Priority Area Overview – Substance misuse: Alcohol
This report has been prepared to support the Review of Health Improvement Programmes. A series of priority areas have been identified for the review derived from policy and strategy documents. The Review has a number of identified outputs, one of which is a high level summary of each priority area which highlights, based on current evidence of effectiveness, which interventions have the greatest potential to improve health in each priority area.
Methodology
The Review is being conducted within a limited timeframe, as a result an extensive review of the literature across all of the priority areas and initiatives is not feasible. The review team has adopted the following approach:
- Evidence from systematic reviews or reviews of reviews
- Guidelines derived from an assessment of the available evidence
- Reviews from sources which have a clearly defined methodology and quality assurance process that is nationally or internationally recognised.
The Library and knowledge management service of Public Health Wales has undertaken an initial search of the following sources using agreed search terms:
- NICE Guidelines
- Cochrane Database of Systematic Reviews (Cochrane Reviews Only)
- Campbell Collaboration Reviews
- EPPI Centre Reviews
- The Community Guide Recommendations
Where limited material was identified, or specific information gaps, or where the reviews or recommendations are more than 5 years old, a further search has been undertaken of DARE and Health Evidence Canada for reviews conducted within the last five years, which are rated as moderate to good quality.
Reviews have been screened for inclusion based on agreed criteria e.g. health promotion interventions, interventions which involve clinical preventative services were excluded and those which focus on primary or secondary prevention.
Key information has been extracted and summarised in the evidence table attached. An assessment has been made about the strength and direction of the evidence from the review based on the grading system developed and attached as Appendix 1. A subjective assessment has also been made by the reviewer of the extent of adoption or implementation of the intervention in Wales. The grading of the evidence and the implementation assessment were reviewed by the team for consistency.
There are a number of limitations to this approach which it is important to consider when interpreting this report:
- this is not an extensive review of the evidence in each area, a large amount of material will not have been considered
- the sources used mean that the interventions used are more likely to reflect established or well-tested approaches and less likely to reflect innovative technologies and approaches
- the assessment of implementation is subjective and based on the knowledge of the review team
- the evidence gradings are designed to give an indication of the strength of the evidence and enable current understanding of the efficacy of different interventions to be compared, the quality of the studies included within the reviews is drawn from the assessment by the reviewers
Version 1 / 1 / November 2012
Public Health Wales Observatory / Health Improvement Review- Evidence Sub Group
Priority Area / Substance misuse
Sub Division / Alcohol
Study Details / Outcome measures / Main findings / Results / Current Implementation Wales / Evidence Grading
NICE, 2012
Alcohol-use disorders: preventing the development of hazardous and harmful drinking.
National Institute for Health and Clinical Excellence
Hazardous and harmful drinking prevention
All groups / Alcohol consumption, alcohol misuse, alcohol-related harm,
social problems, costs and economic impact / There are a number of recommendations in this guideline. This is a summary (refer to full guidance for detail).
Policy recommendations:
Recommendation 1: price.Making alcohol less affordable is the most effective way of reducing alcohol related harm.
Recommendation 2: availabilityInternational evidence suggests that making it less easy to buy alcohol, by reducing the number of outlets selling it in a given area and the days and hours when it can be sold, is another effective way of reducing alcohol-related harm
Recommendation 3: marketingThere is evidence that alcohol advertising does affect children and young people and that they should be protected as much as is possible by strengthening the current regulations.
Recommendations for practice
Recommendation 4: licensing review local evidence [crime and related trauma data]
Recommendation 5: resources for screening and brief interventions
Recommendation 6: supporting children and young people aged 10 to 15 years
Recommendation 7: screening young people aged 16 and 17 years
Recommendation 8: extended brief interventions with young people aged 16 and 17 years
Recommendation 9: screening adults
Recommendation 10: brief advice for adults
Recommendation 11: extended brief interventions for adults
Recommendation 12: referral
/ This guidance is based on a series of evidence reviews, supporting evidence statements and economic
analysis / Overall this has been categorised as red – implementation not currently taking place.
However, the power to enforce minimum unit pricing is not devolved to Wales, and some components are being implemented for example alcohol brief intervention training is being delivered across Wales.
NICE, 2007
Interventions in schools to prevent and reduce alcohol use among children and young people.
National Institute for Health and Clinical Excellence
Alcohol prevention
Children and young adults
Working age adults / Prevention and reduction in alcohol use among children and young people / There are a number of recommendations in this guideline. This is a summary (refer to full guidance for detail).
Recommendation 1
• Ensure alcohol education is an integral part of the
curriculum.
