Evaluation of work-based screening for early signs of alcohol-related liver disease in hazardous and harmful drinkers: the PrevAIL study.

BACKGROUND: The direct cost of excessive alcohol consumption to health services is substantial but dwarfed by the cost borne by the workplace as a result of lost productivity. The workplace is also a promising setting for health interventions. The Preventing Alcohol Harm in Liverpool and Knowsley (PrevAIL) project aimed to evaluate a mechanism for detecting the prevalence of alcohol related liver disease using fibrosis biomarkers. Secondary aims were to identify the additive effect of obesity as a risk factor for early liver disease; to assess other impacts of alcohol on work, using a cross-sectional survey. METHODS: Participants (aged 36-55 y) from 13 workplaces participated (March 2011-April 2012). BMI, waist circumference, blood pressure and self-reported alcohol consumption in the previous week was recorded. Those consuming more than the accepted UK threshold (men: >21 units; female: >14 units alcohol) provided a 20 ml venous blood sample for a biomarker test (Southampton Traffic Light Test) and completed an alcohol questionnaire (incorporating the Severity of Alcohol Dependence Questionnaire). RESULTS: The screening mechanism enrolled 363 individuals (52 % women), 39 % of whom drank above the threshold and participated in the liver screen (n = 141, complete data = 124 persons). Workplaces with successful participation were those where employers actively promoted, encouraged and facilitated attendance. Biomarkers detected that 30 % had liver disease (25 %, intermediate; 5 % probable). Liver disease was associated with the frequency of visits to the family physician (P = 0.036) and obesity (P = 0.052). CONCLUSIONS: The workplace is an important setting for addressing alcohol harm, but there are barriers to voluntary screening that need to be addressed. Early detection and support of cases in the community could avert deaths and save health and social costs. Alcohol and obesity should be addressed simultaneously, because of their known multiplicative effect on liver disease risk, and because employers preferred a general health intervention to one that focused solely on alcohol consumption.

Holidays, celebrations, and commiserations: measuring drinking during feasting and fasting to improve national and individual estimates of alcohol consumption.

BACKGROUND: Accurate measures of alcohol consumption are critical in assessing health harms caused by alcohol. In many countries, there are large discrepancies between survey-based measures of consumption and those based on alcohol sales. In England, surveys measuring typical alcohol consumption account for only around 60% of alcohol sold. Here, using a national survey, we measure both typical drinking and atypical/special occasion drinking (i.e., feasting and fasting) in order to develop more complete measures of alcohol consumption. METHODS: A national random probability telephone survey was implemented (May 2013 to April 2014). Inclusion criteria were resident in England and aged 16 years or over. Respondents (n = 6,085) provided information on typical drinking (amounts per day, drinking frequency) and changes in consumption associated with routine atypical days (e.g., Friday nights) and special dinking periods (e.g., holidays) and events (e.g., weddings). Generalized linear modelling was used to identify additional alcohol consumption associated with atypical/special occasion drinking by age, sex, and typical drinking level. RESULTS: Accounting for atypical/special occasion drinking added more than 120 million UK units of alcohol/week (~12 million bottles of wine) to population alcohol consumption in England. The greatest impact was seen among 25- to 34-year-olds with the highest typical consumption, where atypical/special occasions added approximately 18 units/week (144 g) for both sexes. Those reporting the lowest typical consumption (≤1 unit/week) showed large relative increases in consumption (209.3%) with most drinking associated with special occasions. In some demographics, adjusting for special occasions resulted in overall reductions in annual consumption (e.g., females, 65 to 74 years in the highest typical drinking category). CONCLUSIONS: Typical drinking alone can be a poor proxy for actual alcohol consumption. Accounting for atypical/special occasion drinking fills 41.6% of the gap between surveyed consumption and national sales in England. These additional units are inevitably linked to increases in lifetime risk of alcohol-related disease and injury, particularly as special occasions often constitute heavy drinking episodes. Better population measures of celebratory, festival, and holiday drinking are required in national surveys in order to adequately measure both alcohol consumption and the health harms associated with special occasion drinking.

Parental knowledge of alcohol consumption: a cross sectional survey of 11-17 year old schoolchildren and their parents.

