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Literature searches completed on 27.7.99

Chapter 2: Alcohol misuse

This bulletin is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation.
Alcohol misuse causes a substantial number of deaths, injuries and other health problems. UK rates of drinking in excess of sensible limits are high, particularly amongst young people in Wales.
The Statements The Evidence
2.1 Prevalence
2.1a. The misuse of alcohol has a high prevalence in the UKi. In 1996, it was estimated that 27% of male and 14% of females over 18s drank in excess of sensible limits. Trends reflect rising consumption for women across all age groups and in young men. 6% of men and 2% of women drink at harmful levelsii. i. The 1997 Health Education Monitoring Survey. London: Office for National Statistics, 1998
http://www.ons.gov.uk/nsils_f.htm [accessed 3.3.00]
(Type IV evidence – statistics)

ii. Health Related Behaviour: Prevalence of Alcohol Consumption above 21/14 Units a week for Men/Women aged 18 and over. General Household Survey 1996. London: The Stationery Office, 1998
(Type IV evidence – statistics)
2.1b. Amongst young people, research shows that the age at which young people begin to drink is decreasing, whilst the amount drunk and the frequency of consumption has increased, often in the context of other high risk activity including the use of illicit drugsi-iii. Comparative studies across Europe have also found that 15 year olds in Wales in 1990 and 1993/4 were consuming significantly more alcohol than young people of the same age in other European countriesiv. i. Newcombe R, Measham F, Parker H. A survey of drinking and deviant behaviour among 14/15 year olds in North West England. Addiction Research 1995; 2(4): 319 – 341.
(Type IV evidence – cohort study of 776 young people)
ii. Miller P McC, Plant M. Drinking, smoking and illicit drug use among 15-16 year olds in the United Kingdom. British Medical Journal 1996; 313: 394-397
http://www.bmj.com/cgi/content/full/313/7054/394 [accessed 3.3.00]
(Type IV evidence – cross-sectional survey of 70 secondary schools)

iii. Royal College of Physicians and British Paediatric Association. Alcohol and the Young. London: Royal Colleges of Physicians, 1995
(Type V evidence – expert opinion)
iv. Harkin AM, Anderson P, Lehto J. Alcohol in Europe - A Health Perspective. Copenhagen: WHO Regional Office for Europe, 1995
(Type V evidence – expert opinion)
2.1c. Some 4,500 deaths in the UK in 1996 were directly attributable to alcohol misuse and it was implicated in up to 40,000 deaths in totali,ii. It is also a major factor in causing injuries, including 15% of road traffic accidentsiii, 30% of pedestrian accidentsiii, and 25% of work related accidentsiv. Alcohol misuse has been associated with up to 47% of drowningsv. i. Office for National Statistics. Mortality Statistics, Cause, England and Wales, 1997. London: Stationery Office, 1998
(Type IV evidence – statistics)
ii. Raistrick D, Hodgson RJ, Ritson B (eds.); Society for the Study of Addiction. Tackling Alcohol Together. The Evidence Base for a UK Alcohol Policy. London: Free Association Books, 1999
(Type V evidence – expert opinion)
iii. Department of Environment, Transport and the Regions. Road Accidents Great Britain. 1997. The Casualty Report. London: DETR, 1998
(Type IV evidence – statistics)
iv. International Labour Office. Responses to Drugs and Alcohol in the Workplace. Geneva: ILO, 1987. (cited in National Alcohol Strategy, Alcohol Concern.)
(Type V evidence – expert opinion)
v. Hingson R, Howland J. Alcohol and non-traffic unintended injuries. Addiction 1993; 88: 877-883
(Type IV evidence – 36 studies of drowning incidents)
2.1d. Significant health problems associated with alcohol use include hypertension, haemorrhagic stroke, cardiovascular disease, and liver cirrhosis as well as alcohol dependence and other behavioural and social problemsi, ii. i. Royal College of Physicians, Royal College of Psychiatrists and the Royal College of General Practitioners. Alcohol and the Heart: Sensible Limits Reaffirmed. London: Royal College of Physicians, 1995
(Type V evidence – expert opinion)
ii. Anderson P, Babor TF and Edwards G et al (eds). Alcohol Policy and the Public Good. Oxford: Open University Press, 1994.
(Type V evidence – expert opinion)
2.1e. It is estimated that 8 out of 10 people needing treatment at Accident and Emergency Departments at peak times have alcohol-related injuries or problemsi. i. Waller S, Thom B, Harris S, Kelly M. Perception of alcohol related attendances in A & E departments in England: A National Survey. Alcohol and Alcoholism 1998; 33(4): 354-361
(Type IV evidence – survey, in 1997, of all Accident and Emergency Departments in England)