• Ensure alcohol education is tailored for different age
groups and takes different learning needs into account
• Introduce a ‘whole school’ approach to alcohol, involving staff, parentsand pupils
• Where appropriate, offer parents or carers information
about where they can get help to develop their parenting skills.
Recommendation 2
• Where appropriate, offer brief, one-to-one advice on
the harmful effects of alcohol use, how to reduce the
risks and where to find sources of support.
• Where appropriate, make a direct referral to external
services (without providing one-to-one advice).
• Follow best practice on child protection, consent
and confidentiality.
Recommendation 3
• Maintain and develop partnerships to:
– support alcohol education in schools
– ensure school interventions on alcohol use are
integrated with community activities
– find ways to consult with families about initiatives to
reduce alcohol use and to involve them in those
initiatives
– monitor and evaluate partnership working and
incorporate good practice into planning. / This guidance is based on a series of evidence reviews, supporting evidence statements and economic
analysis / This intervention is implemented locally in some areas but does not have a consistent national programme or a co-ordinated approach OR is implementation nationally on an ad-hoc basis
Faggiano F et al, 2005
School-based prevention for illicit drugs' use
Cochrane Database of SystematicReviews
Substance misuse prevention
Children and young adults / Outcomes variables (self reported and measured using specific tests):
(1) knowledge:
(2) attitudes
(3) acquirement of personal skills including:
- self-esteem
- peer pressure resistance
(4) peers/adults substance use :
(5) intention to use substances
(6) use of substances:
(7) changes in behaviours including:
- arrests
- school performance / Skills based programs appear to be an effective form of school based intervention in deterring early use of alcohol (and other drugs)
The pathways of risk and risk factors for alcohol,
tobacco and drugs among the young were shown to be the same or similar and the review favoured the delivery of a single school-level intervention to prevent the initial use of all the harmful substances. Whilst the review is primarily focused in illicit drugs, the scope of the search included substance use generally, including alcohol and tobacco. / 32 controlled studies were included, of which 29 were randomised, comparing school-based programs aimed at preventionof substance use with the usual curriculum.
46,539 students involved mainly in sixth or seventh grade, mainly in the USA.
Programs that focusedon knowledge improved knowledge to some degree, in six randomised trials.
Social skills programs were more widely used (25randomised trials) and effectively increased drug knowledge, decision-making skills, self-esteem, resistance to peer pressure, and druguse including of marijuana (RR 0.8) and hard drugs (heroin) (RR 0.5).
Effects of the interventions on assertiveness, attitudes towards substances, and intention to use were not clearly different in any of the trials. / This intervention is implemented locally in some areas but does not have a consistent national programme or a co-ordinated approach OR is implementation nationally on an ad-hoc basis / C. There is some evidence supporting the use of this intervention but it is not conclusive
Foxcroft D, Tsertsvadze A, 2011
Universal school based prevention programmes for alcohol misuse in young people
Cochrane Database of Systematic Reviews
Alcohol prevention
Children and young adults / Primary outcomes
direct self-reported or objective measures of alcohol
consumption or problem drinking e.g. Alcohol use, quantity and frequency and incidence of drunkenness
Outcome measures related to
psychological perception/attitudes or awareness were deemed asindirect and therefore were not considered. / This review identified studies that showed no effects of preventive interventions, as well as studies that demonstrated statistically
significant effects.
There was no easily discernible pattern in characteristics that would distinguish trials with positive results from those
with no effects.
Most commonly observed positive effects across programs were for drunkenness and binge drinking.
Current evidence
suggests that certain generic psychosocial and developmental prevention programs can be effective and could be considered as policy and practice options. / 53 trials were included, most of which were cluster-randomised. The reporting quality of trials was poor, only 3.8% of them reporting
adequate method of randomisation and program allocation concealment. Incomplete data was adequately addressed in 23% of the
trials. Due to extensive heterogeneity across interventions, populations, and outcomes, the results were summarized only qualitatively.
Six of the 11 trials evaluating alcohol-specific interventions showed some evidence of effectiveness compared to a standard curriculum.
In 14 of the 39 trials evaluating generic interventions, the program interventions demonstrated significantly greater reductions in
alcohol use either through a main or subgroup effect. Gender, baseline alcohol use, and ethnicity modified the effects of interventions.
Results from the remaining 3 trials with interventions targeting cannabis, alcohol, and/or tobacco were inconsistent. / This intervention is implemented locally in some areas but does not have a consistent national programme or a co-ordinated approach OR is implementation nationally on an ad-hoc basis / D. The evidence is inconsistent and it is not possible to draw a conclusion but there is some evidence of effect
Foxcroft D, Tsertsvadze A, 2011
Universal family-based prevention programs for alcohol misuse in young people.
Cochrane Database of Systematic Reviews
Alcohol prevention
Children and young adults / Primary outcomes
direct self-reported or objective measures of alcohol
consumption or problem drinking e.g. Alcohol use, quantity and frequency and incidence of drunkenness
Outcome measures related to
psychological perception/attitudes or awareness were deemed asindirect and therefore were not considered. / Effects of family-based prevention interventions are small but generally consistent and also persistent into the medium- to longer-term.
One of the interventions included was the Iowa Strengthening Families programme. This was shown to be significantly better than the control, but not significantly different to another programme called Preparing for the Drug-Free Years. / 12 parallel-group trials were included.
The reporting quality of trials was poor, only 20% of them reporting adequate method of
randomisation and program allocation concealment.
Incomplete data was adequately addressed in about half of the trials and this information was unclear for about 30% of the trials.
Due to extensive heterogeneity, the results were summarized only qualitatively.
9 of the 12 trials showed some evidence of effectiveness compared to a control or other intervention group, with persistence of effects
over the medium and longer-term. Four of these effective interventions were gender-specific, focusing on young females. One study
with a small sample size showed positive effects that were not statistically significant, and two studies with larger sample sizes reported no significant effects of the family-based intervention for reducing alcohol misuse. / This intervention is implemented locally in some areas but does not have a consistent national programme or a co-ordinated approach OR is implementation nationally on an ad-hoc basis / C. There is some evidence supporting the use of this intervention but it is not conclusive
Foxcroft D, Tsertsvadze A, 2011
Universal multi-component prevention programs for alcohol misuse in young people.
Alcohol prevention
Cochrane Database of Systematic Reviews
Children and young adults
Working age adults / Primary outcomes
direct self-reported or objective measures of alcohol
consumption or problem drinking e.g. Alcohol use, quantity and frequency and incidence of drunkenness
Outcome measures related to
psychological perception/attitudes or awareness were deemed asindirect and therefore were not considered. / There is some evidence that multi-component interventions for alcohol misuse prevention in young people can be effective.
However, there is little evidence that interventions with multiple components are more effective than interventions with single components. / Due to extensive heterogeneity across interventions, populations, and outcomes, the results were summarized only qualitatively.
12 of the 20 trials showed some evidence of effectiveness compared to a control or other intervention group, with persistence of effects
ranging from 3 months to 3 years.
Of the remaining 8 trials, one trial reported significant effects using one-tailed tests and 7 trials reported no significant effects of the multi-component interventions for reducing alcohol misuse.
Reporting quality of trials was poor. / Unknown / D. The evidence is inconsistent and it is not possible to draw a conclusion but there is some evidence of effect
Kaner EF, et al, 2007.
Effectiveness of brief alcohol interventions inprimary care populations.
Cochrane Database of Systematic Reviews
Primary care
Children and young adults
Working age adults / Primary outcomes
(1)Self or other reports of drinkingquantity, frequency and intensity.
(2) Levels of laboratory markers of reduced alcohol consumption
(3) Alcohol related harm to the drinkers or to affected others
Secondary outcomes
(4) Patient satisfaction
(5) Health-related quality of life
(6) Economic measures including use of health services / Brief interventions lowered alcohol consumption.
When data were available by gender, the effect was clear in men at one year of follow up, but not in women.
Longer duration of counselling probably has little additional effect. The benefits of brief intervention were similar in
the normal clinical setting and in research settings with greater resources. Longer counselling had little additional benefit. Future trials should focus on women and on delineating the most effective components of interventions. / Meta-analysis of 22 RCTs (enrolling 7,619 participants) showed that participants receiving brief intervention had lower alcohol
consumption than the control group after follow-up of one year or longer (mean difference: -38 grams/week, 95% CI: -54 to -23), although there was substantial heterogeneity between trials
Sub-group analysis (8 studies, 2,307 participants) confirmed the benefit of brief intervention in men (mean difference: -57 grams/week, 95% CI: -89 to -25, I2 = 56%), but not in women (mean difference: -10 grams/week, 95% CI: -48 to 29, I2 = 45%). / Alcohol brief intervention project has now trained 1200 health, social care and community professionals across Wales.
Take up varies across Health Boards, but there is some nationally guided delivery. / B. This intervention is supported by moderate to good quality evidence of its effectiveness, however these are efficacy-type trials and not in a service delivery context.
