolved policy areas in Scotland, Wales, and Northern Ireland. Devolution in other policy areas varies, with criminal justice, policing, and licensing devolved in Scotland and Northern Ireland, but not in Wales.

8. Devolution recognises the value of devolved solutions for problems that differ from the average UK picture. Alcohol health and social harms are notably greater in Scotland than the UK average.2 In both Wales and Northern Ireland, they are somewhat greater than the UK average.

9. It is important for the UK Government and the Devolved Administrations to work together on all areas of public policy—to share best practice in areas that are devolved; and to ensure policy in areas of reserved policy such as alcohol taxation and the regulation of broadcast advertising is taken forward in a way that benefits the whole of the UK.

The role of the alcohol industry in addressing alcohol-related health problems, including the Responsibility Deal, Drinkaware, and the role of the Portman Group

10. Both the Alcohol Strategy and Healthy Lives, Healthy People make clear that everyone has a part to play in improving public health, including government, business, the third sector and individuals themselves. We have made clear from the start that the Responsibility Deal is just one strand of the Government’s wide public health policy. It is part of our wider strategy to achieve responsible growth where economic development and businesses’ role in improving health and wellbeing go hand in hand.

11. Priorities for action to improve public health are defined by Government; and informed by research, advice from scientists, health professionals and others. But this does not mean that Government is necessarily best placed to deliver them. The Public Health Responsibility Deal is a new mechanism to deliver on these priorities.

12. The Responsibility Deal taps into the potential for businesses to improve public health through their influence over food, physical activity, alcohol, and health in the workplace. These are areas where “doing nothing” simply isn’t an option, but the “something” to be done is not necessarily best done by Government. However, that is not to say that Government does not have a role. The role of Government in this case is to facilitate action and to build the partnerships that will enable genuine advances to be made in a way that is consistent with the public health needs of the country.

13. A plenary group, chaired by the Secretary of State for Health, oversees the development the Public Health Responsibility Deal. This group includes senior representatives from the business community, the voluntary sector, non-governmental organisations and local government.

14. Alongside this, five networks—considering food, alcohol, physical activity, health at work and behaviour change—have been established to develop pledges for action that are the outputs of the Public Health Responsibility Deal. The networks are each supported by a Minister and industry and health NGO co-chairs. Their membership brings together a wide range of representatives from the business community, the voluntary sector, non-governmental organisations and local government.

15. Partners committing to pledges provide delivery plans, laying out how they intend to meet each of the pledges they have signed up to. They provide annual updates on their progress each year. A list of the alcohol pledges is included in Annex A.

16. The Responsibility Deal is already influencing what businesses are doing as well as peoples’ choices towards a healthier lifestyle, eg calorie information on menus, significant reductions in salt and removing artificial trans fats; improved alcohol unit labelling and clear warnings for pregnant women; and simple practical actions by employers to improve staff health with a resulting benefit on productivity.

17. The successes so far clearly demonstrate the potential that this voluntary approach has and we are now looking to broaden the impact by focusing on areas that will make the biggest difference such as the new pledge to remove one billion units of alcohol from the market by 2015.3

18. Companies signing up to this pledge are committing to reducing the number of units of alcohol that people drink, without necessarily reducing the number of drinks that they buy.

19. For example, Accolade Wines, the biggest wine company in the UK, is already leading the way in the drive towards lower alcohol wines—both through product innovation of new lighter wines and an incremental reduction in alcohol by volume (ABV) strength across large sections of their existing portfolio.

20. Their new 5.5% ABV wines are forerunners for a style that they are committed to extending across their portfolio and they have already gained listings in the major supermarkets. In addition to their commitment to lighter wines, they are also exploring ways to reduce the ABV on many of their different wine styles, whether by picking grapes earlier in the harvest or by other methods.

21. Modelling suggests that in a decade, removing one billion units from sales (from the current total of 52 billion units) is estimated to result in around 1,000 fewer alcohol related deaths per year; many thousands of fewer hospital admissions and alcohol related crimes, as well as substantial savings to health services and crime costs each year.

22. Reducing the amount of alcohol that people consume, without necessarily changing the number of drinks that they purchase has the benefit of both helping to reduce their chances of suffering an alcohol-related illness and also providing industry with a meaningful way to benefit public health without damaging the viability of their business.

23. Consumers will benefit from a greater range of choice of lower alcohol products and more easily available smaller measures, so that those looking to reduce their alcohol intake will find it easier to do so.

24. Achievement of the pledge will be measured on an industry-wide basis including using HMRC clearance data and sales data and ultimately assessed by the Alcohol Network’s monitoring and evaluation sub-group.

25. They will determine if the 1 billion units reduction can be identified as resulting from actions taken as part of this pledge ie that consumers drink the same products but which now contain less alcohol by volume, consumers switch to lower alcohol products, the actions that companies take increases the market share of lower alcohol products at the expense of those with higher alcohol content and consumers switch to smaller measures.

26. Drinkaware is an independent, UK-wide charity funded by donations from the alcohol industry and not from the public purse. Current funders include nearly all major retailers, pub companies and producers, who have pledged approximately £5.2 million per year through to 2012.

27. Drinkaware aims to change the UK’s drinking habits for the better. For those who choose to drink, they promote drinking within the lower-risk guidelines and look for innovative ways to challenge the national drinking culture.

28. One of the Responsibility Deal alcohol pledges is about support for Drinkaware: “We commit to maintaining the levels of financial support and in-kind funding for Drinkaware and the ‘Why let the Good times go bad?’” campaign as set out in the Memoranda of Understanding between Industry, Government and Drinkaware.

29. In addition, through the Responsibility Deal, Drinkaware has addressed unit awareness among adults and young adults through the development of two complementary initiatives with the British Beer and Pub Association and the Wine and Spirits Trade Association. The “2–2-2–1” creative, rolled out in pubs across the UK and in the off-trade, will provide consumers with a mnemonic device to help them remember unit guidelines.

30. As a market provider, Drinkaware is well placed to deliver some key messages, such as how strong drinks are (how many units are in each drink) and can reach environments (eg pubs) that no current Government brand can.

31. Their campaigns target those drinking above the lower-risk guidelines who are 30–45 year olds, employed, at-home and who drink to relax and unwind. This audience typically drinks wine and consumes alcohol above the lower-risk guidelines most days of the week.

32. The 2009 Addendum to the Drinkaware Memorandum of Understanding, requires a strategic review of their activities in 2012.

33. Under the aegis of a Steering Committee of stakeholders, the review will audit the effectiveness of Drinkaware’s performance against its objectives. It will require a review of the policy context, an analysis of Board papers and a wide range of other documents, possible interviews with industry, government and public health community representatives.

34. The results will inform Drinkaware’s 2013–2020 business planning and resources model.

35. The Portman Group was established in 1989 as a not for profit organisation funded by nine member companies who represent every sector of drinks production and collectively account for about 40% of the UK alcohol market.

36. It introduced a Code of Practice on the Naming, Packaging and Promotion of Alcoholic Drinks in 1996. All alcohol products sold or marketed in the UK are subject to the rules of the Code, which prevent alcohol being marketed to children or in a way that would encourage excessive or irresponsible consumption. This is a self-regulatory approach with enforcement—if a product is found to have infringed the Code, the Portman Group can issue a Retailer Alert Bulletin notifying retailers not to stock the product. The Code does not have legal status but is referenced in the statutory guidance that supports the Licensing Act.4 Licensing authorities can attach conditions that require premises to comply with these bulletins.

37. Portman Group members introduced a number of initiatives to help educate the public about responsible drinking. These include improved labelling, the widespread promotion of responsible drinking messages and contributing to the creation of Drinkaware. Portman Group members continue to provide significant funding for Drinkaware’s education and campaigning work.

38. The Portman Group has a direct interest in marketing, non-paid advertising and labelling; and regulates industry activity in these areas, working in partnership with the Advertising Standards Authority, which regulates paid advertising.

39. As part of the Responsibility Deal they have an interest in five of the eight collective pledges (labelling, funding for Drinkaware, on-trade information, under-age sales “Challenge” programs and advertising and marketing) and in some of the individual pledges that their members have made.

40. They have also published guidelines to businesses looking to implement the Responsibility Deal collective pledge on alcohol labelling and will report on the delivery of this pledge through an independent market survey.

41. A public consultation on the Portman Group Code of Practice on the Naming, Packaging and Promotion of Alcohol Drinks (as part of the Responsibility Deal pledge on marketing) closed in January 2012. This considers, among other things, the introduction of a code on sports sponsorship.

42. We will work with the Portman Group to make sure that the Code is robust and that it actively encourages marketing, which builds more positive associations.

The evidence base for, and economic impact of, introducing a fixed price per unit of alcohol of 40p, including the impacts on moderate and harmful drinkers; evidence/arguments for setting a different unit price; the legal complexities of introducing fixed pricing

Government approach

43. Currently, there is no minimum price threshold in place to prevent alcohol retailers from selling very cheap alcohol. As a consequence, alcohol has been so heavily discounted that it is now possible to purchase a can of lager for as little as 20p and a two litre bottle of cider for £1.69 with £42.1 billion being spent on alcohol in England and Wales in 2010 alone. The availability of such cheap alcohol has contributed to a culture of “binge-drinking”5 and excessive drinking, with significant impacts on health and crime.

44. As the Alcohol Strategy sets out, the availability of cheap alcohol in supermarkets and off-licences has resulted in practices such as “pre-loading” at home prior to a night out. In a recent study, 66% of 17–30 year olds arrested in a city in England claimed to have “pre-loaded”6 before a night out, with pre-loaders two and half times more likely to be involved in violence than other drinkers. This has contributed to a fifth of all violent incidents occurring in, or around, a pub or club. Responsible retailers, particularly those in the on-trade that typically offer a more controlled drinking environment, are less able to address the issues that take place on or around their premises without Government intervention to reduce the availability of cheap alcohol in supermarkets and off-licences.

45. The Government has therefore committed to introducing a minimum unit price for alcohol, but will consult on the level to be set.

46. Government analysts have carried out an initial estimation of the potential impacts of a 40p minimum unit price on health and crime considering a range of evidence and data including the Sheffield University study. However, these are only initial estimates and further research will be carried out through the Government’s Impact Assessment and forthcoming public consultation.

Evidence base for a 40p MUP

47. A large number of studies (including by the World Health Organisation and many academic reviews) agree that there is a close link between alcohol price changes and levels of consumption.

48. The expected impact of minimum unit pricing is borne out by experience in Canadian provinces that have implemented a similar policy: social reference pricing.7 Looking at Canada, there is a correlation between provinces that have introduced minimum pricing and those that have experienced sustained reduction in violent crime.