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2.2 Public Education and Campaigns

2.2a. Information campaigns can improve knowledge and raise awarenessi, ii. For example drink driving campaigns have been shown to increase public awareness, heighten perceived risk of detection when drinking and driving and raise awareness of the penaltiesiii, iv. It is recommended that effectiveness will be maximised if campaigns are placed within a broader context of community actioni, ii.
(Health gain notation - 2 "likely to be beneficial")
i. Gorman DM, Speer PW. Preventing alcohol abuse and alcohol related problems through community intervention: A review of evaluation studies. Psychology and Health 1996; 11: 95-131
(Type I evidence – systematic review of 8 community based studies)
ii. Gerstein D, Green L (eds). Preventing Drug Abuse What Do We Know? London: Committee on Drug Abuse Prevention Research, National Research Council, National Academy Press, 1993.
(Type V evidence – expert opinion)
iii. Holder H. Mass communication as an essential aspect of community prevention to reduce alcohol in traffic crashes. Alcohol, Drugs and Driving 1994; 10 (3-4): 295-307
(Type III evidence – non randomised community trial)
iv. Hingson R, McGovern T, Heeren T, Winter M, Zakocs R. Impact of the Saving Lives Program, 19th Annual Alcohol Epidemiology Symposium, Krakow, Poland, June 1993, cited in Edwards G et al (eds). Alcohol and the Public Good. Oxford: Open University Press, 1994
(Type V evidence – expert opinion)
2.2b. Educational messages will be more effective if tailored for specific sub groups of recipients, for example, children, adolescents, young adults, elderly and specific situations such as at work, during pregnancy and if driving, in order to help clarify the advice around safe limits and the benefits of alcoholi,ii.
(Health gain notation - 2 "likely to be beneficial")
i. Health Promotion With Young People for Prevention of Substance Misuse. Health Promotion Effectiveness Review. London: Health Education Authority, 1997
http://www.hea.org.uk/research/download/ereview5.html [accessed 3.3.00]
(Type V evidence – expert opinion based on a systematic review)

ii. Anderson P, Babor TF and Edwards G et al (eds). Alcohol and the Public Good. Oxford: Open University Press, 1994
(Type V evidence – expert opinion)
2.2c. The sensible limits recommended by the Royal Colleges of Physicians, Psychiatrists and General Practitioners are:
Low risk: 0-14 units of alcohol per week for women and 0-21 units for men.
Increasing risk: 15-35 units of alcohol per week for women, 22-50 units per week for men
Harmful: over 35 units per week for women and over 50 units per week for meni,ii,iii.
One study has identified a strong positive relation between alcohol consumption and risk of mortality from stroke, with men drinking 35 or more units, having double the risk of non-drinkers, even after adjustment. Overall, risk of all cause mortality was higher in men drinking 22 or more units a weekiv.
1 unit = 1 glass of wine or 1 single spirits or half pint of beer.
i. Royal College of Physicians, Royal College of Psychiatrists and the Royal College of General Practitioners. Alcohol and the Heart: Sensible Limits Reaffirmed. London: Royal College of Physicians, 1995
(Type V evidence – expert opinion)
ii. Marmot M. A not so sensible drinks policy. Lancet 1995; 346: 1643-4,
(Type V evidence – expert opinion)
iii. Edwards G. Sensible Drinking. Doctors should stick with the independent medical advice. British Medical Journal 1996; 312: 1-2, http://www.bmj.com/cgi/content/full/312/7022/1 [accessed 3.3.00]
(Type V evidence – expert opinion)

