A Major Public Health Issue
ALCOHOL AND HEALTH IN WALES: A MAJOR PUBLIC HEALTH ISSUE
Contact details: Dr E C Coles, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN
Telephone: 029 2074 2311
Copyright © 2006 National Public Health Service for Wales
Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context. Acknowledgement to the National Public Health Service for Wales to be stated.
1 Purpose of the paper
This paper aims to summarize[1] the major Public Health implications of the issue of alcohol misuse in Wales. The new structural changes to the delivery of the Substance Misuse Strategy may have led to an undue emphasis on accidents and violence as a cause of the ill effects on health of immoderate alcohol use.1 However, there are other important associations between excessive alcohol use and a wide range of adverse health effects.
2 The rising trend
Although alcohol consumption is not as high as it was a century ago, it has approximately doubled since 1960 (Figure 1). During the same period of time the price of alcohol relative to national income has more than halved.2 During the 1990s, the expenditure on alcohol advertising, and consumption amongst 11-15 year old children, in successive years have followed each other very closely (r=0.995).3 Heavy drinking among teenagers in Wales is as bad as any European country except possibly Denmark.4
Source: The Academy of Medical Sciences2
Alcohol-related deaths in Wales have also risen markedly over the last twenty years (Figure2).5 Those who do die are dying younger than a decade ago. Alcohol accounts directly for some 8,000 potential years of life lost in Wales and indirectly for another 5,000.6
Source: NPHS based on ONS data
3 Crime and disorder
Alcohol-related crime and disorder is undoubtedly an important issue, with its costs in Wales estimated to be some £750million a year.6 Each year in Wales, about 30,000 bed days are related to alcohol, 15% of admissions being due to alcoholic intoxication.7 Almost half of the victims of violence report that they believe that their assailant was under the influence of alcohol.8 Alcohol plays a role in around a third of cases of violence between spouses and partners and some 64,000 Welsh children are adversely affected by parental alcohol problems.7 Perpetrators of sexual assault have often been drinking, and many are also chronic heavy drinkers. Almost two-thirds of male prisoners and over a third of female prisoners have problems with alcohol.9
4 Major alcohol-related health effects
Alcohol is a major cause of disease and injury. It accounts for some 9.2% of the years of life either lost or lived with a disability.10 However, against this should be set the fact that in men over the age of 40 and in post-menopausal women, moderate alcohol consumption may well confer a benefit with regard to the risk of coronary heart disease and of ischaemic stroke.2
4.1 Cardiovascular disease
As well as the possible protective effect mentioned above, heavy alcohol use leads to hypertension. This causes some 230 deaths per year in Wales, a tenth of which are attributable to alcohol.5 Chronic high alcohol intake raises the risk of both ischaemic and haemorrhagic stroke. Haemorrhagic stroke kills some 80 people in Wales each year.6
4.2 Gastro-intestinal disease
Excessive alcohol consumption is a major cause of serious liver disease, which is often fatal. Liver disease is responsible for some 1,600 hospital admissions per year in Wales. Cirrhosis is the most serious liver problem caused by alcohol.
It should be noted that the so-called ‘Mediterranean pattern’ of alcohol consumption does not reduce deaths from cirrhosis (see Figure 3).11
Fig 3 Alcohol consumption and cirrhosis death rates in different European countries for those aged 15+
Source: Ramstedt M11
The increasing prevalence of the Hepatitis C virus is also a worry as it causes hepatitis and liver cancer, and alcohol probably adds to this effect. One in five heavy drinkers has cirrhosis, but a high alcohol intake can also lead to oesophagitis, gastritis, gastric ulcer and pancreatitis.7
4.3 Psychiatric disease
Heavy drinkers have poorer mental health, but this is not necessarily a causative relationship. Heavy drinking can contribute to both anxiety and depression and can accelerate the development of other psychiatric disorders, including psychosis. About a third of those with a serious mental illness have a problem of substance misuse, commonly alcohol misuse. Alcohol dependency syndrome accounts for some 1,500 to 1,800 hospital admissions per year in Wales.6 Alcohol is often implicated in the 50 or so suicides in Wales each year.
4.4 Cancers
More than 200 deaths from cancer per year in Wales are attributable to alcohol.7 These include cancers of the oropharynx, oesophagus, stomach, liver, pancreas, colon and rectum, and a small proportion of breast cancers in women.