49. Government analysts have estimated that a 40p minimum unit price would lead to an estimated 30,000 fewer alcohol-related hospital admissions per year after 10 years, and approximately 50,600 fewer total crimes per year. This is expected to lead to an annual saving of £140 million in health and crime costs after 10 years.

50. Minimum unit pricing could also bring wider benefits, for example to productivity, as suggested by the Sheffield University study. Further work will be required to understand the magnitude of these effects in more detail.

Economic impact of a 40p MUP

51. A minimum unit price set at 40p per unit is unlikely to affect the on-trade as there is a significant price disparity between the off-trade and on-trade. The level of the minimum unit price will need to take into account the impact on alcohol duty receipts. We will take forward further work on the economic impact of minimum unit pricing as part of the Government’s Impact Assessment.

Impact on moderate and harmful drinkers

52. There is substantial evidence to suggest that cheap alcohol is targeted by those who consume the most alcohol overall and by under 18s who drink alcohol. Furthermore, those who consume the most alcohol are known to “shop around” for the cheapest form of alcohol.

53. ONS data from 2010 suggests that 22% of people say they drink regularly at levels above alcohol guidelines and academic research8 suggests that alcohol drunk as part of a binge drinking occasion accounts for over 50% of alcohol consumed.

54. The aim of minimum unit pricing is to end the sale of very cheap alcohol, drunk disproportionately by hazardous and harmful drinkers. Therefore, it is important that the minimum unit price is set at a level which affects an appropriate proportion of the market. If the level is set too low then it might not have any substantial impact and if it is set too high then it may begin to affect the majority of consumers who drink responsibly (moderate drinkers).

55. Specifically, the Sheffield study found that those who buy more alcohol are most affected by the price of alcohol, and changes in spending affect mostly harmful drinkers, with hazardous drinkers somewhat affected and spending for moderate drinkers affected very little (in terms of their consumption and spending). This issue will be further assessed in the Government’s Impact Assessment of minimum unit pricing.

Evidence/arguments for setting a different unit price

56. The Sheffield study found that general price increases lead to reductions in mean alcohol consumption with increasing benefits as the price per unit increases. This is partly due to limited scope for switching between products (because prices increase across the board) and partly because all consumer groups are targeted equally.

57. Sheffield University found that higher minimum unit prices will reduce switching effects. The study estimated overall changes in consumption for 20p, 25p, 30p, 35p, 40p, 45p, 50p, 60p, 70p, and showed that increasing levels of minimum pricing lead to steep reductions in alcohol consumption. Specifically, Sheffield estimates that a 40p minimum unit price will reduce alcohol consumption by 2.4%.

58. The estimated effect of setting a minimum price of 35p or below is that only the very cheapest alcohol products in the off-trade are likely to be affected. This is likely to affect only a limited amount of “loss-leading” products and is therefore unlikely to have a significant impact on reducing alcohol consumption and health and crime harms.

59. The estimated effect of setting a minimum price of 50p per unit or above is that products in the on-trade are more likely to be affected. This would have a more significant impact on health and crime harms, but may begin to affect moderate consumers disproportionately.

60. The Government is committed to reducing excessive alcohol consumption without unfairly penalising moderate drinkers. Therefore, the Government will consult on the level to be set for a minimum unit price and will consider the impact on moderate drinkers in its Impact Assessment.

The legal issues

61. There are number of issues to consider when implementing minimum unit pricing. The Government continues to take legal advice and will consider any potential legal implications as we take forward this proposal and consult on a proposed level of minimum unit price.

The effects of marketing on alcohol consumption, in particular in relation to children and young people

62. The Government continues to work closely with the independent and industry media regulators to ensure that any emerging concerns about the possible impact of advertising and marketing have been fully examined and that the latest evidence on the effects of marketing on alcohol consumption is properly reflected in the regulatory codes.

63. The most extensive recent systematic review of research undertaken in this area was the University of Sheffield’s, School of Health and Related Research review, commissioned by the Department of Health and published in 2008.9

64. The Sheffield review indicated that there was consistent evidence from longitudinal studies that exposure to TV and other broadcast media is associated with inception of and levels of drinking by young people. It noted that much of the evidence came in the form of cohort studies from the USA, New Zealand and otherwise outside the UK, but found there was sufficient consistency of effect across a wide range of advertising media to suggest the need for preventive measures, particularly as many of those affected are young people who are not legally able to purchase alcohol.

65. The Science Group of the European Alcohol and Health Forum published a review of longitudinal studies of the impact of alcohol advertising on young people in 2009, which came to similar conclusions.

66. We are also aware of a more recent study from the UK that has suggested exposure to alcohol marketing has an impact on both the likelihood of young people drinking and the frequency with which they drink, however, the authors note that further research exploring levels of exposure to alcohol marketing and association with youth drinking in the UK would be helpful.10

67. The Sheffield review found that there was substantial uncertainty in the evidence on the potential impact of advertising restrictions, including the effect of complete bans on alcohol advertising.

68. The Sheffield research also highlighted the on-going methodological debate on how advertising effects can and should be investigated and the inherent difficulties of evaluating the relationship between expenditure on advertising, restrictions on advertising, and alcohol consumption.

The impact that current levels of alcohol consumption will have on the public’s health in the longer term

69. The long term trend of UK alcohol consumption has been to follow growth in GDP and we are now at around the EU average for consumption and harm, with a tendency above the average to drink in binge patterns resulting in a high level of crime and social impacts.

70. Long term illness caused by alcohol tends for the most part to be the result of many years of sustained heavy drinking. For some illnesses, such as oesophageal cancer, research has shown that risks to an individual heavy drinker would continue to grow for two years after stopping drinking. The risks would then begin to fall, taking more than 20 years to fall to the level of a non-drinker.11

Any consequential impact on future patterns of service use in the NHS and social care, including plans for greater investment in substance misuse or hepatology services

Alcohol treatment and prevention

71. While there has been some improvement in provision for treatment of people dependent on alcohol, it is very likely that there is still significant under-provision overall. We estimate that numbers of people in England mildly or severely dependent on alcohol rose by 24% between 2000 and 2007.12 Without the decisive steps we are taking through our strategy to end the availability of cheap alcohol and to strengthen local powers to prevent the growth of alcohol misuse, it is likely that needs for treatment would grow in the future.

72. Levels of need vary greatly from place to place. It is right that plans for investment in alcohol treatment and prevention are for decision at local level. Our reforms to the NHS and Public Health will ensure a greater focus on commissioning of alcohol services to meet local needs.

73. The Department—and in future Public Health England—will support better local commissioning of alcohol treatment:

Through Payment by Results (PbR) programmes. The tools and learning from these programmes will be made available for local areas to incorporate into their local commissioning and service delivery systems.

By developing an evidence-based model to enable local areas to estimate needs for specialist alcohol treatment.

Through sharing best practice, including via the on-line Alcohol Learning Centre.

Liver disease

74. Alcohol is currently the single largest cause of liver disease. Approximately 60% of people with liver disease in England have alcoholic liver disease, which, in turn, accounts for 84% of liver deaths.

75. Around 9% of the male population and 4% of the female population of England are thought to be drinking at harmful levels, which means they are consuming more than 50 units and 35 units of alcohol per week, respectively. More than 90% of people who sustain drinking at these levels will go on to develop excessive fat accumulation in their livers—this is reversible if drinking is reduced, but, if not, 15–30% of those will develop more serious inflammation as a result and up to 10% could develop cirrhosis.13

76. The Department estimated that in 2006–07 liver disease was costing secondary and tertiary care in the NHS around £460 million per year. Based on a projected increase from Hospital Episode Statistics of 10% per annum, this would mean the cost of liver disease to the NHS would exceed £1 billion by 2015–16. This takes no account of the costs of GP visits for liver disease.

77. The Government believes that such severe financial pressure on the NHS from liver disease, as this is a preventable illness, is unacceptable. We expect the new Strategy to ameliorate this pressure.

78. The Liver Disease Strategy, to be published in due course, will set out our vision for how the NHS and local areas need to tackle liver disease better.

Whether the proposed reforms of the NHS and public health systems will support an integrated approach to future planning of services for people who experience alcohol-related harm

79. The Government’s reforms to public health and the NHS will empower local communities to shape their own responses to local issues. Preventing and responding to alcohol-related harm cannot be achieved by one agency or service alone. Effective partnership is essential.

80. Local authorities have a wide role covering such services as housing, benefits, and child care, a broad interest in the wellbeing of their communities, and a reach to all sections of the community, including deprived groups, which should enable them to carry out their new public health responsibilities effectively.

81. Local Authorities’ new public health responsibilities will mean they take on the main responsibility for commissioning alcohol prevention and treatment services, as we have described in the Strategy. For the first time, they will receive a ring fenced public health grant.

82. Alongside LA commissioned services the NHS will continue to have a vital contribution to preventing and treating health harm from alcohol.

83. It is the role of the Health and Wellbeing Boards to bring the whole system together to enable key local agencies to agree a strategic approach. They will maximise opportunities for integration between the NHS, public health and social care in promoting joint commissioning. This will also help to address properly the needs of specific groups, such as offenders.

84. Health and Wellbeing Boards are responsible for understanding local needs and priorities through the joint strategic needs assessment (JSNA) and are responsible for developing a joint Health and Wellbeing Strategy, which will provide the basis for both NHS and Public Health commissioning decisions.

85. We have retained the power for the Secretary of State to issue guidance on the preparation of JSNAs, and under the Health and Social Care Act 2012 we have a new power to issue guidance on the preparation of Joint Health and Wellbeing Strategies (JHWSs). New guidance to support Health and Wellbeing Boards in discharging their duties regarding JSNAs and JHWSs is currently under development and we will consult on this shortly. This guidance will not prescribe form or content of JSNAs and JHWSs as they are local strategic planning processes and need to be sensitive to local circumstances. The guidance will, however emphasise the need to consider a wide variety of needs and how they impact upon health and wellbeing outcomes, including drug and alcohol misuse.

86. The current JSNA support packs for local areas include an overview of the local population using alcohol treatment services. In the future, Public Health England will have the key role in support local areas to have an understanding of how this impacts on the health and wellbeing of their local communities.

International evidence of the most effective interventions for reducing consumption of alcohol and evidence of any successful programmes to reduce harmful drinking, such as:

public health interventions such as education and information;

reducing the strength of alcoholic beverages;

raising the legal drinking age; and

plain packaging and marketing bans

Public health interventions such as education and information

87. In 2005, the Department of Health and the Home Office commissioned a review of international evidence on the effectiveness of alcohol harm reduction communications and related campaigns.14 It found no clear cut evidence that mass media campaigns alone can achieve behavioural change, although clearly they have a role to play. It found that many evaluations do not measure behaviour change, but changes in awareness. It can also be difficult to separate the impact of a campaign from that of other interventions.

