Lay epidemiology and the interpretation of low-risk drinking guidelines by adults in the United Kingdom

Aims To explore how the concept of lay epidemiology can enhance understandings of how drinkers make sense of current UK drinking guidelines. Methods Qualitative study using 12 focus groups in four sites in northern England and four sites in central Scotland. Participants were 66 male and female drinkers, aged between 19 and 65 years, of different socio-economic backgrounds. Data were analysed thematically using a conceptual framework of lay epidemiology. Results Current drinking guidelines were perceived as having little relevance to participants' drinking behaviours and were generally disregarded. Daily guidelines were seen as irrelevant by drinkers whose drinking patterns comprised heavy weekend drinking. The amounts given in the guidelines were seen as unrealistic for those motivated to drink for intoxication, and participants measured alcohol intake in numbers of drinks or containers rather than units. Participants reported moderating their drinking, but this was out of a desire to fulfil work and family responsibilities, rather than concerns for their own health. The current Australian and Canadian guidelines were preferred to UK guidelines, as they were seen to address many of the above problems. Conclusions Drinking guidelines derived from, and framed within, solely epidemiological paradigms lack relevance for adult drinkers who monitor and moderate their alcohol intake according to their own knowledge and risk perceptions derived primarily from experience. Insights from lay epidemiology into how drinkers regulate and monitor their drinking should be used in the construction of drinking guidelines to enhance their credibility and efficacy

Mental health problems: Are they or are they not a risk factor for dropout from drug treatment? A systematic review of the evidence

Background: A sizeable number of recent studies investigating whether clients with substance misuse and mental health problems (dual diagnosis clients) are at heightened risk of dropout from drug treatment have been published. It is timely that their findings are brought together in a comprehensive review of the current evidence. Aims: The aim of the review is to examine whether dually diagnosed clients are less likely to be retained in drug treatment than clients without mental health problems, and, if so, whether this varies for clients diagnosed with different types of mental health problems. Methods: The review considers peer-reviewed research published after 1 January 1990, which was located using the literature databases Medline and PsycInfo. Predefined search terms were used. Further papers were identified from the bibliographies of relevant publications. Findings: 58 studies (84% from the USA) met the inclusion criteria for the review. The findings suggest that for most clients, having a past history of mental health problems does not influence the likelihood of being retained in drug treatment. The body of evidence regarding concurrent mental health problems is contradictory. On the whole, the majority of studies suggest that neither presence nor severity of depressive, anxiety, or other Axis-I disorders is related to retention, but these findings are not entirely unequivocal, as a few studies report strong positive or negative associations between depression and anxiety disorders and retention. Few researchers looked separately at psychotic spectrum disorders hence no conclusions could be drawn. The presence of most personality disorders also did not appear to affect treatment tenure, with the exception of antisocial personality disorder, for which the evidence points towards a greater risk of dropout. Conclusions: The balance of evidence suggests that, overall, dual diagnosis clients with Axis-I disorders who seek treatment in drug treatment services are retained as well as clients without dual diagnosis. Subgroups of clients who appear more vulnerable to premature dropout include those with antisocial personality disorder. Methodological shortcomings of the reviewed studies and resulting implications for this review and future research are discussed

Investigating local policy drivers for alcohol harm prevention: a comparative case study of two local authorities in England

AbstractBackground The recent transfer of public health teams to local authorities in England offers opportunities for new policy approaches to tackling alcohol harm. The new responsible authority status of directors of public health, for example with regard to licensing applications, raises the prospect of reducing excessive alcohol consumption through local availability measures. Local authorities are also responsible for the commissioning of community-based treatment services. We used a case study approach to identify the major drivers and characteristics of local alcohol policies and services in two contrasting local authorities. Methods The many sources used were semi-structured interviews with key informants, including two in public health, two in licensing and trading standards, one in the police, and one information specialist; documentary analysis, including two alcohol strategies; two statements of licensing policy; and field observation (attending a licensing committee hearing). Focusing on alcohol harm prevention programmes and their underlying objectives, we used storyboards and constant comparative methods to describe and explain differences in the alcohol policy landscape between the two local authorities. Ethics approval was obtained from the University of Sheffield Ethics Committee. Findings Substantial differences in the stated priorities of alcohol harm prevention strategies were shown in the contrasting policy responses of the two local authorities. Concern about how best to reduce high rates of alcohol-related hospital admissions in local authority 1 led to an emphasis on health-service approaches, such as screening and brief intervention, whereas a public disorder focus in local authority 2 resulted in policies aimed at reducing availability through licensing measures. Perceived tensions were apparent for local authority 1 between maintaining a supportive environment for local businesses at a time of economic recession and introducing policy measures with a regulatory focus. Field observations highlighted the underlying importance of well-functioning working relationships between licensees and all responsible authorities, for achieving acceptable implementation plans for novel policies. Resource constraints and a lack of clear policy champions were also barriers to more preventive measures in local authority 1. Interpretation Devolved responsibility for alcohol harm prevention clearly presents the potential for local authorities to tailor policies closely to their identified population needs. The exercising of responsible authority status in reducing availability through licensing approaches is best achieved however when fully integrated into the full spectrum of alcohol harm reduction activities, from prevention through to treatment-based interventions

Differences in client and therapist views of the working alliance in drug treatment

Background - There is growing evidence that the therapeutic alliance is one of the most consistent predictors of retention and outcomes in drug treatment. Recent psychotherapy research has indicated that there is a lack of agreement between client, therapist and observer ratings of the therapeutic alliance; however, the clinical implications of this lack of consensus have not been explored. Aims - The aims of the study are to (1) explore the extent to which, in drug treatment, clients and counsellors agree in their perceptions of their alliance, and (2) investigate whether the degree of disagreement between clients and counsellors is related to retention in treatment. Methods - The study recruited 187 clients starting residential rehabilitation treatment for drug misuse in three UK services. Client and counsellor ratings of the therapeutic alliance (using the WAI-S) were obtained during weeks 1-12. Retention was in this study defined as remaining in treatment for at least 12 weeks. Results - Client and counsellor ratings of the alliance were only weakly related (correlations ranging from r = 0.07 to 0.42) and tended to become more dissimilar over the first 12 weeks in treatment. However, whether or not clients and counsellors agreed on the quality of their relationship did not influence whether clients were retained in treatment. Conclusions - The low consensus between client and counsellor views of the alliance found in this and other studies highlights the need for drug counsellors to attend closely to their clients' perceptions of the alliance and to seek regular feedback from clients regarding their feelings about their therapeutic relationship

Effects of minimum unit pricing for alcohol on different income and socioeconomic groups: a modelling study

Background: Several countries are considering a minimum price policy for alcohol, but concerns exist about the potential effects on drinkers with low incomes. We aimed to assess the effect of a £0·45 minimum unit price (1 unit is 8 g/10 mL ethanol) in England across the income and socioeconomic distributions. Methods: We used the Sheffield Alcohol Policy Model (SAPM) version 2.6, a causal, deterministic, epidemiological model, to assess effects of a minimum unit price policy. SAPM accounts for alcohol purchasing and consumption preferences for population subgroups including income and socioeconomic groups. Purchasing preferences are regarded as the types and volumes of alcohol beverages, prices paid, and the balance between on-trade (eg, bars) and off-trade (eg, shops). We estimated price elasticities from 9 years of survey data and did sensitivity analyses with alternative elasticities. We assessed effects of the policy on moderate, hazardous, and harmful drinkers, split into three socioeconomic groups (living in routine or manual households, intermediate households, and managerial or professional households). We examined policy effects on alcohol consumption, spending, rates of alcohol-related health harm, and opportunity costs associated with that harm. Rates of harm and costs were estimated for a 10 year period after policy implementation. We adjusted baseline rates of mortality and morbidity to account for differential risk between socioeconomic groups. Findings: Overall, a minimum unit price of £0·45 led to an immediate reduction in consumption of 1·6% (−11·7 units per drinker per year) in our model. Moderate drinkers were least affected in terms of consumption (−3·8 units per drinker per year for the lowest income quintile vs 0·8 units increase for the highest income quintile) and spending (increase in spending of £0·04 vs £1·86 per year). The greatest behavioural changes occurred in harmful drinkers (change in consumption of −3·7% or −138·2 units per drinker per year, with a decrease in spending of £4·01), especially in the lowest income quintile (−7·6% or −299·8 units per drinker per year, with a decrease in spending of £34·63) compared with the highest income quintile (−1·0% or −34·3 units, with an increase in spending of £16·35). Estimated health benefits from the policy were also unequally distributed. Individuals in the lowest socioeconomic group (living in routine or manual worker households and comprising 41·7% of the sample population) would accrue 81·8% of reductions in premature deaths and 87·1% of gains in terms of quality-adjusted life-years. Interpretation: Irrespective of income, moderate drinkers were little affected by a minimum unit price of £0·45 in our model, with the greatest effects noted for harmful drinkers. Because harmful drinkers on low incomes purchase more alcohol at less than the minimum unit price threshold compared with other groups, they would be affected most by this policy. Large reductions in consumption in this group would however coincide with substantial health gains in terms of morbidity and mortality related to reduced alcohol consumption. Funding: UK Medical Research Council and Economic and Social Research Council (grant G1000043)