iv. Hart CL, Davey Smith G, Hole DJ, Hawthorne VM. Alcohol consumption and mortality from all causes, coronary heart disease and stroke: results from a prospective cohort study of Scottish men with 21 years of follow up. British Medical Journal 1999; 318: 1725-1729. http://www.bmj.com/cgi/content/full/318/7200/1725 [accessed 3.3.00]
(Type IV evidence – prospective cohort study of 5766 men)
2.2d. Campaigns can contribute to an effect on the social climate surrounding alcohol use. They can be used to reinforce specific environmental efforts to reduce high risk drinking in general, and drinking and driving in particulari. Messages will be most effective when combined with pressures from legal and other restrictionsii, iii.
(Health gain notation - 2 "likely to be beneficial")
i. Holder H. Mass communication as an essential aspect of community prevention to reduce alcohol-involved traffic crashes. Alcohol, Drugs and Driving 1994; 10(3-4): 295-307
(Type III evidence – non randomised community intervention trial)
ii. Anderson P, Babor TF and Edwards G et al (eds). Alcohol and the Public Good. Oxford: Open University Press, 1994
(Type V evidence – expert opinion)
iii. Harkin AM, Anderson P, Lehto J. World Health Organisation Regional Office for Europe. Alcohol in Europe - a health perspective. Copenhagen: WHO, 1995
(Type V evidence – expert opinion)
2.2e. When campaigns/information are supplemented with more interactive, or personally directed interventions, this is more likely to direct behaviour changei,ii,iii.
(Health gain notation - 2 "likely to be beneficial")
i. Health Promotion With Young People for Prevention of Substance Misuse. Health Promotion Effectiveness Review. London: Health Education Authority, 1997
http://www.hea.org.uk/research/download/ereview5.html [accessed 3.3.00]
(Type I evidence – systematic review)

ii. Anderson P, Babor TF and Edwards G et al (eds). Alcohol and the Public Good. Oxford: Open University Press, 1994
(Type V evidence – expert opinion)
iii. Anderson K. Young People and Alcohol, Drugs and Tobacco. World Health Organisation Regional Publications European Series No. 66. Copenhagen: WHO, 1995
(Type V evidence – expert opinion)
2.2f. Health Benefits. Advice has been given that men over 40 and postmenopausal women may reduce the risk of coronary heart disease by drinking between 1 – 2 units of alcohol a day. Other recommendations include nil consumption of alcohol where maximum physical co-ordination and cognitive ability is required such as driving or operating machinery; lower benchmarks for pregnant women and the need to avoid heavy sessional drinking and intoxicationi.
Any message which increases drinking on the basis of hoped for gains in coronary heart disease prevention, would be likely to result in more harm to the population than benefitii.
(Health gain notation - 6 "likely to be ineffective or harmful")
i. Department of Health. Sensible Drinking: The Report of an Inter-Departmental Working Group. London: Department of Health, 1995
(Type V evidence – expert opinion)
ii. Anderson P, Babor TF and Edwards G et al (eds). Alcohol and the Public Good. Oxford: Open University Press, 1994
(Type V evidence – expert opinion)