88. The review did find useful evidence about how to understand and analyse the behaviour of different target groups and how to segment groups according to their attitudes and beliefs, how to use the right mix of media for each target group, and how to seek to use other influences such as social norms. Crucially, it was clear that mass communications need to be supported by other interventions, if they are to be effective.

89. Social marketing campaigns however, remain an important strand within any alcohol strategy. The evaluation of the integrated marketing campaigns focused on alcohol related health harms in 2010 and 2012 demonstrate the effectiveness of recent campaigns in encouraging self-identification amongst at risk drinkers, acceptance of the potential health risks and reframing the “norms” around moderate drinking. These are important initial stages in the behaviour change journey.

90. A number of other international evidence reviews and studies have considered the effectiveness of education and information more broadly.15 Their findings are broadly consistent with those of the review we commissioned in 2005. The Department’s background paper considers further evidence from research we have commissioned.

91. There will be a UK-wide review of the alcohol guidelines, lead by Dame Sally Davies, the UK Government’s Chief Medical Officer, so that people at all stages of the life can make more informed choices about their drinking.

Reducing the strength of alcoholic beverages

92. The following international examples are taken from a rapid literature review by the Centre for Public Health, Liverpool John Moores University.

93. In Australia in the early 1980s differential tax rates for low (<3%abv) and full strength beers were introduced to promote consumption of lower-alcohol beer. Between 1980 and 2002, per capita consumption fell by 24% and lower strength beers now make up more than 20% of the total beer market.16

94. 50% of beer sales in the USA are now made up by <4.5% products and between 1999 and 2005 beer shipments increased by 8% but volume of pure alcohol rose by only 6%, suggesting that consumers were substituting lower strength products for regular/higher strength beers. A number of States have also introduced restrictions on the sale of beer eg Oklahoma and Utah only permit the sale of beer below 4% abv from supermarkets, petrol stations and convenience stores. In Oklahoma, full strength beers can only be sold from off-licences and by 2003 98% of beer sold was under 4% abv.17

95. A further study in the USA among university students found that substituting lower alcohol beers for regular beers did not result in a higher number of drinks being consumed when the students were unaware of the alcoholic content of the drink. It also recorded lower Blood Alcohol Concentration (BAC) levels when the lower-alcohol beers were consumed. A more recent study replicated these results.18

96. Studies conducted in Sweden found no significant additive trend among purchasing patterns following the introduction of a lower alcohol beer, although they also found no significant substitution effect as well. There was some evidence of both substitution and addition (consumers choosing the lower alcohol product over higher strength beers plus an increase in consumption of the lower alcohol beer in situations where no alcohol was previously consumed), but some of this was attributed to the relatively lower price of the lower alcohol beers compared to regular strength drinks.19 However, abolition of the sale of higher strength beers in grocery stores is credited with an overall reduction in alcohol consumption and alcohol-related harm amongst young people.20

97. Conversely, Finland found that allowing medium strength beers to be sold in grocery stores resulted in an increase in consumption. This is attributed to people switching up from lower strength beers rather than switching down from other higher strength drinks.21

Raising the legal drinking age

98. We are not aware of any international studies comparing the effectiveness of different minimum purchase ages in different countries, for example 18 or 21, although there is evidence that raising a minimum purchase age reduces harm.22 Minimum purchase ages vary between countries, although 18 is the most common legal limit within Europe.

99. We believe that a minimum purchase age should be set with reference to the evidence of harm to adolescents from drinking alcohol. The Chief Medical Officer for England published guidance on the consumption of alcohol by young people in December 2009. The report provides a comprehensive review of the scientific evidence on the links between alcohol-related harm and children and young people. It details key studies from an epidemiological review of the harms associated with adolescent alcohol consumption, upon which the guidance is based. It also draws on findings from a review of the associations between alcohol use and teenage pregnancy and consultation with the public, including parents and young people. The new advice was that:

An alcohol-free childhood is the healthiest and best option.

If children do drink alcohol, they should not do so until at least 15 years old.

If 15 to 17 year olds drink alcohol, it should be rarely, and never more than once a week. They should always be supervised by a parent or carer.

If 15 to 17 year olds drink alcohol, they should never exceed the recommended adult daily limits (3–4 units of alcohol for men and 2–3 units for women).

100. There is substantial evidence that introducing or raising a minimum purchase age reduces harm to young people from alcohol, including road casualties, alcohol-related injury admissions to hospital, and deaths from alcohol-related injury.

101. There is good evidence on the importance of enforcement and that low and inconsistent levels of enforcement can make it easy to purchase alcohol under age, especially when there is little community support for under age enforcement.23

102. The Government believes its actions set out in the Strategy to improve enforcement and increase penalties for businesses selling to under 18s are consistent with the evidence base and that this should be a priority for action in local communities. We very much welcome extended industry support for Community Alcohol Partnerships, which mobilise community support for better enforcement on under age purchase. We would wish to see this go further in the future.

Plain packaging and marketing bans

103. We have noted in the Strategy that some countries, such as Norway, have banned alcohol advertising altogether. France has banned TV and cinema advertising of alcohol, with controls on the content of advertising in other media. As we have noted already, evidence on the impact of such restrictions is very limited and it is very hard to show that they are proportionate.

104. Where there has been evidence of likely harm sufficient to justify action, UK regulators have acted robustly. In 2005, the advertising regulators, Ofcom and the Advertising Standards Authority (ASA) significantly strengthened the alcohol advertising rules in response to evidence which suggested that advertising has some influence on young viewers’ attitudes to drinking.

105. The current rules are designed to protect young people and vulnerable groups. In particular, the rules ensure that alcohol ads do not reflect or encourage any antisocial or undesirable behaviours associated with alcohol misuse. There are also extensive scheduling restrictions to protect young people.

106. As part of their most recent review of the advertising codes, the ASA’s code writing bodies, CAP and BCAP, undertook a comprehensive analysis of the latest research in this area, which included assessment of the Sheffield review. The advertising regulators’ analysis of the existing research highlighted uncertainty in relation to the evidence on the potential impact of alcohol advertising and on the merits of more extensive restrictions. CAP and BCAP took the view that there was insufficient evidence to suggest the already robust alcohol advertising rules needed to be strengthened further. However, as set out in the Government’s Alcohol Strategy, we will work with the ASA and Ofcom to examine ways to ensure that adverts promoting alcohol are not shown during programmes of high appeal to young people. We will also work with them to ensure the full and vigorous application of ASA powers to online and social media.

107. In addition to the advertising codes the Portman Group’s Code of Practice, supported throughout the alcohol industry, applies to the naming, packaging and promotion of alcoholic drinks. We look to the Portman Group to ensure that the UK drinks industry continues to promote its products in a socially responsible way, reflecting the best evidence. In broad terms, the Portman Group’s Code rules reflect the restrictions in the CAP and BCAP codes for advertising, for example, in prohibiting any encouragement of immoderate drinking, any association of drinking with sexual or social success, or inclusion of images of people aged under 25.

108. Plain packaging is not an intervention widely used for alcohol and we are not aware of any research on this.

109. We will continue to monitor the effectiveness of the UK’s advertising and marketing regulatory regimes to ensure the rules implemented by the regulators continue to be based on best evidence and sufficient to protect the public—children and young people in particular.

May 2012

Annex A

Responsibility Deal Alcohol Network—Alcohol Pledges

A1—Alcohol Labelling

We will ensure that over 80% of products on shelf (by December 2013) will have labels with clear unit content, NHS guidelines and a warning about drinking when pregnant.

A2—Awareness of Alcohol Units in the On –trade

We will provide simple and consistent information in the on-trade (eg pubs and clubs), to raise awareness of the unit content of alcoholic drinks, and we will also explore together with health bodies how messages around drinking guidelines and the associated health harms might be communicated.

A3—Awareness of Alcohol Units etc in the Off –trade

We will provide simple and consistent information as appropriate in the off-trade (supermarkets and off-licences) as well as other marketing channels (eg in-store magazines), to raise awareness of the units, calorie content of alcoholic drinks, NHS drinking guidelines, and the health harms associated with exceeding guidelines.

A4—Tackling Under—Age Alcohol Sales

We will provide simple and consistent information as appropriate in the off-trade (supermarkets and off-licences) as well as other marketing channels (eg in-store magazines), to raise awareness of the units, calorie content of alcoholic drinks, NHS drinking guidelines, and the health harms associated with exceeding guidelines.

A5—Support for Drinkaware

We commit to maintaining the levels of financial support and in-kind funding for Drinkaware and the “Why let the Good times go bad?” campaign as set out in the Memoranda of Understanding between Industry (MoU), Government and Drinkaware.

A6—Advertising & Marketing Alcohol

We commit to further action on advertising and marketing, namely the development of a new sponsorship code requiring the promotion of responsible drinking, not putting alcohol adverts on outdoor poster sites within 100m of schools, and adhering to the Drinkaware brand guidelines to ensure clear and consistent usage.

A7—Community Actions to Tackle Alcohol Harms

In local communities we will provide support for schemes appropriate for local areas that wish to use them to address issues around social and health harms, and will act together to improve joined up working between such schemes operating in local areas as:

Best Bar None and Pubwatch, which set standards for on-trade premises;

Purple Flag which make awards to safe, consumer friendly areas;

Community Alcohol Partnerships, which currently support local partnership working to address local issues, such as under-age sales and alcohol related crime, are to be extended to work with health and education partners in local Government; and

Business Improvement Districts, which can improve the local commercial environment.

A8—Unit Reduction

As part of action to reduce the number of people drinking above the guidelines, we have already signed up to a core commitment to “foster a culture of responsible drinking which will help people drink within guidelines”.

To support this we will remove 1bn units of alcohol sold annually from the market by Dec 2015 principally through improving consumer choice of lower alcohol products.

Individual Pledges


By 30 April 2011 we will no longer display alcohol in the foyers of any our stores.


We will provide an additional £1 million to tackle alcohol misuse by young people.


We will aim to remove 100 million units of alcohol from the UK market each year through lowering the strength of a major brand by 2013.


We will distribute 11 million branded glasses into the UK on trade showing alcohol unit information by end of 2011.


Three year project to extend the NOFAS-UK “What Do You Tell A Pregnant Woman About Alcohol” programme across England & Wales to inform over 1 million pregnant women of what they need to know about alcohol in pregnancy.