A cybernetic participatory approach for policy system of systems mapping: Case study of Inclusive Economies

Traditional participatory systems modelling demands synchronous time from many experts and face-to-face interaction. This is not always feasible (e.g., during a pandemic) and can restrict which participants can be included. There are additional limitations in the effectiveness of physical paper-based modelling when handling large complex systems with numerous variables and links between them. The key challenge facing practitioners is then how can we retain the benefits of traditional participatory modelling whilst exploiting the advantages of new technologies? This paper contributes to development of an original systematic methodology inspired by Cybernetic principles. The proposed method, referred to as 5X – standing for Expose, Explore, Exploit, Explain, and Expand – offers a fully virtual co-produced environment for iterative cycle of stakeholder engagement and feedback before, during and after workshops, leading to developing more confidence in systems mapping, and promoting knowledge across policy areas. A primary application of the proposed method in a real policy setting illustrates its capability to generate a shared policy understanding of a complex inclusive economy system, where there is conflicting or dispersed knowledge about system structure, refine this understanding through online feedback channels and dynamic visualisations, and transfer this understanding to wider policy and academic partners

Effectiveness of subnational implementation of minimum unit price for alcohol: policy appraisal modelling for local authorities in England

Aims: Evidence exists on the potential impact of national level minimum unit price (MUP) policies for alcohol. This study investigated the potential effectiveness of implementing MUP at regional and local levels compared with national implementation. Design: Evidence synthesis and computer modelling using the Sheffield Alcohol Policy Model (Local Authority version 4.0; SAPMLA). Setting: Results are produced for 23 Upper Tier Local Authorities (UTLAs) in North West England, 12 UTLAs in North East England, 15 UTLAs in Yorkshire and Humber, the nine English Government Office regions and England as a whole. Cases: Health Survey for England (HSE) data 2011–13 (n = 24 685). Measurements: Alcohol consumption, consumer spending, retailers’ revenues, hospitalizations, National Health Service costs, crimes and alcohol-attributable deaths and health inequalities. Findings: Implementing a local £0.50 MUP for alcohol in northern English regions is estimated to result in larger percentage reductions in harms than the national average. The reductions for England, North West, North East and Yorkshire and Humber regions, respectively, in annual alcohol-attributable deaths are 1024 (−10.4%), 205 (−11.4%), 121 (−17.4%) and 159 (−16.9%); for hospitalizations are 29 943 (−4.6%), 5956 (−5.5%), 3255 (−7.9%) and 4610 (−6.9%); and for crimes are 54 229 (−2.4%), 8528 (−2.5%), 4380 (−3.5%) and 8220 (−3.2%). Results vary among local authorities; for example, annual alcohol-attributable deaths estimated to change by between −8.0 and −24.8% throughout the 50 UTLAs examined. Conclusions: A minimum unit price local policy for alcohol is likely to be more effective in those regions, such as the three northern regions of England, which have higher levels of alcohol consumption and higher rates of alcohol harm than for the national average. In such regions, the minimum unit price policy would achieve larger reductions in alcohol consumption, alcohol-attributable mortality, hospitalization rates, NHS costs, crime rates and health inequalities

Equity impact of minimum unit pricing of alcohol on household health and finances among rich and poor drinkers in South Africa

INTRODUCTION: South Africa experiences significant levels of alcohol-related harm. Recent research suggests minimum unit pricing (MUP) for alcohol would be an effective policy, but high levels of income inequality raise concerns about equity impacts. This paper quantifies the equity impact of MUP on household health and finances in rich and poor drinkers in South Africa. METHODS: We draw from extended cost-effectiveness analysis (ECEA) methods and an epidemiological policy appraisal model of MUP for South Africa to simulate the equity impact of a ZAR 10 MUP over a 20-year time horizon. We estimate the impact across wealth quintiles on: (i) alcohol consumption and expenditures; (ii) mortality; (iii) government healthcare cost savings; (iv) reductions in cases of catastrophic health expenditures (CHE) and household savings linked to reduced health-related workplace absence. RESULTS: We estimate MUP would reduce consumption more among the poorest than the richest drinkers. Expenditure would increase by ZAR 353 000 million (1 US$=13.2 ZAR), the poorest contributing 13% and the richest 28% of the increase, although this remains regressive compared with mean income. Of the 22 600 deaths averted, 56% accrue to the bottom two quintiles; government healthcare cost savings would be substantial (ZAR 3.9 billion). Cases of CHE averted would be 564 700, 46% among the poorest two quintiles. Indirect cost savings amount to ZAR 51.1 billion. CONCLUSIONS: A MUP policy in South Africa has the potential to reduce harm and health inequality. Fiscal policies for population health require structured policy appraisal, accounting for the totality of effects using mathematical models in association with ECEA methodology