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2.3 Minimal Interventions
2.3a. Minimal interventions delivered at a primary care level i.e. a few minutes of advice and encouragement, are effective in reducing alcohol consumption and associated harm, especially amongst male excessive drinkersi-iii.
(Health gain notation - 1 "beneficial")
Caveat: Different interventions will be required to target younger, heavier drinkersiv. It should be noted that some primary care staff feel inadequately trained to cope with the issue and time is often a barrier. There may be a need for training and raising awareness of other specialist help available.
Further research into the potential of similar interventions being delivered in a community setting by non-specialist staff such as social workers, probation officers and other front line generic workers is recommended.
i. Bien TH, Miller VR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction 1993; 88(3): 315-336
(Type I evidence – systematic review of 32 studies)
ii. Brief interventions and alcohol use. Effective Health Care 1993; 7
(Type I evidence – systematic review of 7 randomised controlled trials)
iii. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. A randomized controlled trail in community based primary care practices. Journal of the American Medical Association 1997; 277(13): 1039-1045
(Type II evidence – randomised controlled trial of 723 subjects)
iv. Edwards AGK, Rollnick S. Outcome studies of brief alcohol interventions in general practice: the problem of lost subjects. Addiction 1997; 92 (12): 1699-1704.
(Type V evidence – expert opinion)
2.3b. The potential of administering minimal or brief interventions has yet to be firmly establishedi,ii,iii. One study has shown promising results providing brief interventions (three counselling sessions) delivered by trained nurses.
(Health gain notation - 4 "unknown")
More research is needed, however, to clarify who should deliver the intervention, to whom (those that recognise their problem or as an opportunistic intervention) and in what way – a formal counselling session or as part of A & E routine (stitching or dressing)ii.
i. Green M, Setchell J, Hames P, Stiff G, Touquet R, Priest R. Management of alcohol abusing patients in accident and emergency departments. Journal of the Royal Society of Medicine 1993; 86: 393-395
(Type III evidence – pilot intervention study of 104 patients identified with an alcohol problem)
ii. Hodgson R, Abbasi T, John B, Smith A. Alcohol Problems in A & E: A Window of Opportunity. (Paper commissioned by the Health Education Authority) Cardiff: Cardiff Addiction Research Unit, University of Wales College of Medicine, 1999
(Type III evidence – intervention study in 3 Accident & Emergency Departments in England)
iii. Heather N (1996) The public health and brief interventions for excessive alcohol consumption: the British experience. Addictive Behaviours 1996; 21(6): 857-868
(Type III evidence – non-systematic review of intervention studies)

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2.4. Family

2.4a. Family social learning and family processes are an important influence on adolescent alcohol use in a positive and negative wayi,ii,iii,iv.
(Health gain notation - 2 "likely to be beneficial")
Caveat: Prevention programmes have rarely included parents, guardians or siblings as an integral part of the prevention approach.
Research is needed into the effectiveness of programmes which include a family component, combining drug and alcohol prevention skills with other general parenting skills.
i. Elmguist, DL. A systematic review of parent-orientated programmes to prevent children’s use of alcohol and other drugs. Journal of Drug Education 1995; 25(3): 251–279
(Type IV evidence – systematic review and analysis of 72 programmes)
ii. Foxcroft DR, Lowe G Adolescent drinking behaviour and family socialisation factors: a meta analysis. Journal of Adolescence 1991; 14: 255-273
(Type IV evidence – systematic review of 30 observational studies)
iii. Fergusson DM, Lynskey MT, Horwood JL. Childhood exposure to alcohol and adolescent drinking patterns. Addiction 1994; 89(8): 1007-1016.
(Type IV evidence – cohort study, from birth, of 1265 children)
iv. Foxcroft DR, Lowe G. Adolescents alcohol use and misuse: the socialising influence of perceived family life. Drug: Education, Prevention and Policy 1997; 4(3): 215–229
(Type IV evidence – questionnaire study of 4000 school pupils)
2.5. The Workplace
2.5a. The workplace can be an effective setting in influencing patterns of alcohol consumption and reducing alcohol related problemsi,ii,iii. Intervention should take place in the context of a workplace alcohol policy which covers the following.
  • Drinking at the workplace.
  • Workplace discipline.
  • Recognition and help for those with alcohol related problems.
  • Alcohol education.