Molson Coors, Heineken & Bacardi Brown Forman.

We; Bacardi Brown-Forman Brands, Diageo, Heineken and Molson Coors commit to working with the BII (British Institute of Innkeeping) and The Home Office to support the continuation and further development of the Best Bar None scheme for at least the next three years. We will invest at least £500,000 (commencing May 2011) and add a further 20 schemes in that time.

Wine & Spirits Trade Association

Community Alcohol Partnerships (WSTA & supporting partners) We will expand the reach of Community Alcohol Partnerships (CAPs) in the UK through an investment of at least £800,000 by alcohol retailers and producers over the next three years. This will allow us to significantly increase the number of CAP schemes in local communities and extend the remit of CAPs beyond tackling under-age sales to wider alcohol-related harm and in particular.

Annex B

The Evidence on Alcohol Misuse and Harm in England Today

1. This evidence paper has been written in support of the Government’s alcohol strategy and as part of the Department’s evidence to the Health Committee’s inquiry. It considers briefly:

the nature and seriousness of harm from alcohol in England today, along with some issues on alcohol and wellbeing;

trends in alcohol consumption and harm; and

our view of which policy interventions work to change which drinking behaviours.

The Nature and Seriousness of Harm From Alcohol

The costs of alcohol misuse

2. We estimate the costs of alcohol misuse in England as follows:

NHS costs, at about £3.5 billion per year at 2009–10 costs.24

Alcohol-related crime, at £11 billion per year at 2010–11 costs.25

Lost productivity due to alcohol, at about £7.3 billion per year at 2009–10 costs (UK estimate).26

We estimate total costs at about £21 billion per year. This does not include any estimate for the economic costs of alcohol misuse to families and social networks.

Levels of alcohol consumption

3. People who drink alcohol vary enormously in how much they drink and how often, where and what they drink.

Over half (57%) of the population in 2009 said that they had not drunk alcohol, or drank alcohol only once in the previous week. 16% of the population were classified as non-drinkers.27

Around a quarter of adult men (26%) and a fifth of women (18%) reported drinking at levels which are above the NHS guidelines. 2.2m people (7% of men and 4% of women) said they drank more than twice the NHS guidelines, putting themselves at most risk of illness and death from alcohol.

While public concern has tended to focus on binge drinking by young people and young adults, it is worth noting that heavy drinking is not just a problem for the young. Particularly for men, drinking above the NHS guidelines in 2009 was greater for the age 45–64 group (31%) than for 16–24s (23%). The pattern was different for women with more 16–24s (23%) drinking above the guidelines than 45–64s (20%).

4. Self-reported data from surveys tend to underestimate true consumption levels. HM Revenue & Customs data show alcohol sold in the UK that is 67% more than the total that people report to surveys, eg those from the Office of National Statistics.

5. Taking account of under-reporting, we estimate that the highest consuming 10% of the population are drinking more than 40% of all alcohol consumed in the UK.

More than 40% of alcohol consumption is concentrated in 10% of the population28

Binge drinking

6. Some drinkers in England drink to drunkenness, a pattern known as “binge drinking”. In England, this is measured imperfectly in population surveys by reference to those who say they drank more than double the NHS guideline limits for men (ie more than eight units) and women (ie more than six units) on their heaviest drinking day in the previous week. This is not a perfect measure, as people vary a great deal in how drunk they become from the same amount of alcohol.

7. Several comparative studies within Europe show most northern European countries reporting more binge drinking compared with southern European countries, with the UK among those showing most weekly or monthly binge drinking.29

8. The UK has compared poorly with other European countries for drinking by 15–16 year old students in regular ESPAD30 surveys. The UK is consistently in the top five European countries for binge drinking and drunkenness among school children.31 Compared with other countries, young people in the UK are more likely to report that they drink alcohol at least weekly.32

9. Studies from the UK have shown that exposure to alcohol marketing has an impact on both the likelihood of young people drinking and the frequency with which they drink.33 These findings are consistent with the evidence of a number of longitudinal studies from other countries.34 , 35 The Government’s Alcohol Strategy proposes further work in the UK to minimise the harmful effects of alcohol advertising for young people.

Binge drinking in 15–16 year old students in Europe, defined as five+ drinks on a single occasion, three or more times in 30 days Source: ESPAD 2007 (Hibbell et al 2009). The data for Denmark and Spain has limited comparability.

Harms to health and social impacts from alcohol

10. Over 60 diseases or conditions can be caused by drinking alcohol.36 Alcohol can impact on health through three linked mechanisms:

11. Direct biochemical effects on the body: through long term consumption. The four biggest disease groups are heart disease, stroke, liver disease, and cancer.

12. In pregnancy, alcohol can cause a range of harms to the foetus, including miscarriage, low birth weight, cognitive deficiencies, and fetal alcohol spectrum disorders (FASD).

13. Like any food, alcohol contributes to calorific intake. We estimate that for adults who drink 9% of energy intake on average comes from alcohol.37 This is in a context where six in ten adults are overweight or obese.38

14. Risks of these diseases, broadly, rise in line with levels of consumption, with a main exception—there is a “J-shaped curve” for heart disease, meaning that low levels of drinking are associated with reduced risks for men over 40 and women post-menopause.39 This effect lessens for people over 70.40

15. Drunkenness, due to single, heavy drinking episodes (“binge drinking”) has been shown to have a number of health and social consequences on the drinker and/or on other people, such as:

Injuries, for example from falls.

Violence and aggression, including alcohol-related crime and disorder and domestic violence41 increase with drunkenness and with heavier drinking in general. If the heavy drinker is a parent, this can contribute to a variety of childhood mental and behavioural disorders.42 Systematic reviews have suggested that alcohol is a contributory factor in 16% of child abuse cases.43

Increased risk of stroke,44 heart arrhythmias, and sudden coronary death, even in people with no evidence of pre-existing heart disease45—any protective effect of regular, moderate consumption may be lost through binge drinking, even if this is infrequent.

Harming home life or marriage.46

Damaging work performance.47

Limiting young people’s educational attainment.48

16. The risk of alcohol dependence rises with both the volume of alcohol consumption49 and a pattern of binge drinking.50 The risk of dependence is increased by starting drinking at a young age.51 Alcohol dependence is most common among young adults. In 2007, there were an estimated 1.6 million moderately or severely dependent on alcohol in England. We estimate that, on a like for like basis, the numbers dependent rose by 24% between the 2000 and 2007 UK Adult Psychiatric Morbidity Surveys.

17. A clear association exists between mental ill heath and alcohol misuse. Alcohol psychoses and dependence account for a major part of the burden of ill health from alcohol, though a small proportion of deaths. Symptoms of depression and anxiety have been shown to increase with alcohol consumption.52 People with depression and mood disorders are at increased risk of alcohol dependence and vice versa.53 Many depressive syndromes improve markedly within a short period (days or weeks) of abstinence.54

Alcohol and violence

18. Research suggests:

a substantial proportion of incidents of aggression and violent crime involves one or more participants who have been drinking alcohol;55

increased risks of involvement in violence, including homicide, among heavy drinkers, with the risks stronger for intoxication than for overall consumption;56

an overall association between greater alcohol use and criminal and domestic violence, with particularly strong evidence from studies of domestic and sexual violence;57 the relationship is moderated by other factors such as culture, gender, and social class;

personality has also been found to be a mediating factor in the link between aggression and alcohol consumption. Studies have demonstrated that people who have high trait levels of aggression are more likely to behave aggressively under the influence of alcohol, but not necessarily when they are sober;58

a review of experimental studies has found that we are also affected by how we expect to behave when drunk. Studies have shown that when people believe they are consuming alcohol, they are more likely to be aggressive (even if they have not actually drunk any alcohol at all) than if they believe that they are consuming non-alcoholic drinks. However, the effect on aggression of drinking alcohol is greater than drinking a placebo;59 and

studies have found that the belief that alcohol is linked with aggressive behaviour is stronger in some cultures than others. However, there is little evidence showing cultural variations in the link between alcohol and observed aggressive behaviour (rather than the belief that alcohol and aggression are linked).60 , 61

Alcohol and crime

19. There is a strong link between alcohol and crime, disorder and anti-social behaviour, particularly violent crime. In 2010–11, according to the British Crime Survey, the victim believed the offender to be under the influence of alcohol in 44% of violent incidents (around 930,000), a significant reduction since 2009/10. This was the case in over a half (58%) of incidents of stranger violence and just under a third (31%) of domestic violence incidents. Nearly a quarter (24%) of BCS respondents in 2010–11 considered people being drunk or rowdy in public places to be a very or fairly big problem in their local area.

20. There is a link between the amounts of alcohol an individual drinks and increased offending. According to analysis of the Offending Crime and Justice survey,62 adult binge drinkers (18 to 65) were significantly more likely to have offended in the past 12 months than any other drinking group. Nearly a fifth (19%) of all adult binge drinkers reported committing an offence in the previous year compared with 6% of other regular drinkers and 3% of those who occasionally or never drank alcohol. There is also some evidence that people who “pre-load” before going out for further drinking are more likely to become involved in violent crime. A small scale local study found that those pre-loading were 2.5 times more likely to have been in a fight.63

21. Many of those are not long-term or repeat offenders, but acting up on alcohol. A recent evaluation of Alcohol Arrest Referral schemes found that around six out of 10 individuals participating in the schemes had no previous arrest history in the previous six months.64 This finding is consistent with a study of arrests around licensed premises in the West Midlands, which found that around 40% of those arrested for one or two violent offences had no other criminal involvement over a period of several years.

22. A significant amount of violence is linked to the night-time economy.65 As Figure 11 shows, a fifth (20%) of all violent incidents in 2010–11 took place in or around a pub or club. This rises to 30% for stranger violence. More than two thirds (67%) of violent offences occur in the evening or at night and 45% at the weekend.66

Figure 11


Source: British Crime Survey 2010/11

The burden of disease and death from alcohol

23. Disability adjusted life years (DALY) are a measure of combined ill health (adjusted for severity) and premature death. Alcohol is 10% of the UK burden of disease and death, as measured by DALYs lost-smoking is 15%.67 By this measure, alcohol is one of the three biggest lifestyle risk factors for disease and death in the UK, after smoking and obesity. This takes account of the net benefit from a reduced risk of heart disease for moderate consumption.

24. It is important to note that DALYs take account of long term health damage and loss of life, short term accidents and injuries, which account for a high proportion of early deaths, and the burden of ill health linked to dependence. It is all of these together that account for alcohol’s importance as a risk factor.