BACKGROUND: Developing timely and effective strategies for preventing alcohol misuse in young people is required in order to prevent related harms since, worldwide, alcohol consumption was associated with 320,000 deaths amongst 15-29 year olds in 2004. Providing guidance and advice to parents is essential if alcohol misuse is to be reduced. However, prevention of risky behaviours is hampered if parents are unaware of the risks involved. METHODS: A cross-sectional school-based survey of parent-child dyads, simultaneously questioning 935 children aged 11-17 years old and their parent(s). Univariate and multivariate associations are reported between demography, alcohol behaviours and parental knowledge of their child's alcohol consumption. RESULTS: 41.1% (n = 384) of children reported drinking alcohol. Of these, 79.9% of their parents were aware of their child's alcohol consumption. Children aged 11-14 years had over a twofold greater odds of consuming alcohol without parental knowledge compared with 15-17 year olds (AOR: 2.7, 95% CI: 1.3-5.7). Of parent-child dyads where the child reported consuming alcohol, 92.7% of parents reported that they had spoken to their child about alcohol at least once in the past three months, whereas 57.3% of their children reported that this had occurred. Children who consumed alcohol and whose parents did not know they drank alcohol were less likely to report having a parental discussion about alcohol in the last three months (AOR: 0.4, 95% CI: 0.1-1.0) or report lifetime receipt of at least one other parenting protective measure (AOR: 0.5, 95% CI: 0.2-0.9) compared with those children who drank alcohol with parental knowledge. CONCLUSIONS: Whilst only small numbers of young adolescents in our sample were drinking alcohol compared with older adolescents, those who did were more likely to do so without their parents' knowledge. These two factors combined (drinking earlier and drinking without parental knowledge) could place children at risk of immediate harm. Further research is essential to identify whether public health strategies should be developed which could support parents to employ lifestyle parenting techniques even before the parent believes the child to be at risk.

The Big Drink Debate: perceptions of the impact of price on alcohol consumption from a large scale cross-sectional convenience survey in north west England.

BACKGROUND: A large-scale survey was conducted in 2008 in north west England, a region with high levels of alcohol-related harm, during a regional 'Big Drink Debate' campaign. The aim of this paper is to explore perceptions of how alcohol consumption would change if alcohol prices were to increase or decrease. METHODS: A convenience survey of residents (≥ 18 years) of north west England measured demographics, income, alcohol consumption in previous week, and opinions on drinking behaviour under two pricing conditions: low prices and discounts and increased alcohol prices (either 'decrease', 'no change' or 'increase'). Multinomial logistic regression used three outcomes: 'completely elastic' (consider that lower prices increase drinking and higher prices decrease drinking); 'lower price elastic' (lower prices increase drinking, higher prices have no effect); and 'price inelastic' (no change for either). RESULTS: Of 22,780 drinkers surveyed, 80.3% considered lower alcohol prices and discounts would increase alcohol consumption, while 22.1% thought raising prices would decrease consumption, making lower price elasticity only (i.e. lower prices increase drinking, higher prices have no effect) the most common outcome (62%). Compared to a high income/high drinking category, the lightest drinkers with a low income (adjusted odds ratio AOR = 1.78, 95% confidence intervals CI 1.38-2.30) or medium income (AOR = 1.88, CI 1.47-2.41) were most likely to be lower price elastic. Females were more likely than males to be lower price elastic (65% vs 57%) while the reverse was true for complete elasticity (20% vs 26%, P < 0.001). CONCLUSIONS: Lower pricing increases alcohol consumption, and the alcohol industry's continued focus on discounting sales encourages higher drinking levels. International evidence suggests increasing the price of alcohol reduces consumption, and one in five of the surveyed population agreed; more work is required to increase this agreement to achieve public support for policy change. Such policy should also recognise that alcohol is an addictive drug, and the population may be prepared to pay more to drink the amount they now feel they need.

Under-reporting of foetal alcohol spectrum disorders: an analysis of hospital episode statistics.