(Health gain notation - 2 "likely to be beneficial")

i. Hermansson MSW, Knutsson, A Ronnberg, S, Brandt L. Feasibility of brief intervention in the workplace for the detection and treatment of excessive alcohol consumption. International Journal of Occupational and Environmental Health 1998; 4(2): 71-78
(Type III evidence – screening intervention of 327 employees)
ii. Henderson, MM, Davies JB, Hutcheson, G et al. Alcohol in the Workplace. London: Department of Education and Employment, 1995
(Type V evidence – expert opinion)
iii. Fauske S, Wilkinson DA, Shain M. Communicating alcohol and drug prevention strategies and models across cultural boundaries: preliminary report on an ILO/WHO/UNDCP (International Drug Control Program) Interagency Program. Substance Use and Misuse 1996; 31 (11-12): 1599–1617
(Type V evidence – expert opinion)
iv. Faculty of Public Health Medicine. Preventing the  Harm Related to Alcohol Use: Reducing the Individual Risk. Guidelines for Health Promotion No.47. London: Faculty for Public Health Medicine, 1996
(Type V evidence – expert opinion)
2.5b. Brief interventions may work well in the workplace settingi. One study identified 80% of employees as being amenable to alcohol screening as part of their regular occupation health check. There is also growing support within the industrial sector for banning alcohol consumption across the working day, with 80% backing the idea in principleii.
(Health gain notation – 2 "likely to be beneficial")
i. Hermansson MSW, Knutsson, A Ronnberg, S, Brandt L. Feasibility of brief intervention in the workplace for the detection and treatment of excessive alcohol consumption. International Journal of Occupational and Environmental Health 1998; 4(2): 71-78
(Type III evidence – screening intervention of 327 employees)
ii. Measure of concern. Personnel Today. 1995; 6 June: 31-32
(Type IV evidence – survey during 1995 of 261 personnel managers and directors, carried out by Alcohol Concern and Personnel Today)

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2.6. Community Based Approaches

2.6a. Community-based interventions have demonstrated some effectivenessi. The Mid Western Prevention Project targeted at high risk adolescents demonstrated reductions in alcohol use for up to 1.5 yearsii. Similarly, in a 5 year project designed to reduce alcohol-involved injuries, effectiveness was demonstrated by 78 fewer alcohol-involved traffic crashes as a result of the drinking and driving component alone (approximately a 10% reduction); a significant reduction in under age sales of alcohol, i.e. off-premises outlets sold to minors about one half as often as in comparison communities; increased implementation of responsible beverage service policies by bars and restaurants and increased adoption of local ordinances and regulations to reduce concentration of alcohol outletsiii.
Suggested components are; community involvement, school programmes, parental programmes, local information campaigns, leisure, and employment projects as well as attempts to limit the availability of alcohol and regulate the marketing and sales practices of local merchantsi, iv.
(Health gain notation - 2 "likely to be beneficial")
i. Gorman DM, Speer PW. Preventing alcohol abuse and alcohol related problems through community interventions: A review of evaluation studies. Psychology and Health 1996; 11: 95-131
(Type I evidence – systematic review of 8 community-based studies)
ii. Chou CP, Montgomery S, Pentz M et al. Effects of a community–based prevention program on decreasing drug use in high risk adolescents. American Journal of Public Health 1998; 88(6): 944-948
(Type II evidence – randomised controlled trial of 3412 students)
iii. Holder H, Saltz RF, Grube JW, Treno AJ, Reynolds RI, Voas RB, Gruenewald PJ. Summing up: lessons from a comprehensive community prevention trial. Addiction 1997; 92(suppl.2): S293-301
(Type III evidence – non randomised community trial)
iv. Holder H, Saltz RF, Grube JW, Voas RB, Gruenewald PJ, Treno AJ. A community prevention trial to reduce alcohol-involved accidental injury and death: overview. Addiction 1997; 92(suppl.2): S155-171.
(Type III evidence – non randomised community trial)
iv. Caswell S, Gilmore L, Maguire V, Ransom R. Changes in public support for alcohol policies following a community based campaign; British Journal of Addiction 1989; 84: 515–522
(Type V evidence – expert opinion)
v. Botvin GJ, Botvin EM. School-based and Community-based Prevention Approaches, in Substance Abuse: A Comprehensive Textbook Second Edition Edited by JH Lowinson, P Rruiz, RB Millman and JG Langrod. Philadelphia: Lippincot, Williams and Wilkins, 1992, pp 910-927
(Type V evidence – expert opinion)

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2.7. Settings

2.7a. Interventions that target drugs as well as alcohol should take account of the context of misuse, should take account of attitudes to substances and should target the specific needs of individuals or target groupsi.