Alcohol and health inequalities

25. ONS data suggests lower than average consumption among those with the lowest weekly incomes.68 Health harm from alcohol appears to be highest among these groups. Over the years 2001–2005, alcohol-specific mortality in the most deprived quintile of local authorities in England was 5.5 times the rate of the least deprived.69

26. We need to understand more about why our current measures of drinking patterns do not account for the higher levels of alcohol related harms falling on more deprived communities. However, some of the disproportionate impact of alcohol on deprived communities may be due to under-reporting by higher risk drinkers in these groups—a recent study in Greater Manchester70 found that under-reporting was most evident with higher risk drinkers. Other possible reasons could include combinations of apparently lower risk levels of regular drinking with binge drinking, combinations of problematic drinking with smoking and unhealthy diets, and better access to social and financial support and to treatment and care by better off individuals.

Alcohol harm and the life course

27. Risks to health from alcohol occur at every age of life. This graph shows how the biggest net risks affect different adult age groups in England.71 The relatively young ages of those suffering deaths due to alcohol is apparent.

28. In England, the average years of life lost for men and women dying from alcohol-attributable conditions during 2003–05 was 20 years and 15 years respectively.72

Harm to young people from alcohol

29. The Chief Medical Officer for England’s 2009 guidance that young people under 15 should not drink alcohol at all is based on the fact that young people who start drinking alcohol at an early age drink more frequently and more than those who delay drinking; as a result, they are more likely to develop alcohol problems in adolescence and adulthood. Beginning to drink before age 15 is associated with:73

increased health risks, including alcohol-related injuries;

truancy, exclusion, and lower educational attainment;

involvement in violence;

suicidal thoughts and attempts;

having more sexual partners;

pregnancy and sexually transmitted infections;

using drugs; and

employment problems.

30. Young people who binge drink in adolescence (ie under 18) are more likely to be binge drinkers as adults and have an increased risk of developing alcohol dependence in young adulthood. They are also more likely to experience drug use and dependence, be involved in crime and be a victim of crime, and to achieve lower educational attainment by the time they are adults.

31. Research undertaken by North West Public Health Observatory74 found there was an association between alcohol-related hospital admissions and teenage pregnancy, in both males and females. This was true even after controlling for the effect of deprivation. The same was true of the more common sexually transmitted infections. There is evidence that alcohol consumption and being drunk can result in lower inhibitions and poor judgements regarding sexual activity and risky sexual behaviour. Early alcohol consumption means that young people have an increased likelihood of having sex at a younger age. Alcohol misuse is linked to a greater number of sexual partners, regretted or coerced sex. There is also a strong relationship between hazardous alcohol consumption and non-consensual sex.75

Impact on productivity of alcohol misuse

32. Work for the Prime Minister’s Strategy Unit published in 200376 summarised damage to productivity as:

increased sickness absence;

unemployment and early retirement from inability to work; and

premature deaths among economically active people of working age.

33. Our updated estimate (above) using the same methodology suggests a loss from all three factors of up to £7.3bn per year in 2009–10.

34. Research suggests additionally that heavy drinking and binge drinking episodes increase the risks of poor work performance and that the costs are likely to be considerable.

Fire and alcohol

35. The Department for Communities and Local Government (DCLG) carried out a study in 2011 into fires that occurred in people’s homes. This showed that alcohol resulted in 2,656 fires, resulting in 60 deaths and 1,267 injuries. The remaining 27,502 fires resulted in 85 deaths and 4,512 injuries.77 Where alcohol was a contributory factor, 49% of fire incidents resulted in casualties, compared to 14% for other fire incidents.

36. The estimated cost of fires where alcohol was suspected to be a contributing factor was almost £131 million. This compares to just over £286 million for other fires in the study.

Attitudes of the public—how good is the public’s understanding?

37. There is good evidence that the public in general underestimates the risks of excessive alcohol consumption. This is not unique to the UK.78

38. ONS surveys show that in 2009 only 13% of the public said they keep a check on the number of units they drink. This was the same figure in 1997. 90% of people had heard of units of alcohol (up from 79% in 1997), and the more people drank the more likely they were to have heard of units. Knowledge of the actual number of units in a particular drink was lower, but for frequent beer drinkers 69% know the correct number of units and 83% of frequent wine drinkers similarly.

39. Monitoring by Drinkaware suggests that (a) accurate understanding of the daily guidelines can be improved through social marketing and (b) this can easily be lost again, if social marketing campaigns are not sustained.79

40. After the Department of Health’s Alcohol Effects campaign in February 2010, awareness of the link with mouth cancer moved from 5% to 24%.

41. Individual long term health risks from alcohol can be difficult to grasp, in the same way as long term risks from over-eating and obesity.

Alcohol and Wellbeing

42. The Government’s wellbeing agenda seeks to give policy a broader focus than just economic growth. It sees quality of life as equally important.

43. Some drivers of wellbeing are those commonly considered in Government policy, for example, individuals’ own and their family’s health and the experience of crime in their local community.

44. Other drivers relate to issues like social relationships, social trust, and the opportunities for people to control or influence their situations.

45. The main positive impact of moderate alcohol consumption on adults’ wellbeing seems to relate to social forms of alcohol consumption, although research in this area is limited.80 Recent research in the North West of England shows a complex picture.81

46. While, clearly, alcohol consumption also happens in social settings in people’s own homes, there may be a particular value in the ways in which well run pubs provide opportunities for social interaction as part of an experience involving moderate drinking and sometimes eating.

47. However, an approach which does not favour “normalising” alcohol consumption at the expense of alternatives could be important for young people, given the evidence of the harm alcohol can do to their wellbeing, and for young adults, given that many still choose not to drink alcohol, or to drink it infrequently.82

48. There is good evidence, from what people themselves tell researchers, that excessive alcohol consumption is bad for individuals’ own wellbeing, not just for their health. It can also be damaging to the wellbeing of families and others close to heavy drinkers.83

Trends in alcohol consumption and harm

49. Trends in consumption have broadly followed growth in Gross Domestic Product (GDP), with gradual, but sustained, long term growth—UK consumption per head doubled between 1950 and the peak in 2004. Consumption fell by 12% from 2004 to 2009, of which 9% occurred in the two years 2008 and 2009. There was no further fall in 2010. The recent fall should also be viewed in the context of the long term rise of 91% in consumption per head since 1960.

50. The rising level of abstainers from alcohol is a trend of longstanding. 9% of the population were non-drinkers in 1992 and 16% in 2009.84 HMRC data on trends in consumption per head therefore understates the growth in consumption per drinker over that period.

51. UK average consumption is now at about the EU average, having been much below it. The average long term trend in EU countries was an increase to the mid-1970s, followed by a long term decline from about 15 litres pure alcohol per head to 11 litres per head.85 Countries such as France or Italy have shown much bigger declines in consumption per head since 1961 and are now very close to and below the UK level respectively.86

52. Binge drinking is measured imperfectly in population surveys in England by reference to those who say they drank more than double the NHS guideline limits for men (ie more than eight units) and women (ie more than six units) on their heaviest drinking day in the previous week. This is not a perfect measure, as people vary a great deal in how drunk they become from the same amount of alcohol. Recent trends in self-reported data used as a measure of binge drinking were as follows. Data before 2006 are not directly comparable, due to a change of methodology.87

A decline from 23% in 2006 to 19% in 2010 for men drinking more than eight units on at least one day.

A decline from 15% in 2006 to 12% in 2010 for women drinking more than six units on at least one day.

53. The decline between 2006 and 2010 was most marked for men and women aged 16–24—from 30% to 24% for men and from 27% to 17% for women,88 suggesting a possible link to economic weakness over that period.

Trends in alcohol consumption by young people

54. Survey data on drinking by 11–15 year olds89 suggests some reasons for encouragement, but with continuing concerns. While fewer young people are drinking, those who drink do have not reduced how much they drink. Data on units drunk before 2007 are not directly comparable, due to a change of methodology:

The proportion of 11–15 year old pupils who reported they had drunk alcohol in the last week fell from 18% in 2009 to 13% in 2010. The level has fallen in most years since 2001, when it was 26%.

In 2010, average alcohol consumed by pupils who had drunk in the last week was 13 units.

Alcohol consumed by those pupils who do drink was 12.7 units in 2007 (when the methodology changed) and 12.9 units in 2010.

The changing market dynamics

55. Since 2000, off-trade sales (eg. supermarkets, off-licences) of alcohol have come to be dominant over on-trade sales (eg. pubs, clubs). By 2009, the off-trade share had advanced to 65%.90


Litres per head of 100% alcohol consumed

Litres per head of 100% alcohol consumed

Litres per head of 100% alcohol consumed


2. On Trade

3. Off Trade

4. Total Trade









































56. The off-trade’s dominance of alcohol sales is the culmination of a long term trend to liberalise alcohol retailing. For example, in 1978 only one third of supermarkets had a licence to sell alcohol.91 Until the Licensing Act 2003 came into force (in late 2005), there were effective quantity limits on individual purchases from the off-trade—no more than 12 bottles of wine, for example.

57. The price of off-trade alcohol has fallen in real terms and this is probably a major factor in the off-trade’s increasing market share. Off-trade prices of wine and beer were broadly stable in cash terms and so well below Retail Price Inflation (RPI) from 1998 to 2006. On-trade prices have risen faster than RPI.


58. The following table suggests that a higher proportion of moderate drinkers than excessive drinkers choose to drink in the on-trade, but that young adult binge drinkers and many under 18s (many of whom will be 16–17 year olds) have tended to choose the on-trade as a preferred venue for drinking. This would tend to support the Government’s policies set out in our Strategy for tougher penalties and better enforcement on under-age sales of alcohol and to restrict the availability of cheap alcohol, particularly in the off-trade.


Average units per drinker per week

% consumption in the on-trade

% consumption in the off-trade

11–17 year old drinkers




18–24 year old binge drinkers




Age 25+ moderate drinkers




Age 25+ increasing risk drinkers




Age 25+ higher risk drinkers




Average for all drinkers




Promotional offers on alcohol

59. It is well established that people like offers and buy more when products are on offer, there is lots of evidence that when there are volume offers people buy more. The influence of multiple unit price promotions (volume offers) on sales was first evidenced by a field study by Blattberg and Neslin (1990).93

60. The decision about whether to consume the additional alcohol requires a trade-off between the pleasure derived from consumption today with the possible health harm in the future as a result of drinking too much today. Empirical studies have shown that the standard economic assumption that people will have the same preferences in the future as they have today, that is they will be able to balance today’s enjoyment with their desire for a healthy future, is incorrect and in fact people tend to overvalue the pleasure derived from consumption today.94

61. It is not unreasonable to expect that when people buy a bigger portion (because alcohol is on a volume based discount) they will tend to consume more. This is confirmed by research in other product areas such as food95 and would be consistent with clear findings on the effects of discounted alcohol promotions on increased drinking,96 as many such promotions are volume-based promotions.