BACKGROUND: Internationally, 0.97 per 1,000 live births are affected by foetal alcohol syndrome (FAS). However, prevalence intelligence has been limited in the UK, hindering the development of appropriate services. This analysis compares hospital admissions over time, between regions and with alcohol-related admissions for adult females to assess whether established patterns (such as the North experiencing elevated harms) can be identified. METHODS: A retrospective analysis of hospital admissions data (April 2002 to March 2008) for foetal alcohol spectrum disorder (FASD)-related conditions: foetal alcohol syndrome (dysmorphic) (n = 457); foetus and newborn affected by maternal use of alcohol (n = 157); maternal care for (suspected) damage to foetus from alcohol (n = 285); and 322,161 women admitted due to alcohol-related conditions. RESULTS: Whilst the rate of admission for alcohol-related conditions in women aged 15-44 years increased significantly by 41% between 2002/03 and 2007/08 (p < 0.0001), no such increases were seen in the numbers of FASD-related conditions (all p < 0.05). Established regional rates of admission for alcohol-related conditions in women aged 15-44 years old were not associated with admission for FASD-related conditions. CONCLUSIONS: It would be expected that the North West and North East regions, known to have higher levels of alcohol harm would have higher levels of FASD-related conditions. However, this was not reflected in the incidence of such conditions, suggesting under-reporting. With incomplete datasets, intelligence systems are severely limited, hampering efforts to develop targeted interventions. Improvements to intelligence systems, practitioner awareness and screening are essential in tackling this.

A cross-sectional survey of compliance with national guidance for alcohol consumption by children: measuring risk factors, protective factors and social norms for excessive and unsupervised drinking.

BACKGROUND: The Chief Medical Officer for England has developed the first guidance in England and some of the first internationally on alcohol consumption by children. Using the most recent iteration of a large biennial survey of schoolchildren we measure the extent to which young people's drinking fell within the guidelines just prior to their introduction and the characteristics of individuals whose drinking does not; how alcohol related harms relate to compliance; and risk factors associated with behaving outside of the guidance. METHODS: A cross-sectional survey was conducted utilising a self-completed questionnaire with closed questions. A total of 11,879 schoolchildren, aged 15-16 years, from secondary schools in North West England participated in the study. Data were analysed using chi square and conditional logistic regression. RESULTS: Alcohol consumption is an established norm by age 15 years (81.3%). Acute alcohol related violence, regretted sex and forgetfulness were experienced by significantly fewer children drinking within the guidance (than outside of it). Over half of drinkers (54.7%) reported routinely drinking more heavily than guidance suggests (here ≥ 5 drinks/session ≥ 1 month), or typically drinking unsupervised at home or at a friend's home when parents were absent (57.4%). Both behaviours were common across all deprivation strata. Children with greater expendable incomes were less likely to consume within guidance and reported higher measures for unsupervised, frequent and heavy drinking. Although drinking due to peer pressure was associated with some measures of unsupervised drinking, those reporting that they drank out of boredom were more likely to report risk-related drinking behaviours outside of the guidance. CONCLUSIONS: Successful implementation of guidance on alcohol consumption for children could result in substantial reductions in existing levels of alcohol related harms to young people. However, prolonged social marketing, educational and parental interventions will be required to challenge established social norms in heavy and unsupervised child drinking across all social strata. Policy measures to establish a minimum price for alcohol and provide children with entertaining alternatives to alcohol should also increase compliance with guidance.

Use of fake identification to purchase alcohol amongst 15-16 year olds: a cross-sectional survey examining alcohol access, consumption and harm.