Other characteristics associated with effective school-based interventions were:-

  • Intensive programmes in primary and secondary schools, using interactive methods with follow up booster sessionsi.
  • Programme development based on a needs assessment, including social influence and skill training, and supported by other elements such as parental training, local media and involvement of community groupsi, iv, v.
  • Credible messages and messengers (i.e. avoiding delivery by uniformed police officers)i.
  • Attention to the drinking patterns and circumstances which cause harm (the risks of intoxication, multiple drug use, unprotected sex, accidents and injuries/driving). In particular, interventions should focus on those who are already experimenting with drugs who may progress to regular usei, iii, v.

Caveat: research from the USA indicates that interactive programmes, in particular those that employ peer education are the most effective. How far this finding transfers to European cultures is relatively untestedii .

i. Health Promotion With Young People for Prevention of Substance Misuse. Health Promotion Effectiveness Review. London: Health Education Authority, 1997
http://www.hea.org.uk/research/download/ereview5.html [accessed 3.3.00]
(Type I evidence – systematic review)

ii. Tobler NS, Stratton H. Effectiveness of school-based drug prevention programmes: a meta analysis of the research. Journal of Primary Prevention 1997; 18(1): 71-128
(Type I evidence – systematic review and meta-analysis of 120 programmes)
iii. May C. Research on alcohol education for young people: a critical review of the literature. Health Education Journal 1991; 50(4): 195-1999
(Type IV evidence – non-systematic review of observational studies)
iv. Gorman DM. Do school-based social skills training programmes prevent alcohol use among young people? Addiction Research 1996; 4(2): 191-210
(Type IV evidence – review of 12 evaluation studies)
v. Anderson K, Plant M. Plant M. Associations between drinking, smoking and illicit drug use among adolescents in the Western Isles of Scotland, Implications for harm minimisation. Journal of Substance Misuse 1998; 3(1):13-20
(Type IV evidence – Survey, carried out in 1994, of 804 school pupils aged 13-16 years)
2.7b. A systematic review of alcohol misuse prevention programmes for young people concluded that a lack of reliable evidence meant that no one type of prevention programme could be recommended i.
(Health gain notation - 4 "unknown")
The review recommended the design of evaluation in alcohol intervention needs to be improved so that more reliable evidence of the effectiveness of different approaches which target young peoples’ alcohol misuse may be generated.
i. Foxcroft D, Lister Sharp D, Lowe G. Alcohol misuse prevention for young people: a systematic review reveals methodological concerns and lack of reliable evidence of effectiveness. Addiction 1997; 92(5): 531-537
(Type I evidence – systematic review of 33 studies, most with methodological shortcomings)

 