4.5 Pregnancy
As well as leading to unintended pregnancy, drinking while pregnant may cause miscarriage. Fetal alcohol syndrome is a condition of babies born to mothers with a clearly identifiable drinking problem. It includes deficient growth, lowered IQ, central nervous system defects and facial malformation.12
4.6 Accidents
More than 80 deaths per year in Wales are a result of accidents in which alcohol played a part.6 Alcohol is strongly linked with deaths in fires and from drowning.6
5 Financial costs to the NHS
As well as a cost to employment of some £300m, of alcohol-related absenteeism, lost working days and deaths, and a cost of up to £370m on crime and disorder, the health services incur a heavy cost. The estimated health service cost of alcohol-related chronic disease and alcohol-related acute incidents is between £70m and £85m.6
6 Organizational issues
Within Wales the Welsh Assembly Government substance misuse strategy includes the misuse of alcohol alongside the misuse of illegal drugs.1 This is different from the situation in England where illegal drugs are dealt with by a separate strategy. Within Wales responsibility for the delivery of the WAG strategy, including both the treatment and prevention aspects, is now the responsibility of Community Safety Partnerships. Funding has followed this organizational change with income streams moving away from the NHS.
The effects of this change do focus attention on the community safety and crime and disorder aspects of alcohol misuse. It is important that Local Health Boards should also continue to focus on the health specific aspects of alcohol misuse and take responsibility in this area.
Despite the massive resource implications for the NHS of alcohol misuse, the strategic and financial framework targets for LHBs do not refer to the issue, or define specific actions.
7 Way forward
There is no doubt that excessive alcohol consumption is injurious to health: this information should be widely known. Sensible drinking for men consists of not more than 21 units of alcohol per week and not regularly consuming more than four units a day. For women, with their greater susceptibility to alcoholic liver disease, these limits are 14 and three respectively.13
As well as evidence-based measures to reduce binge drinking, the public’s heath would benefit from an overall reduction in the number of people who drink more than the guidelines. The two mechanisms that have been shown to produce a substantial reduction in alcohol consumption are increased price and reduced availability.14
For those with a serious alcohol problem, it is important that the NHS provides good-quality, evidence-based treatment and rehabilitation programmes.
References
1 National Assembly for Wales. Tackling substance misuse in Wales. A partnership approach. Cardiff: NAfW; 2000
2 The Academy of Medical Sciences. Calling time: the nation’s drinking as a major health issue. London: The Academy of Medical Sciences; 2004
3 World Advertising Research Centre. Advertising statistics yearbook. Henley-upon-Thames: WARC; 2002
4 Schmid H, Gabhainn SC. Alcohol use. In Currie C, Roberts C, Morgan A, et al editors. Young people’s health in context: Health Behaviours in School-aged Children (HBSC) study: international report from the 2001/2002 survey. Geneva: World Health Organisation; 2002
5 National Public Health Service for Wales based on data from the Office for National Statistics
6. Prime Minister’s Strategy Unit. Alcohol misuse: how much does it cost? London: The Stationery Office; 2003
7 Prime Minister’s Strategy Unit. Interim analytical report. London: The Stationery Office; 2003
8 Home Office. British crime survey 2001-2002. London: The Home Office; 2002
9 Office of National Statistics. Psychiatric morbidity among prisoners in England and Wales. London: The Stationery Office; 1998
10 World Health Organisation. The World health report 2002. Reducing risks, promoting healthy life. Geneva: WHO; 2002
11 Ramstedt M. Per capita alcohol consumption and liver cirrhosis mortality in 14 European countries. A time series analysis of the post war era. Available
www.sofi.su.se/ecascirrhos2.PDF [Accessed 10th April 2006]
12 Royal College of Obstetricians and Gynaecologists. Alcohol consumption in pregnancy. London: RCOG: 1999
13 Royal College of Physicians. Alcohol – can the NHS afford it? Recommendations for a coherent strategy for hospitals. London: RCP; 2001
14 Room R, Babor T, Rehm J. Alcohol and public health. Lancet 2005; 365:519-30
Version: 2.0 / Date: 21/04/06 / Status: NPHS paper 2006Author: Dr Edward C Coles
NPHS and Cardiff University / Page: 1 of 6
[1] Note that many estimates are based on England & Wales or UK estimates scaled pro rata to the population.