Moreira MT, Smith LA, Foxcroft D, 2009
Social norms interventions to reduce alcohol misuse in University or College students.
Cochrane Database of Systematic Reviews
Alcohol reduction
Children and young adults, / Primary outcomes
Alcohol use and misuse as measured by self-reported
measures of consumption
Secondary outcomes
Measures of alcohol related problems e.g. Adverse legal events as a consequence of alcohol i.e.
violence, driving offences; Inappropriate risky behaviours; and Alcohol related injuries / Web/computer feedback and individual face to face feedback are probably effective in reducing alcohol misuse.
The results were not significant for mailed and group feedback and for social norms marketing campaigns.
(Social norms refers to our perceptions and beliefs of what
is ’normal’ behaviour in the people close to us, and these beliefsare influential on behaviour e.g. perceptions of how much peers drink. Interventions involved web based, individual face-to-face, mailed and group social norms interventions) / Twenty-two studies were included (7,275 participants).
Significant reduction in alcohol related problems (SMD -0.31 95%Cl -0.59 to -0.02), peak blood alcohol content (SMD-0.77 95%Cl -1.25 to -0.28), drinking frequency (SMD -0.38 95%Cl -0.63 to -0.13) and drinking quantity (SMD -0.35 95% Cl -0.51 to -0.18) with web/computer feedback / P
This intervention is currently being implemented as a trial / D. The evidence is inconsistent and it is not possible to draw a conclusion but there is some evidence of effect
Stade BC et al, 2009
Psychological and/or educational interventions for reducing alcohol consumption in pregnant women and women planning pregnancy.
Cochrane Database of Systematic Reviews
Alcohol reduction
Women: young adults, working age adults / This systematic review aims to examineall trials including pregnant women or womenplanningfor pregnancy which compare psychological and/or educational
interventions versus no intervention (or usual care) for reducingthe consumption of alcohol during pregnancy.
Outcomes – alcohol intake plus health outcomes for mother and baby / No meta-analyses performed as the interventions and outcomes measured in the studies were not sufficiently similar.
Results from individual studies suggest that interventions may encourage women to abstain from alcohol in pregnancy.
There was very little information provided on the effects of interventions on the health of mothers and babies although some. / Four studies met the inclusion criteria (715 pregnant women), The studies involved women
Who were less than 28 weeks pregnant and consuming some alcohol. All were carried out in the USA and reported on at least one of the outcomes of interest.
The main conclusion of this review is that overall there is very little evidence about the effects of educational and psychological interventions aiming to reduce alcohol consumption in pregnancy, and in particular, on the effect of such interventions on the health of women and babies. / Services for pregnant women tend to focus on drugs, rather than alcohol and safeguarding, rather than general harm to health issues. / D. The evidence is inconsistent and it is not possible to draw a conclusion but there is some evidence of effect
Thomas RE, Lorenzetti D, Spragins W, 2011
Mentoring adolescents to prevent drug and alcohol use.
Cochrane Database of Systematic Reviews
Alcohol prevention
Children and young people / To assess the effectiveness of mentoring on:
1)Abstinence
2)Use of alcohol or drugs
3)Reduction in consumption of drugs and or alcohol
4)Not being involved in alcohol or drug-related aggression or accidents / Two out of the four included RCTs found that mentoring reduced rates of initiation of use of alcohol, and one reduced initiation
of use of drugs. No adverse effects were identified.
All four RCTs were in the US, and included “deprived” and mostly minority adolescents. Participants were young (in two studies age12, and in two others 9-16). All students at baseline were non-users of alcohol and drugs.
The studies assessed structured programmes and not informal mentors. /
- 4 RCTs (1,194 adolescents) were identified. No RCT reported enough detail to assess whether a strong randomisation method was used or allocation was concealed. Blinding was not possible as the intervention was mentoring. Three RCTs provided complete data.
- Three RCTs provided evidence about mentoring and preventing alcohol use. Two RCTs were pooled(RR for mentoring compared to no intervention = 0.71 (95% CI = 0.57 to 0.90, P value = 0.005). A third RCT found no significant differences.
- Three RCTs provided evidence about mentoring and preventing drug use, but could not be pooled. One found significantly less use of “illegal“ drugs,” one did not, and one assessed only marijuana use and found no significant differences.
- One RCT measured “substance use” without separating alcohol and drugs, and found no difference for mentoring.
Alcohol concern may offer this type of programme. / D. The evidence is inconsistent and it is not possible to draw a conclusion but there is some evidence of effect
The Community Guide Recommendations