BACKGROUND: Despite legislation and enforcement activities to prevent underage access to alcohol, underage individuals continue to be able to access alcohol and to do so at levels which put them at significant risk of alcohol-related harm. METHODS: An opportunistic survey of 15-16 year olds (n = 9,833) across North West England was used to examine alcohol consumption, methods of access and related harms experienced (such as regretted sex). Associations between these were analysed using chi square and logistic regression techniques. RESULTS: Over a quarter (28.3%) of 15-16 year old participants who drank reported having bought their own alcohol. One seventh (14.9%) of these owned at least one form of fake identification for which by far the most common purchase method was online. Logistic regression analyses showed that those who owned fake identification were significantly more likely to be male (AOR = 2.0; 95% CI = 1.7-2.5; P < 0.001) and to receive a higher personal weekly income (comparing those who received > pound30 with those who received < or = pound10: AOR = 3.7; 95% CI = 2.9-4.9; P < 0.001). After taking into account differences in demographic characteristics and personal weekly income, ownership of fake identification was significantly associated with binge drinking (AOR = 3.5, 95% CI = 2.8-4.3; P < 0.001), frequent drinking (AOR = 3.0, 95% CI = 2.5-3.7; P < 0.001) and public drinking (AOR = 3.3, 95% CI = 2.5-4.1; P < 0.001) compared with those who did not own fake identification. Further, those who reported owning fake identification were significantly more likely to report experiencing a variety of alcohol-related harms such as regretted sex after drinking (chi square, all P < 0.001). CONCLUSIONS: Young people (aged 15-16 years) who have access to fake identification are at a particularly high risk of reporting hazardous alcohol consumption patterns and related harm. Owning fake identification should be considered a risk factor for involvement in risky drinking behaviours. Information on these hazards should be made available to schools and professionals in health, social and judicial services, along with advice on how to best to work with those involved.

Cross-sectional measures and modelled estimates of blood alcohol levels in UK nightlife and their relationships with drinking behaviours and observed signs of inebriation.

BACKGROUND: Management of nightlife in UK cities focuses on creating safe places for individuals to drink. Little is known about intoxication levels as measuring total alcohol consumption on nights out is complicated by early evening interviews missing subsequent consumption and later interviews risking individuals being too drunk to recall consumption or participate at all. Here we assess mixed survey and modelling techniques as a methodological approach to examining these issues. METHODS: Interviews with a cross sectional sample of nightlife patrons (n = 214) recruited at different locations in three cities established alcohol consumption patterns up to the point of interview, self-assessed drunkenness and intended drinking patterns throughout the remaining night out. Researchers observed individuals' behaviours to independently assess drunkenness. Breath alcohol tests and general linear modelling were used to model blood alcohol levels at participants' expected time of leaving nightlife settings. RESULTS: At interview 49.53% of individuals regarded themselves as drunk and 79.43% intended to consume more alcohol before returning home, with around one in ten individuals (15.38% males; 4.35% females) intending to consume >40 units (equal to 400 mls of pure alcohol). Self-assessed drunkenness, researcher observed measures of sobriety and blood alcohol levels all correlated well. Modelled estimates for blood alcohol at time of going home suggested that 71.68% of males would be over 0.15%BAC (gms alcohol/100 mls blood). Higher blood alcohol levels were related to drinking later into the night. CONCLUSIONS: UK nightlife has used substantive health and judicial resources with the aim of creating safer and later drinking environments. Survey and modelling techniques together can help characterise the condition of drinkers when using and leaving these settings. Here such methods identified patrons as routinely getting drunk, with risks of drunkenness increasing over later nights. Without preventing drunkenness and sales to intoxicated individuals, extended drinking hours can simply act as havens for drunks. A public health approach to nightlife is needed to better understand and take into account the chronic effects of drunkenness, the damages arising after drunk individuals leave city centres and the costs of people avoiding drunken city centres at night.

Teenage drinking, alcohol availability and pricing: a cross-sectional study of risk and protective factors for alcohol-related harms in school children.