Trends in alcohol-related harm

62. Over the last 10 years, health harms have continued to grow. Alcohol-attributable deaths in England rose by 7%, from 14,406 in 2001 to 15,479 in 2010. Over the same period, alcohol-specific deaths, ie from conditions wholly caused by alcohol, rose by 30%. In contrast, total deaths in England fell by 7%.97 The rate of liver deaths in the UK has nearly quadrupled over 40 years, a very different trend from most other European countries. Chronic liver disease can be driven by factors other than alcohol, notably obesity, although alcohol remains the main driver in the UK.

63. The rate of alcohol-related hospital admissions has also continued to rise by an average of 4% each year over the eight years 2002–03 to 2010–11. (Alcohol-related admissions are defined in the Public Health Outcomes Framework by reference to admissions where the primary diagnostic code is for an alcohol-related condition.)

64. There have been significant decreases since 1995 in the number of violent incidents believed by victims to involve offender(s) under the influence of alcohol. This is in the context of the overall fall in the number of violent crimes in which the proportion of alcohol-related incidents has remained similar over this period—41% in 1995 and 44% in 2010/11.98


Source: Adapted from British Crime Survey 2010–1199

Drink driving

65. Drink driving remains a significant cause of death and injury, even though drink drive casualties fell by more than 75% between 1979 and 2009. Deaths in Great Britain fell from 560 in 2006 to 380 in 2009.

66. Alcohol-related deaths are the third highest cause of deaths among under 25s, with drink drive deaths nearly half of these.

Policy Interventions

What kinds of interventions work to change drinking behaviour—and for whom?

67. Research shows that, typically, drinking patterns evolve as individuals grow and move through life, in response to changing social groups, partners, family, or work pressures. Life events such as becoming a parent, divorce, bereavement, or a health scare, may influence drinking—the same life events may trigger more drinking in one person, less in another.

68. Many people who drink heavily later cut down, without consciously being motivated—for example, they may feel they “have to” for work reasons, or feel less desire to drink with family responsibilities. In one study, only one third of a high risk cohort maintained higher risk drinking levels for as long as 8 years.100


69. Cutting down drinking with no direct intervention is most common among former binge drinkers,102 particularly in early adulthood.103 It is less common among those who are living alone, unemployed, or unavailable for work.104

70. Key points are:

“At risk” drinkers are not a static group. Many will dip in and out of risky drinking patterns throughout their lifetime.

Anyone drinking to excess may be at risk over time—at risk of health harm or at risk of dependence on alcohol. It is not currently possible to predict an individual who is most at risk.

Changing behaviour across a lifetime indicates broad reaching interventions, sustained over the long-term.105

There are some key stages in the lifecourse:

young people drinking too early and too much increase their risks of drinking problems and dependence later in life; and

young adults who drink heavily are also at particular risk of alcohol dependence, which may increase in severity and later become entrenched for a minority.

Yet, because many people change drinking patterns throughout their lifetime, all stages of life including adulthood and old age matter; typically, chronic diseases from long term heavy drinking will be incurred in middle age, resulting in early death.

Price Interventions

71. The strongest evidence for reducing population consumption is through increasing the price of alcohol.

72. A large body of evidence from extensive research on alcohol price also confirms that lower alcohol prices, or increasing affordability of alcohol, increase both consumption and harm.106 Lower prices or increasing affordability over a period of time may be likely, therefore, to reduce the impact of other interventions. While raising price is effective for reducing a population’s consumption, the evidence shows that this is no less effective for regular heavy drinkers and is particularly effective for young drinkers under 18.107

73. The aim of minimum unit pricing is to end the sale of very cheap alcohol, drunk disproportionately by the heaviest drinkers. There is substantial evidence (IFS, Sheffield University study and other academic reviews) to suggest that cheap alcohol is targeted by those who consume the most alcohol overall and by under 18s who drink alcohol. The expected impact of minimum unit pricing is borne out by experience in Canadian provinces that have implemented a similar policy: social reference pricing.108 There is a correlation between Canadian provinces that have introduced social reference pricing and those that have experienced a sustained reduction in violent crime.

Limiting Availability

74. Limiting availability is also well evidenced to reduce harm. Limiting availability through:

Reduced premises density.

Enforcing refusal to serve customers when drunk.

Restricting late night trading.

Enforcing the law on age of purchase.

is most effective in reducing binge drinking and alcohol-related crime109 and drinking by young people.110

Brief Interventions

75. Brief intervention (IBA) by health care workers is well evidenced and a cost-effective route to reduce consumption and harm among at risk drinkers.

76. A short interview with a trained health care professional at a “teachable moment”, such as a time of concern about the individual’s health, or after an accident, can change both attitudes and drinking behaviour.

77. This is effective for at risk drinkers, for those drinking above NHS guidelines. Dependent drinkers will usually need specialist treatment.

78. At least one in eight at risk drinkers reduce their drinking and experience improved health as a result—an even better outcome than for smoking cessation services.

79. Initial summary findings (March 2012) from the Alcohol Screening and Brief Intervention Research (SIPS) project may be found at: These cover primary care, hospital emergency departments, and probation. Later summaries are expected to report on impacts on health and re-offending.

80. Brief interventions were not found to be effective in a pilot scheme aiming to reduce offending in those individuals arrested for an alcohol-related offence.111

Specialist Treatment and Support

81. Specialist treatment and support is effective in treating severe alcohol dependence, but is usually accessed only in response to harm being experienced.

82. Alcohol dependence is a long-term condition, which may involve recurring relapses even after good quality treatment. Sufferers typically also experience multiple health problems and are heavy users of health services. Treating alcohol dependence, where successful, has been shown to prevent future illnesses and reduce health service use.

83. The Royal College of Physicians have long advocated the appointment of dedicated Alcohol Liaison Nurses in major acute hospitals to provide an in-reach service including staff training; advice on management of alcohol withdrawal and referral to specialist alcohol services in the community.112 , 113 Over an 18-month period, an Alcohol Liaison Nurse service in the Royal Liverpool Hospital had prevented about 15 admissions or re-admissions per month.

84. The UK Alcohol Treatment Trial (UKATT) found that £1 invested in treatment would save £5 in future costs across the public sector.114 These include reduced costs of health care and in the criminal justice system. 25% of patients involved in the UKATT study had a successful outcome, reporting no continuing alcohol-related problems and 40% of patients reported being much improved, reducing their alcohol problems by two thirds.115

85. NICE has reviewed the clinical evidence and cost-effectiveness information and released guidance on alcohol dependence and harmful alcohol use This guidance outlines the need to provide a comprehensive package of treatment for dependent drinkers that include assessment and engagement; care co-ordination; withdrawal management; psychosocial interventions; pharmacotherapy; and recovery services.

86. The High Impact Changes promoted by DH advocate the increase in treatment and support for dependent drinkers.116

Education and Information

87. Evidence for changing drinking behaviour through education or information alone is limited. But information can change attitudes and reinforce motivation among some groups.

88. A review of international evidence has shown limited evidence for mass media campaigns changing drinking behaviour, but some evidence that they can change attitudes.117

89. The evidence from research commissioned by the Department of Health is that the impact of communicating health risks is greater for less entrenched drinkers and those more motivated by long term health, such as people aged 35–54, those in ABC1 social groups, and many women. Younger adults tend not to see long term health risks as compelling.118

90. Research for previous Department of Health and Home Office campaigns suggests that most heavy drinkers in particular are not motivated to change their drinking behaviour by information alone. For them to change drinking behaviour consciously would require, inter alia:

A change in the balance of risks and consequences against the perceived benefits and enjoyment from their drinking.

Willingness to take personal responsibility and self-belief in the ability to change—even after cutting down as part of our research, many heavy drinkers did not believe they would sustain this.

A positive social and physical environment, a supportive network of friends or family and limited drinking triggers or temptations.

1 Annex B.


3 “As part of action to reduce the number of people drinking above the guidelines, we have already signed up to a core commitment to ‘foster a culture of responsible drinking which will help people drink within guidelines’. To support this we will remove 1 billion units of alcohol sold annually from the market by December 2015 principally through improving consumer choice of lower alcohol products.”

4 Guidance issued under section 182 of the Licensing Act 2003.

5 Binge drinking in the population is measured as the number who self-report drinking on their heaviest drinking day in the previous week more than eight units per day for men and more than six units per day for women.

6 Barton, A and Husk, K (forthcoming) Controlling pre-loaders: alcohol related violence in an English night time economy. Drugs and alcohol today.

7 Does minimum pricing reduce consumption? The experience of a Canadian province. Addiction (February 2012). T Stockwell et al.

8 Baumberg (2009), Alcohol & Alcoholism 44(5):523–528.

9 Independent Review of the Effects of Alcohol Pricing and Promotion, Part A: Systematic Reviews, University of Sheffield, 2008.

10 Gordon R et al (2010): The Impact of Alcohol Marketing on Youth Drinking Behaviour: A Two-stage Cohort Study, Alcohol and Alcoholism 45 (5): 470–480.

11 Rehm et al International Journal of Cancer 121, 1132–1137 (2007).

12 Data from the Adult Psychiatric Morbidity Survey, 2000 and 2007.

13 Unpublished report for the Department of Health, “Unmasking Liver Disease: the forgotten killer”, Bell Pottinger, 2009.

14 Edcoms (2005): Review of the evidence base around effective alcohol harm reduction, prepared for COI on behalf of DH and Home Office.

15 Anderson P, Baumberg B, Alcohol in Europe: a public health perspective: report to the European Commission, Institute of Alcohol Studies, 2006; WHO Expert Committee on Problems related to Alcohol Consumption, 2nd Report, World Health Organisation, 2007.

16 AC Neilsen (2006).

17 International Centre for Alcohol Policies (2007).

18 Geller et al (1991), Segal and Stockwell (2009).

19 Skog (1988) and Whitehead and Szandrowska (1977).

20 Ramstedt (2002).

21 Mustonen and Sund (2002) and Osterberg (2012).

22 Anderson P, Baumberg B, Alcohol in Europe: a public health perspective: report to the European Commission, Institute of Alcohol Studies, 2006.

23 Wagenaar, A C and Wolfson, M (1994): Enforcement of the legal minimum drinking age in the United States, Journal of Public Health Policy 15: 37–53; Wagenaar A C and Wolfson, M (1995): Deterring sales and provision of alcohol to minors: A study of enforcement in 295 counties in four states, Public Health Reports 110: 419–7.

24 The Department of Health has updated the previous estimate of around £2.7 billion at 2006–07 prices, using the same methodology.

25 The Home Office has recently updated the estimate of the cost of alcohol-related crime: £11 billion in 2010–11 prices. This figure includes the cost of general offences (like violent crime) that are alcohol-related, the cost to the Criminal Justice System of alcohol specific offences (like drink driving) and the cost of issuing Penalty Notices for Disorder. This estimate was arrived at using the same methodology as that which lay behind the widely quoted figure of £8–13 billion in 2006–07 prices. The previous estimate was presented as a range due to a methodological uncertainty, which has now been resolved. Further information is available on request from the Home Office.

26 The Department of Health has updated the previous estimate of around £6.4 billion at 2006–07 prices, using the same methodology.

27 Statistics on Alcohol, England 2011, Table 2.1 (Information Centre for Health and Social Care).

28 Policy options for alcohol price regulation: the importance of modelling population heterogeneity, Meier et al, Addiction 105, 383-393, 2009.

29 Anderson P, Baumberg B, Alcohol in Europe: a public health perspective: report to the European Commission, Institute of Alcohol Studies, 2006—this considers a range of comparative studies and methodological issues.

30 European School Survey Project on Alcohol and other Drugs,

31 ESPAD, 2007, Figure 29b.

32 Currie C, Gabhainn S N, Godeau E, et al (eds) (2008): Inequalities in young people’s health: Health behaviour in school aged children. International report from the 2005/23006 survey, WHO policy series: Health policy for children and adolescents, Issue 5.

33 Gordon R et al (2010): The Impact of Alcohol Marketing on Youth Drinking Behaviour: A Two-stage Cohort Study, Alcohol and Alcoholism 45 (5): 470–480.

34 Anderson et al (2009): Impact of Alcohol Advertising and Media Exposure on Adolescent Alcohol Use: A Systematic Review of Longitudinal Studies. Alcohol and Alcoholism 44 (3): 229-243.

35 Booth et al (2008): Independent review of the effects of alcohol pricing and promotion.

36 Corrao et al. (2004): A meta-analysis of alcohol consumption and the risk of 15 diseases. Preventive Medicine 38, 613–9.

37 National Diet and Nutrition Survey 2008–09 to 2009–10.

38 Health Survey for England 2009.

39 Gunzerath et al (2004): National Institute on Alcohol Abuse and Alcoholism Report on moderate drinking: Alcoholism: Clinical and Experimental Research 28, 829–47. Corrao et al (2000): Alcohol and Coronary Heart Disease: a meta-analysis. Addiction, 95(10), 1505–23.

40 Groenbaek et al (1998): Alcohol and mortality: Is there a U-shaped relation in elderly people? Age and Ageing 1998, 27, 739–44.

41 Wells S, et al (2005): Drinking patterns, drinking contexts and alcohol-related aggression among late adolescent and young adult drinkers. Addiction 100, 933-944. Wechsler et al (1994): Health and behavioural consequences of binge drinking in college: a national survey of students at 140 campuses, JAMA, 272, 1672–1677 Wechsler et al (1995): Correlates of college student binge drinking. American Journal of public health, 85, 921–6. Wechsler et al (1998): Changes in binge drinking and related problems among American college students between 1993 and 1997: results of the Harvard School of Public Health College Alcohol Study. Journal of American College Health, 47, 57–68. Komro et al (1999): The relationship between adolescent alcohol use and delinquent behaviours. Journal of Child and Adolescent Substance Abuse, 9, 13–28. Bonomo et al (2001): Adverse outcomes of alcohol use in adolescents. Addiction, 96, 1485–96. Swahn (2001): Risk factors for physical fighting among adolescent drinkers. American Journal of Epidemiology, 153, S72. Richardson and Budd (2003): Alcohol, Crime and Disorder: a study of young adults. Home Office Research Study, 263. London, Home Office Research, Development and Statistics Directorate. Swahn and Donovan (2004): Correlates and predictors of violent behaviour among adolescent drinkers. Journal of Adolescent Health, 34, 480–92. Wells et al (2005): Drinking patterns, drinking contexts and alcohol-related aggression among late adolescent and young adult drinkers. Addiction, 100, 933–944. Mirrlees-Black (1999): Domestic violence: Findings from a new British Crime Survey self-completion questionnaire. Home Office Research Study No 191. London, Home Office. Abbey et al (2001): Alcohol and Sexual Assault. Alcohol Health and Research World, 25(1), 43–51. Brecklin and Ullman (2002): The roles of victim and offender alcohol use in sexual assaults: results from the National Violence Against Women Survey. Journal of Studies on Alcohol, 63(1), 57–63. White and Chen (2002): Problem drinking and intimate partner violence. Journal of Studies on Alcohol, 63, 205–214. Lipsey et al (1997): Is there a causal relationship between alcohol use and violence? A synthesis of evidence. In: Galanter, M ed. Alcohol and Violence: Epidemiology, Neurobiology, Psychology, Family Issues. Recent Developments in Alcoholism, Vol 13, New York, Plenum Press, pp 245–282. Greenfeld (1998): Alcohol and Crime: An analysis of national data on the prevalence of alcohol involvement in crime. Report prepared for the Assistant Attorney General’s National Symposium on Alcohol Abuse and Crime. Washington DC, US Department of Justice. Heinz A. et al (2011): Cognitive and neurobiological mechanisms of alcohol-related aggression. Nature, Vol 12, 400-413. McKinney, CM. et al (2010): Does Alcohol Involvement Increase the Severity of Intimate Partner Violence? Alcohol Clinical and Experimental Research, Vol 34, No 4 655–8. Foran H M. and O’Leary D (2008): Alcohol and Intimate Partner Violence: A meta-analytic review. Clinical Psychology Review, 28, 1222–34. Klostermann K C. and Fals-Stewart W. Intimate partner violence and alcohol use: Exploring the role of drinking in partner violence and its implications for intervention. Aggression and Violent Behaviour, 11, 587–97.

42 Gmel, G Rehm, J (2003): Harmful alcohol use. Alcohol Research and Health 27, 52–62. Rossow, I (2000): Suicide, violence and child abuse: review of the impact of alcohol consumption on social problems. Contemporary drug problems 27, 397–434

43 English D R, et al, (1995): The quantification of drug caused morbidity and mortality in Australia. Canberra: Commonwealth Department of Human Services and Health. Ridolfo B, Stevenson C, (2001): The quantification of drug caused mortality and morbidity in Australia, 1998. Canberra, Australian Institute of Health and Welfare.

44 Hillbom, M and Kaste, M (1982): Alcohol intoxication: a risk factor for primary subarachnoid hemorrhage, Neurology, 32, 706–11.

45 Robinette et al (1979): Chronic alcoholism and subsequent mortality in World War II veterans, American Journal of Epidemiology, 109, 687-700. Suhonen et al (1987): Alcohol consumption and sudden coronary death in middle-aged Finnish men. Acta Medica Scandinavica, 221, 335–341. Wannamathee and Shaper (1992): Alcohol and sudden cardiac death, British Heart Journal, 68, 443–8. Mukamal et al (2005): (i) Drinking frequency , mediating biomarkers, and risk of myocardial infarction in women and men. Circulation. 112(10): 1406-13. (ii) Alcohol consumption and risk of atrial frbrillation in men and women: the Copenhagen City Heart Study. Circulation, 112(12), 1736–42.

46 Leonard and Rothbard (1999): Alcohol and the Marriage Effect. Journal of Studies on Alcohol (Suppl 13) 139–146S. Fu and Goodman (2000): Association between health-related behaviours and the risk of divorce in the USA, Journal of Biosocial Science, 32, 63–88.

47 Marmot et al (1993): Alcohol consumption and sickness absence: From the Whitehall II Study. Addiction, 88, 369–82. Rehm and Rossow (2001): The impact of alcohol consumption on work and education. In Klingemann H, Gmel G eds. Mapping the Social Consequences of Alcohol Consumption, pp 67–77, Dordrecht: Kluwer Academic Publishers. Gmel and Rehm (2003): Harmful Alcohol Use, Alcohol Research and Health, 27, 52–62. Mangione et al (1999): Employee Drinking Practices and Work Performance. Journal of Studies on Alcohol, 60, 261–270. Other studies are summarised and assessed in Alcohol, Work and Productivity, Scientific Opinion of the Science Group of the European Alcohol and Health Forum, September 2011.

48 A number of studies are summarised in the Chief Medical Officer for England’s, Guidance on the consumption of alcohol by children and young people: Supplementary Report, 2009.

49 UK Adult Psychiatric Morbidity Survey, 2000. A number of other studies are summarised in the Chief Medical Officer for England’s, Guidance on the consumption of alcohol by children and young people: Supplementary Report, 2009.

50 Caetano et al: DSM-IV alcohol dependence and drinking in the US population: a risk analysis, Annals of Epidemiology, 7, 542–549. Bonomo et al (2004): Teenage drinking and the onset of alcohol dependence: A cohort study over seven years. Addiction, 99, 1520–8. A number of other studies are summarised in the Chief Medical Officer for England’s, Guidance on the consumption of alcohol by children and young people: Supplementary Report, 2009.

51 De Wit et al (2000): Age at first alcohol use: a risk factor for the development of alcohol disorders. American Journal of Psychiatry, 157: 745–50.

52 Alati et al (2005): Is there really a J-shaped curve in the association between alcohol consumption and symptoms of depression and anxiety? Findings from the Mater University Study of pregnancy and its outcomes. Addiction 100, 643–651.

53 Regier et al (1990): Comorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) study. Journal of the American Medical Association, 264: 2511–2518 Merikangas et al (1998): Comorbidity of substance use disorders with mood and anxiety disorders: Results of the International Consortium in Psychiatric Epidemiology. Addictive Behaviours: An International Journal, 23(6): 893–907 Pirkola et al (2005): DSM-IV mood- anxiety- and alcohol use disorders and their comorbidity in the Finnish general population. Soc Psychiatry psychitar epidemiol 40, 1–10.

54 Brown and Schuckit (1988): Changes in depression among abstinent alcoholics. Journal of Studies on Alcohol, 49: 412–7 Dackis et al (1986): Evaluating Depression in Alcoholics. Psychiatry Research, 17(2): 105–9 Willenbring (1986): Measurement of Depression in Alcoholics. Journal of Studies on Alcohol, 49: 412–7 Davidson K M (1995): Diagnosis of depression in alcohol dependence: changes in prevalence with drinking status. British Journal of Psychiatry, 166: 199–204.