A theory-based online health behaviour intervention for new university students (U@Uni): results from a randomised controlled trial

BACKGROUND Too few young people engage in behaviours that reduce the risk of morbidity and premature mortality, such as eating healthily, being physically active, drinking sensibly and not smoking. This study sought to assess the efficacy and cost-effectiveness of a theory-based online health behaviour intervention (based on self-affirmation theory, the Theory of Planned Behaviour and implementation intentions) targeting these behaviours in new university students, in comparison to a measurement-only control. METHODS Two-weeks before starting university all incoming undergraduates at the University of Sheffield were invited to take part in a study of new students' health behaviour. A randomised controlled design, with a baseline questionnaire, and two follow-ups (1 and 6 months after starting university), was used to evaluate the intervention. Primary outcomes were measures of the four health behaviours targeted by the intervention at 6-month follow-up, i.e., portions of fruit and vegetables, metabolic equivalent of tasks (physical activity), units of alcohol, and smoking status. RESULTS The study recruited 1,445 students (intervention n = 736, control n = 709, 58% female, Mean age = 18.9 years), of whom 1,107 completed at least one follow-up (23% attrition). The intervention had a statistically significant effect on one primary outcome, smoking status at 6-month follow-up, with fewer smokers in the intervention arm (8.7%) than in the control arm (13.0%; Odds ratio = 1.92, p = .010). There were no significant intervention effects on the other primary outcomes (physical activity, alcohol or fruit and vegetable consumption) at 6-month follow-up. CONCLUSIONS The results of the RCT indicate that the online health behaviour intervention reduced smoking rates, but it had little effect on fruit and vegetable intake, physical activity or alcohol consumption, during the first six months at university. However, engagement with the intervention was low. Further research is needed before strong conclusions can be made regarding the likely effectiveness of the intervention to promote health lifestyle habits in new university students. TRIAL REGISTRATION Current Controlled Trials, ISRCTN67684181

How is alcohol consumption and heavy episodic drinking spread across different types of drinking occasion in Great Britain: An event-level latent class analysis

Background This paper aimed to (i) update a previous typology of British alcohol drinking occasions using a more recent and expanded dataset and revised modelling procedure, and (ii) estimate the average consumption level, prevalence of heavy drinking, and distribution of all alcohol consumption and heavy drinking within and across occasion types. Methods The paper uses a cross-sectional latent class analysis of event-level diary data that includes characteristics of 43,089 drinking occasions in 2019 reported by 17,821 adult drinkers in Great Britain. The latent class indicators are characteristics of off-trade only (e.g. home), on-trade only (e.g. bar) and mixed trade (e.g. home and bar) drinking occasions. These describe companions, locations, purpose, motivation, accompanying activities, timings, consumption volume in units (1 UK unit = 8g ethanol) and beverages consumed. Results The analysis identified four off-trade only, eight on-trade only and three mixed-trade occasion types (i.e. latent classes). Mean consumption per occasion varied between 4.4 units in Family meals to 17.7 units in Big nights out with pre-loading. It exceeded ten units in all mixed-trade occasion types and in Off-trade get togethers, Big nights out and Male friends at the pub. Three off-trade types accounted for 50.8% of all alcohol consumed and 51.8% of heavy drinking occasions: Quiet drink at home alone, Evening at home with partner and Off-trade get togethers. For thirteen out of fifteen occasion types, more than 25% of occasions involved heavy drinking. Conversely, 41.7% of Big nights out and 16.4% of Big nights out with preloading were not heavy drinking occasions. Conclusions Alcohol consumption varies substantially across and within fifteen types of drinking occasion in Great Britain. Heavy drinking is common in most occasion types. However, moderate drinking is also common in occasion types often characterised as heavy drinking practices. Mixed-trade drinking occasions are particularly likely to involve heavy drinking