BACKGROUND: There is a lack of empirical analyses examining how alcohol consumption patterns in children relate to harms. Such intelligence is required to inform parents, children and policy relating to the provision and use of alcohol during childhood. Here, we examine drinking habits and associated harms in 15-16 year olds and explore how this can inform public health advice on child drinking. METHODS: An opportunistic survey of 15-16 year olds (n = 9,833) in North West England was undertaken to determine alcohol consumption patterns, drink types consumed, drinking locations, methods of access and harms encountered. Cost per unit of alcohol was estimated based on a second survey of 29 retail outlets. Associations between demographics, drinking behaviours, alcohol pricing and negative outcomes (public drinking, forgetting things after drinking, violence when drunk and alcohol-related regretted sex) were examined. RESULTS: Proportions of drinkers having experienced violence when drunk (28.8%), alcohol-related regretted sex (12.5%) and forgetting things (45.3%), or reporting drinking in public places (35.8%), increased with drinking frequency, binge frequency and units consumed per week. At similar levels of consumption, experiencing any negative alcohol-related outcome was lower in those whose parents provided alcohol. Drunken violence was disproportionately associated with being male and greater deprivation while regretted sex and forgetting things after drinking were associated with being female. Independent of drinking behaviours, consuming cheaper alcohol was related to experiencing violence when drunk, forgetting things after drinking and drinking in public places. CONCLUSION: There is no safe level of alcohol consumption for 15-16 year olds. However, while abstinence removes risk of harms from personal alcohol consumption, its promotion may also push children into accessing drink outside family environments and contribute to higher risks of harm. Strategies to reduce alcohol-related harms in children should ensure bingeing is avoided entirely, address the excessively low cost of many alcohol products, and tackle the ease with which it can be accessed, especially outside of supervised environments.

Alcohol, nightlife and violence: the relative contributions of drinking before and during nights out to negative health and criminal justice outcomes.

AIMS: To explore differences in alcohol consumption and negative nightlife experiences between young people who drink prior to attending city nightlife venues and those who do not drink until reaching bars and nightclubs. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional survey of 380 young people (aged 18-35 years) in bars and nightclubs in a large city centre in the North-west of England. MEASUREMENTS: An anonymous questionnaire explored participants' basic demographics; frequency of utilizing nightlife; quantities of alcohol consumed prior to and during a typical night out in the city; and negative experiences in the city's nightlife in the previous year [fighting, being verbally abused, being sexually molested (e.g. groped) and being too drunk to walk]. FINDINGS: Participants who reported drinking prior to attending nightlife (e.g. at their own or a friend's home) reported significantly higher total alcohol consumption over a night out than those not drinking until reaching bars and nightclubs. Over a quarter (26.5%) of female and 15.4% of male alcohol consumption over a night out occurred prior to attending nightlife. Individuals who drink before going out were over four times more likely to report drinking >20 units on a usual night out and 2.5 times more likely to have been involved in a fight in the city's nightlife during the previous 12 months. CONCLUSIONS: Measures to tackle drunkenness and alcohol-related violence in nightlife should expand beyond those targeted solely at nightlife environments. Continued disparities in pricing and policing of alcohol between on- and off-licensed premises may increase at-home drinking prior to nights out and alcohol-related problems in residential areas.

Predictors of risky alcohol consumption in schoolchildren and their implications for preventing alcohol-related harm.

BACKGROUND: While alcohol-related health and social problems amongst youths are increasing internationally, both consumption and associated harms are particularly high in British youth. Youth drinking patterns, including bingeing, frequent drinking and drinking in public spaces, are associated with increased risks of acute (e.g. violence) and long-term (e.g. alcohol-dependence) health problems. Here we examine economic, behavioural and demographic factors that predict these risky drinking behaviours among 15-16 year old schoolchildren who consume alcohol. A cross-sectional survey was conducted among schoolchildren in North West England (n = 10,271) using an anonymous questionnaire delivered in school settings. Analysis utilised logistic regression to identify independent predictors of risky drinking behaviour. RESULTS: Of all respondents, 87.9% drank alcohol. Of drinkers, 38.0% usually binged when drinking, 24.4% were frequent drinkers and 49.8% drank in public spaces. Binge, frequent and public drinking were strongly related to expendable income and to individuals buying their own alcohol. Obtaining alcohol from friends, older siblings and adults outside shops were also predictors of risky drinking amongst drinkers. However, being bought alcohol by parents was associated with both lower bingeing and drinking in public places. Membership of youth groups/teams was in general protective despite some association with bingeing. CONCLUSION: Although previous studies have examined predictors of risky drinking, our analyses of access to alcohol and youth income have highlighted eradicating underage alcohol sales and increased understanding of children's spending as key considerations in reducing risky alcohol use. Parental provision of alcohol to children in a family environment may also be important in establishing child-parent dialogues on alcohol and moderating youth consumption. However, this will require supporting parents to ensure they develop only moderate drinking behaviours in their children and only when appropriate.