55 Murdoch, Pihl and Ross (1990): Alcohol and crimes of violence: present issues International Journal of the Addictions, 25, 1065–81. Budd (2003): Alcohol-related assault: findings from the British Crime Survey. Home Office on-line report 35/03

56 Rossow (2000): Suicide, violence and child abuse: review of the impact of alcohol consumption on social problems. Contemporary drug problems, 27, 397–434. Wells et al (2000): Alcohol-related aggression in the general population. Journal of Studies on Alcohol, 61, 626–632.

57 Mirrlees-Black (1999): Domestic violence: findings from a new British Crime Survey self-completion questionnaire. Home Office research study No 191, London, Home Office. Abbey et al. (2001): Alcohol and sexual assault, Alcohol Health and Research World, 25(1), 43-51. Caetano et al (2001): Alcohol-related intimate partner violence among white, Black and Hispanic couples in the United States, Alcohol Research and Health, 25, 58–65. Brecklin and Ullman (2002): The roles of victim and offender alcohol use in sexual assaults: results from the National Violence Against Women Survey, Journal of Studies on Alcohol, 63(1), 57–63.

58 Miller, C, D Parrott, and P Giancola, Agreeableness and Alcohol-Related Aggression: The Mediating Effect of Trait Aggressivity. Experimental Clinical Psychopharmacology, 2010. 17(6): p 445–455.

59 Bushman, B and H Cooper, Effects of Alcohol on Human Aggression: An Integrative Research Review. Psychological Bulletin, 1990. 107(3): p. 341–354. These studies focus on male reactions to alcohol and there is evidence that this is not applicable in females. For further information, see Gussler-Burkhardt, N and P Giancola, A Further Examination of Gender Differences in Alcohol Related Aggression. Journal of Studies on Alcohol and Drugs, 2005. 66(3): p 413–422.

60 MacAndrew, C and R B Edgerton, Drunken Comportment: A Social Explanation1969: Aldine.

61 Lindman, R and A R Lang, The Alcohol-Aggression Stereotype: A Cross Cultural comparison of beliefs. International Journal of Addictions, 1994. 29(1): p 1–13.

62 Matthews S and Richardson A (2005): The 2003 Offending Crime and Justice Survey: alcohol-related crime and disorder. Home Office Research Findings 261.

63 Hughes K, Anderson Z, Morleo M and Bellis M A (2008): Alcohol, nightlife and violence: the relative contributions of drinking before and during nights out to negative health and criminal justice outcomes, Addiction, 103(1), 60–65.

64 Blakeborough L, and Richardson A (2012) Summary of findings from two evaluations of Home Office Alcohol Arrest Referral pilot schemes. Home Office Research Report 60. Home Office: London.

65 Crime in England and Wales, 2010–11.

66 Chaplin R, Flatley J and Smith K (2011): Crime in England and Wales 2010–11, Home Office Statistical Bulletin 10/11, Home Office, London – Tables 7:

67 Balakrishnan R et al (2009): The burden of alcohol-related ill health in the United Kingdom, Journal of Public Health, Vol 31, No 3, 366–373.

68 Information Centre for Health and Social Care: Statistics on Alcohol: England, 2011, Table 2.11.

69 Indications of Public Health in the English Regions, 2008, Table 10.

70 Centre for Public Health (Liverpool John Moores University): Improving accuracy in recording alcohol consumption: a survey in Greater Manchester, May 2011.

71 North West Public Health Observatory: Analysis based on Jones L, Bellis M A, Dedman D, Sumnall H, Tocque K. 2008. Alcohol-attributable fractions for England. Alcohol-attributable mortality and hospital admissions. North West Public Health Observatory, Centre for Public Health, Liverpool John Moores University. ISBN: 978-1-906591-34-2 (data updated to 2010 mortality; NWPHO, March 2012).

72 Indications of Public Health in the English Regions, 2007, Association of Public Health Observatories.

73 Chief Medical Officer for England, Guidance on the consumption of alcohol by children and young people: Supplementary Report, 2009.

74 Bellis M et al (2009): Contributions of Alcohol to Teenage Pregnancy: An initial examination of geographical and evidence based associations. North West Public Health Observatory.

75 Gunby et al Gender differences in alcohol-related non-consensual sex; cross-sectional analysis of a student population, BMC Public Health 2012, 12: 216.

76 Strategy Unit Alcohol Harm Reduction Project, Interim Analytical Report, 2003.

77 Although the DCLG Incident Recording System return does not distinguish between alcohol or drugs related fires, it is possible to separate out casualties that were under the influence of either substance. The study concluded that while there will be a few only drugs related fires, the vast majority of fires were where alcohol was a contributing factor, or at least alcohol or alcohol and drugs related.

78 The World Health Report, 2002, Reducing Risks, Promoting Healthy Life, World Health Organisation.

79 Ability to state the guidelines correctly for women fell from 36% to 31% and for men from 34% to 30% between 2009 and 2010 (Drinkaware Trust).

80 Molnar et al (2009): A longitudinal examination of alcohol use and subjective wellbeing in an undergraduate sample. Journal of Studies on Alcohol and Drugs, Vol 70(5).

81 Bellis et al (2012): Variations in risk and protective factors for life satisfaction and mental wellbeing with deprivation: a cross-sectional study, North West Public Health Observatory (Centre for Public Health).

82 In 2009 62% of 16–17 year olds and 39% of 18–24 year olds said they drank no alcohol in the week before the survey. DH analysis of ONS General Lifestyle Survey.

83 Alcohol’s harm to others: reduced wellbeing and health status for those with heavy drinkers in their lives, by Sally Casswell, Ru Quan You and Taisia Huckle, Addiction 106, 1087–1094, 2011.

84 Statistics on Alcohol, England: 2004 and 2011.

85 Figure 4.1 in Anderson P, Baumberg B, Alcohol in Europe: a public health perspective: report to the European Commission, Institute of Alcohol Studies, 2006.

86 WHO, European Status Report on Alcohol and Health, 2010.

87 Smoking and Drinking among Adults, 2009, a report on the 2009 General Lifestyle Survey, ONS; and: General Lifestyle Survey Overview: A report on the 2010 General Lifestyle Survey, ONS.

88 Smoking and Drinking among adults, 2009, ONS.

89 Smoking, drinking and drug use among young people in England in 2010, Information Centre for Health and Social Care, July 2011.

90 BBPA Statistical Handbook, 2010.

91 Central Policy Review Staff report on alcohol, 1979.

92 Independent /review of the Effects of Alcohol Pricing and Promotion, University of Sheffield, 2008, from Table 28.

93 Blattberg, R C & Neslin, S A (1990). Sales Promotion: Concepts, Methods, and Strategies. Englewood Cliffs, NJ: Prentice-Hall, Inc.

94 See for example: Loewenstein, G (1987). Anticipation on the valuation of delayed consumption. Economic Journal, 87, 666–84.

95 Just, D R (2006), Behavioral Economics, Food Assistance, and Obesity Agricultural and Resource Economics Review 35/2 (October 2006) 209–220.

96 Independent Review of the Effects of Alcohol Pricing and Promotion, Part B, University of Sheffield, 2008.

97 Jones L, Bellis M A, Dedman D, Sumnall H, Tocque K. 2008. Alcohol-attributable fractions for England. Alcohol-attributable mortality and hospital admissions. North West Public Health Observatory, Centre for Public Health, Liverpool John Moores University. ISBN: 978-1-906591-34-2.

98 Chaplin R, Flatley J and Smith K (2011): Crime in England and Wales 2010–11. Home Office Statistical Bulletin 10/11, Home Office, London.

99 Chaplin R, Flatley J and Smith K (2011): Crime in England and Wales 2010–11. Home Office Statistical Bulletin 10/11, Home Office, London.

100 Birmingham Untreated Heavy Drinkers study.

101 Source: COI, created from Birmingham Untreated Heavy Drinkers study, wave 5 (2007) please note, typical example, does not reflect specific individuals.

102 Know Your Limits campaign tracking data, 2008: Females aged 25-40 claimed most success.

103 Jefferis et al (2005): Adolescent drinking level and adult binge drinking in a national birth cohort. Addiction, 100: 543–9.

104 Birmingham Untreated Heavy Drinkers study.

105 Babor T et al Alcohol: no ordinary commodity. Research and public policy. Oxford University Press, 2003 provides broad ranging discussion of evidence on harm from alcohol and effective policy interventions.

106 Independent Review of the Effects of Alcohol Pricing and Promotion, Part A: Systematic Reviews, University of Sheffield, 2008.

107 Modelling to assess the effectiveness and cost-effectiveness of public health related strategies and interventions to reduce alcohol-attributable harm in England using the Sheffield Alcohol Policy Model version 2.0, Report to the NICE Public Health Programme Development Group, 2009; Interventions on Control of Alcohol Price, Promotion and Availability for Prevention of Alcohol Use Disorders in Adults and Young People, University of Sheffield review for the NICE Public Health Programme Development Group, 2009.

108 Does minimum pricing reduce consumption? The experience of a Canadian province. Addiction (February 2012). T Stockwell et al.

109 Interventions on Control of Alcohol Price, Promotion and Availability for Prevention of Alcohol Use Disorders in Adults and Young People, University of Sheffield review for the NICE Public Health Programme Development Group, 2009.

110 Anderson P, Baumberg B. Alcohol in Europe: a public health perspective: report to the European Commission, Institute of Alcohol Studies, 2006.

111 Blakeborough L and Richardson A (2012): Summary of findings from two evaluations of Home Office Arrest Referral pilot schemes, Home Office Research Report 60, Home Office, London.

112 Alcohol—can the NHS afford it? London: Royal college of Physicians, (2001).

113 Alcohol Care Teams: to reduce acute hospital admissions and improve quality of care (

114 UKATT Research Team (2005b). cost-effectiveness of treatment for alcohol problems: Findings of the UK alcohol Treatment Trial. British Medical Journal, 331, 544–547.

115 UKATT Research Team (2005a). Effectiveness of treatment for alcohol problems: Findings of the randomised UK alcohol Treatment Trial (UKaTT). British Medical Journal, 311, 541–544.

116 Signs for improvement – commissioning interventions to reduce alcohol-related harm (2009). Department of Health. London.

117 Edcoms (2005): Review of the evidence base around effective alcohol harm reduction, prepared for COI on behalf of DH and Home Office; BMA Board of Science (2008): Alcohol Misuse: Tackling the UK Epidemic.

118 2CV (2008) Insight and action to help reduce levels of hazardous and harmful drinking, Qualitative research debrief.

Prepared 19th July 2012