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2.8. Supportive Economic and Environmental Measures
2.8a. Taxation of alcohol is an effective environmental mechanism for reducing alcohol consumption. Approximately 10% increase in price leads to approximately a 5% decrease in beer consumption, a 7.5% decrease in wine and 10% decrease in spirit consumption. A 10% decrease in per capita consumption will be reflected in about a 20% decrease in male alcohol-related mortality and a 5% decrease in fatal accidents, suicides and homicides in the whole populationi.
Pricing is the measure most likely to have the biggest and swiftest impact on the drinking habits of young peopleii,iii,iv.
(Health gain notation - 1 "beneficial")
i. Harkin AM, Anderson P, Lehto J. World Health Organisation Regional Office for Europe. Alcohol in Europe - A Health Perspective. Copenhagen: WHO, 1995
(Type V evidence – expert opinion)
ii. Raistrick D, Hodgson RJ, Ritson B (eds.); Society for the Study of Addiction. Tackling Alcohol Together. The Evidence Base for a UK Alcohol Policy. London: Free Association Books, 1999
(Type V evidence – expert opinion)
iii. Coate D, Grosman M. Effects of alcoholic beverage prices and legal drinking ages on youth alcohol use. Journal of Law and Economics 1988; 31: 145-171
(Type IV evidence – survey of 1761 youths aged 16-21)
iv. Ponicki W, Hoder HD, Gruenewald PJ, Romelsjo A. Altering alcohol price by ethanol content: results from a Swedish tax policy in 1992. Addiction 1997; 92(7): 859–870
(Type IV evidence – observational study following a taxation change)
2.8b. Raising the legal drinking age has been shown to have significant results. One study revealed an 18% reduction in late night single vehicle crashes and a 31% reduction in police reported alcohol related traffic crashes among 18 to 20 year oldsi.
(Health gain notation - 2 "likely to be beneficial")
Caveat: This study was carried out in the USA where the age at which it becomes legal to drive and the age at which it becomes legal to drink are different from the UK.
i. Wagenaar AC. Research affects public policy: the case of the legal drinking age in the United States. Addiction 1993; 88 (supplement): 75–81
(Type IV evidence – non-systematic review of observational studies)
2.8c. Enforcing the existing licensing had an impact on the level of alcohol related arrestsi.
(Health gain notation - 2 "likely to be beneficial")
i. Jeffs BW, Saunders WM. Minimising alcohol related offences by enforcement of the existing licensing legislation. British Journal of Addiction 1983; 78: 67-77
(Type IV evidence – summary of two police studies (enforcement and arrest) in one town, population size 60,000)
2.8d. There is a clear relationship between the amount of alcohol consumed and the type and location of setting, one study has demonstrated that music and dancing venues were found to be the most likely to be associated with the highest levels of alcohol consumptioni.
(Health gain notation - 2 "likely to be beneficial")
i. Casswell S, Zhang JF, Wyllie A. The importance of amount and location of drinking for the experience of alcohol related problems. Addiction 1993; 88: 1527-1534
(Type IV evidence – survey of 1680 people in New Zealand)

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2.8e. Responsible server intervention strategies are an effective intervention, especially targeting those who are high risk (male, single and under 25 years and those already drunk).
(Health gain notation - 2 "likely to be beneficial")
Note that evaluations of programs recommend training for licensees and managers and not just bar staff, alongside skills to deal with intoxicated customersi, ii.
i. Lang E, Stockwell T, Rydon P, Lockwood A. Drinking settings and problems of intoxication. Addiction Research 1995; 3(2): 141-149
(Type IV evidence – random household survey of 1160 adults in Perth, Australia)
ii. Plant M, Single E, Stockwell T. Prevention where alcohol is sold and consumed: server intention and responsible beverage service in Alcohol: Minimising the Harm. What works? London: Free Association Books, 1997
(Type V evidence – expert opinion)
2.8f. Simple product labelling/warnings, are unlikely to cause behaviour change. However, it is recommended that standard unit labelling will benefit those drinkers who are motivated to count their drinks whether for health, road safety, personal safety or economic reasons. It is also worth noting that there is a marked preference for unit labels which are accompanied by graphics or symbols of some kind. However, for unit labelling to have its maximum impact it may be necessary to combine the introduction of such labelling with a public education campaign explaining the concepti, ii.
(Health gain notation - 2 "likely to be beneficial")
i. Stockwell T, Single E. Standard unit in labelling of alcohol containers in Plant M., Single E., Stockwell T. Alcohol: Minimising the Harm. What Works? London: Free Association Books, 1997
(Type V evidence – expert opinion)
ii. Anderson P, Babor TF and Edwards G et al. (eds). Alcohol Policy and the Public Good. Oxford: Open University Press, 1994.
(Type V evidence – expert opinion)
2.8g. There is laboratory and observational evidence that toughened beer glasses are safer and their widespread use will result in fewer facial injuries in assaults and accidental hand injuries in bar staffi.
(Health gain notation - 2 "likely to be beneficial")
i. Shepherd J. Preventing injuries from bar glasses. British Medical Journal 1994; 308: 932-933
http://www.bmj.com/cgi/content/full/308/6934/932 [accessed 3.3.00]
(Type IV evidence – editorial citing observational studies)

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk