3 The impact of alcohol on health,
the NHS and society |
35. Over recent years the public have been exposed
to mixed messages from the media with some articles promoting
the benefits of alcohol, especially wine, in preventing cardiovascular
disease, others stressing the harm done in causing cancer and
liver disease and others the consequences of binge-drinking.
36. Doctors tend to stress the harm done. The BMA
points out that whilst alcohol may indeed have some moderate beneficial
cardiovascular effects in older men and women with low intake,
'these are insignificant compared to the dangers of excessive
intake'. Sir Liam
Donaldson, the Chief Medical Officer informed the committee that
there were no safe limits of drinking.
and that "alcohol is virtually akin to smoking as one of
the biggest public health issues we have to face in this country".
37. The acute intoxicating effects of alcohol are
the most visibly shocking to the public. Brian Hayes, a London
Ambulance Paramedic, drew our attention to the consequences of
We are talking about people that because of alcohol
have jumped on a wall because they think it is a bravado thing
to do with their mates, not realising that the drop on the other
side is 60 feet and they have gone down it. Their one massive
night has ended up with a family with someone who is deceased
the injuries we have been faced with have been so horrific, due
to a bus driver who had kicked somebody off his bus and his head
had been used as a football by about five or six blokes who were
all drunk, and he ended up in intensive care. This is happening
week in, week out; it does not have to be a Friday or Saturday
went to one female who was found staggering down a road in south-east
London, completely out of it on alcohol. When we got her into
the ambulance we went to remove her jacket to take her blood pressure
and she had nothing on underneath, and did not have a clue what
had happened to her.
Alcohol also causes accumulating harm to a large
sector of society in much more subtle, long term ways. Alcohol
contributes to liver cirrhosis, acute and chronic pancreatitis,
heart failure, hypertension, depression, strokes and cancer and
can harm developing foetuses .
38. Furthermore alcohol is addictive, with 3.5m people
in the UK dependent on it.
It severely impairs the physical, mental and social well-being
of the user, their families and others.
|Alcohol harms health through three mechanisms:
- acute intoxicating effects, occurring after a single binge.
- chronic toxic effects, following years of drinking at harmful levels.
- propensity for addiction leading to physical and psychological dependency.
39. Alcohol impacts on the entire range of services the NHS provides,
from neonatal care to healthcare for the elderly. Liver disease,
a useful marker of alcohol related harm, is soaring in the UK,
with a five-fold increase since 1970. There were 863,300 alcohol
related hospital admissions per year. Alcohol costs the NHS £2.7
billion per annum.
The impact of alcohol on health
PHYSICAL HEALTH BY AGE
40. Acute intoxication with alcohol following a single 'binge'
can cause alcohol poisoning, injuries and accidents, with young
people being disproportionately affected. Alcohol is strongly
associated with an increased risk of acquiring sexually transmitted
infections (STIs). The rates of STIs increased 63% in the UK between
1998 and 2007 and as many as 76% of people in one genitourinary
clinic in 2006 reported having unprotected sex as a result of
41. The figures below show deaths attributable to
Figure 4: Percentage of male deaths attributable
to alcohol consumption (2005)
Figure 5: Percentage of female deaths attributable
to alcohol consumption (2005)
They show how alcohol affects different age groups.
Between the ages of 16 and 34, more than 20% of male deaths, and
14% of female deaths are attributable to alcohol consumption.
In this age group the main causes are road accidents, injuries
and poisoning, including suicides. Overall between one third and
one seventh of accidental deaths are alcohol relatedamounting
to 1,700 deaths each year.
42. In people over 35 the main alcohol related causes
of death are firstly liver disease, and then cancer and high blood
pressure. Alcohol is the second biggest risk factor for cancer
after smoking. Alcohol especially contributes to cancers of the
mouth and throat, liver, laryngeal, colon (in men) and breast
cancer. It is responsible for many cancer deaths each year; of
these perhaps the most worrying is breast canceralcohol
accounts for 6% of breast cancer in the UK amounting to around
3,000 cases each year.
43. Problem drinking is heavily associated with mental
illness (from anxiety and depression through to schizophrenia)
and personality difficulties, with each driving the other. Heavy
drinkers are more than twice as likely to commit suicide as non-drinkers.
Between 16 and 45% of suicides are thought to be linked to alcohol
and 50% of those 'presenting with self harm' are regular excessive
44. The known association between alcohol and cognitive
decline has been neglected by most of the recent inquiries into
alcohol. Some researchers have recently warned against a possible
surge in alcohol-related dementia in the future, compounding the
expected boom in dementia due to an ageing population.
THE HEALTH OF OTHERS
45. The Royal College of Physicians provided a dramatic
The passive effects of alcohol misuse are catastrophicrape,
sexual assault, domestic and other violence, drunk driving and
street disorderalcohol affects thousands more innocent
victims than passive smoking.
46. According to the British Crime Survey, in 2007,
46% of violent offenders in England and Wales were perceived by
their victims to be under the influence of alcohol.
During 2002 there were 1.2 million incidents of recorded alcohol-related
assault in England and Wales, but it is estimated that only 20%
of such assaults were recorded by police as crime
76,000 facial injuries in the UK each year are linked to drunken
violence. In 2006
6% of all road casualties and 17% of road deaths and serious injury
from road traffic crashes in the UK were due to drivers being
under the influence of alcohol.
47. Alcohol harms the developing foetus. The Royal
College of Midwives informed us that 6,000 babies are born with
Foetal Alcohol Syndrome in the UK each year.
Foetal Alcohol Syndrome (FAS) is the term used to
describe the visible birth defects and invisible organ/brain/nervous
damage that can result from exposure to alcohol during pregnancy.
It is used to describe the most severe form of a wide range of
permanent physical, mental and behavioural problems that begin
before birth. From malformed faces and limbs to heart problems
and diminished intellectual capacity.
48. The National Society for the Prevention of Cruelty
to Children (NSPCC) highlighted the alcohol problems which are
associated with parental neglect and physical abuse and affect
up to 1.3 million children in the UK.
In the year ending March 2008 the NSPCC told us they received
more than 80 calls per week from children where alcohol misuse
by what they described as a 'significant other' (ie a parent or
someone close to them) was the main reason for their call. The
National Association for the Children of Alcoholics (NACOA) in
claimed that alcohol was a factor in 40% of domestic violence
cases, 40% of child protection cases, and 74% of child mistreatment
cases, and supplied evidence that children of alcohol dependent
parents were much more likely to have psychiatric, behavioural
and substance misuse problems.
MORTALITY AND DISEASE
49. ONS data (published in January 2009)
estimated there were 8724 alcohol related deaths in England and
Wales in 2007, double the rate in 1991. However Professor Ian
Gilmore, President of the Royal College of Physicians explained
that this was almost certainly a gross under-estimate, with better
estimates suggesting alcohol-related deaths may be 30-40,000 which
is as much as half that of smoking related deaths:
Those 8,000 are the ONS figures and that is where
alcohol is named on the death certificate as the cause of death.
Nearly all of those are alcohol induced liver cirrhosis. It does
not pick up the accidents, the violence and so on. If you include
cases where alcohol is named on the death certificate as a contributory
cause, then the figures rise to about 15,000, but if you actually
take the percentage of oesophageal cancer that can be attributed
to alcohol etc, using the attributable fraction (which is a well
recognised and scientifically reputable way of doing it) the figure
comes out between 30,000 and 40,000.
50. Dr Peter Anderson told us that 'Disability Adjusted
Life Years' (DALYs)
were a more useful measure of health impact than simple mortality
rates since they accounted for morbidity leading to disability
as well. Worldwide, alcohol is estimated to cause 3.3% of deaths
and 4% of DALYs.
However its effect is much more pronounced in developed countries
where it causes 9.2% of lost DALYs, not far behind tobacco's 12.2%.
51. Professor Gilmore pointed out that alcohol was
a source of health inequalities and Dr Anderson explained
that people from lower socio-economic groups were more harmed
by a given level of alcohol consumption.
In the most deprived areas of the UK, men are 5 times more likely
and women 3 times more likely to die an alcohol related death
than those in the least deprived areas.
This is discussed in more detail in the chapter on pricing below.
52. Most research has examined 'relative risk', i.e.
the proportional increased prevalence of illness in drinkers compared
to non-drinkers. The 'absolute risk' increases as the relative
risk but it also depends on how common the problem is. Data from
a large study of 10,000 people in Copenhagen
showed that the relative risk of clinically apparent liver disease
increased by 50% above 20 units/week, 350% above 40 units/week
and 900% above 90 units/week. The increase in relative risk was
the same for someone in their thirties as in their fifties, but
the absolute risk of being admitted to hospital was much higher
for a 50 year old. So for example, for 50 year man drinking more
than 90 units per week, the risk of dying or being admitted to
hospital with liver disease over the next 10 years was 15-18%,
whereas for a 30 year old man it was 4-6%.
53. Similarly with women and breast cancer, because
it is very common110 women in every 1,000 will get breast
cancer at some stage in their livesthe absolute risk from
alcohol is quite substantial. The World Cancer Research Fund International
estimate that for every thousand women drinking a bottle of wine
each week throughout their lives, approximately ten i.e. 1% will
develop breast cancer as a direct result of the alcohol. If they
drank two bottles of wine each week the number increases to 15-20
women per 1,000, i.e. 1.5 -2%.
54. These risks may seem low, but for comparison
purposes the Health and Safety executive quote some comparative
absolute risks: the risk of dying from a scuba dive is 1 per 100,000
i.e. 0.0001%, from a base jump (jumping off a building with a
parachute) is 1 in 2,000, i.e. 0.05%.
55. Dr Anderson explained that "when you look
at alcohol the risks in relation to harm are pretty well monotonic
or linear meaning that the risk starts at zero and it goes upwards.
The more you drink, the greater the risk"..
Nevertheless, the Government has thought it useful to provide
advice about the risks of drinking. Its latest advice was drawn
up in 1995. It is unclear how the recommended units were decided
upon, but it seems to be the point at which the benefits of alcohol
from reducing cardiovascular disease are outweighed by the risks
of cancer, liver disease and other harms. Essentially, drinking
at this level can be seen to do harm at a population level, but
the risks to an individual are quite low. However, once people
drink at double the recommended limits the risks to an individual
become more substantial. The following table sets out the Department
of Health's different 'risk' categories associated with different
levels of drinking
Table 1: categories of drinkers
|Category||Alcohol consumption in men
||Alcohol consumption in women
|Low risk or 'sensible'
||21 units/week ||14 units/week
|Increasing risk or 'hazardous'
||22-50 units/week||15-35 units/week
|High risk or 'harmful'
||>50 units/week||>35 units/week
A unit of alcohol is defined as 8g or 10 ml of alcohol
The impact of alcohol on the NHS
56. GPs are presented with a range of chronic physical, mental
and social problems arising from alcohol. Problem drinkers consult
their GPs twice as often as the average patient.
Dr Paul Cassidy, a GP in Gateshead, told the committee:
Often, when GPs think alcohol they think alcohol dependence. They
are the patients who seem to give us the biggest problem, because
we have problems getting them into treatment and it is a chronic
illness. I see the non-dependent drinkers, of whom there are a
lot, in every day practice, and the challenge for me is to pick
those people up. The impact is often felt on the more dependent
end, but there are the more subtle effects of raising people's
blood pressure or leading to small injuries that affect the normal
patient who comes through the door. Certainly it is a common and
routine part of clinical practice.
ACCIDENT AND EMERGENCY DEPARTMENTS AND THE AMBULANCE
57. Estimates of the proportion of alcohol related emergency attendance
vary. A national survey of most of the UK's Emergency Departments
by Drummond found that 70% of night time attendances and 40% of
daytime attendances were caused by alcohol. A study from Cambridge
found the lowest proportion of alcohol related attendances was
24% at night and 4% during the day.
The College of Emergency Medicine informed us:
Significant numbers of adults and children attend Emergency Departments
in the UK as a direct result of alcohol consumption. Short-term
harms include serious accidents (some resulting in death and permanent
disability, particularly road traffic collisions), assaults, domestic
violence, collapse and psychiatric problems. Furthermore, all
Emergency Departments also admit, on a daily basis, patients suffering
from the longer-term health effects of sustained alcohol use,
for example acute withdrawal fits secondary to alcohol dependence,
pancreatitis and liver failure.
58. Brian Hayes, a London Ambulance Paramedic, told us about the
added costs of treating alcohol intoxication:
The first thing most of them do as we leave the scene is vomit.
That then renders the ambulance off the road for an hour once
that call has been finished because it has to be deep cleaned
because of infection and so on. Hopefully none of the vomit has
gone over the ambulance crew because if that happenedshower,
change your uniform. So you can be looking at that ambulance being
unavailable to deal with anything else for two hours, two and
a half hours because of alcohol. Then you will get the ones where
the ambulance crews have been assaulted
We have had cases
of paramedics being sliced with knives, punched, kicked, ambulances
being nicked just as a prank through somebody being drunk and
driving it into a row of cars.
59. When secondary diagnoses of an alcohol related disorder are
included, 863,300 alcohol-related admissions occurred in England
in 2007/2008. This
is more than 6% of all admissions and a 69% increase from 2002/2003
and rising by around 70,000 per year.
There has been a two-thirds increase in alcohol-related admissions
in over 65s in past 4 years, from 197,584 in 2002 to 323,595 in
60. Mortality from liver disease is regarded as one of the best
barometers of alcohol related ill health. Between 1970 and 2000
deaths from liver disease in people aged under 65 increased fivefold,
while death rates from other diseases have declined, as figure
6 shows. 
Figure 6: Movements in mortality 1971-2007 (Deaths per million
The British Society of Gastroenterology (BSG) and the British
Association for Study of the Liver (BASL) highlighted:
While the wine drinking countries of Southern Europe always had historically very
high levels of liver deaths from alcohol relatedcirrhosis (figure 7 below); deaths in
these countries have been dropping whereas UK deaths are still rising inexorably.
The UK finally overtook Spain, Italy and France for liver deaths in 2004.
Figure 7: SDR, chronic liver disease and cirrhosis, 0-64 per 100000
Source: WHO, Europe, European HPA Database, January
OVERALL COSTS TO THE NHS
61. Alcohol cost the NHS £2.7 billion in England
in the year 2006-2007 according to the Department of Health.
The NAO found that:
Most of these costs are borne by the front-line and
mainstream NHS: hospital services (inpatient and outpatient) account
for 56% of the total. Ambulance services and accident emergency
services, taken together, bear almost a third
estimated costs, while hospital services account for over a half
of the total. Specialist alcohol treatment services, provided
by non-NHS organisations, account for only two per cent of the
total estimated costs.
The figure below highlights the huge disparity between
the vast indirect costs of alcohol for the NHS and the small amounts
spent on services to treat alcohol problems.
Figure 8: Annual estimated costs of alcohol harm
to the NHS, 2006-07
Source: Department of Health Improvement Analytical
Team report, The cost of alcohol harm to the NHS in England: An
update to the Cabinet Office (2003) study, July 2008
NOTES: 'Hospital' includes inpatient visits directly
and partly attributable to alcohol misuse and outpatient attendances.
'Other healthcare costs' include alcohol-related counselling,
community psychiatric nurse visits and health visits.
The expenditure on Dependency Drugs is estimated
to be at least £2.14 million per annum.
The overall cost of alcohol to
62. Health is just one of many Government departments
which foot the bill for alcohol-related harm. The total cost to
society including costs to the criminal justice system, the economy
and social care were estimated by the Cabinet Office in 2003 to
be £20 billion.
This estimate was composed of £1.7 billion in health costs,
£7.3 billion for crime and public disorder
plus an estimated £4.7 billion for additional human and social
costs of crime, and £6.4 billion from loss of productivity
and profitability in the workplace.
63. However, in 2007 the National Social Marketing
Centre produced a much higher estimate of £55.1 billion.
This estimate was composed of £21 billion cost to individuals
and families/households, £2.8 billion cost to public health
and care services, £2.1 billion cost to the Criminal Justice
System, Education and Social Services, £7.3 billion cost
to employers and £21.9 billion in human cost (reduced quality
of life adjusted years). The box below shows the different estimates
for the costs.
|Estimated annual costs of alcohol-related harm in England|
The National Social Marketing Centre estimated that the total annual societal cost of alcohol misuse in England to be £55.1 billion including:
- £21 billion cost to individuals and families/households (eg loss of income, informal care costs)
- £2.8 billion cost to public health services/care services
- £2.1 billion cost to other public services (eg criminal justice system costs, education and social services costs)
- £7.3 billion cost to employers (eg absenteeism)
- £21.9 billion in human costs (DALYs).
The 2004 PMSU report estimated the overall annual cost of alcohol-related harm in England to be £20 billion including:
- Up to £1.7 billion for the healthcare service
- Up to £7.3 billion from alcohol-related crime and public disorder (£3.5 billion to services as a consequence of alcohol-related crime, £1.7-2.1 billion to services in anticipation of alcohol-related crime, £1.8 billion to the criminal justice system, £0.5 billion from drink-driving)
- Up to £6.4 billion from loss of productivity and profitability in the workplace (£1.2-1.8 from alcohol-related absenteeism, £2.3-2.5 billion from alcohol-related deaths, £1.7-2.1 billion from lost working days).
64. The fact that alcohol has been
enjoyed by humans since the dawn of civilization has tended to
obscure the fact that it is also a toxic, dependence inducing
teratogenic and carcinogenic drug to which more than three million
people in the UK are addicted. The ill effects of alcohol misuse
affect the young and middle aged. For men aged between 16 and
55 between 10% and 27% of deaths are alcohol related, for women
the figures are 6% and 15%.
has a massive impact on the families and children of heavy drinkers,
and on innocent bystanders caught up in the damage inflicted by
binge drinking. Nearly half of all violent offences are alcohol
related and more than 1.3 million children suffer alcohol related
abuse or neglect.
66. The costs
to the NHS are huge, but the costs to society as a whole are even
higher, all of these harms are increasing and all are directly
related to the overall levels of alcohol consumption within society.
42 Ev 20 Back
Q 1018 Back
Q 1029 Back
Q 200 Back
Psychiatric morbidity among adults living in private households,
2000, ONS. http://www.statistics.gov.uk/downloads/theme_health/psychmorb.pdf Back
The NHS Information Centre, Statistics on Alcohol: England,
2009, 2009, p 8. Back
Ev 62: Standerwick K, et al. 2007. Binge drinking, sexual behaviour
and sexually transmitted infection in the UK. International Journal
of STD and AIDS, no. 18, 810-813. Back
Jones L, Bellis MA, Dedman D, Sumnall H, Tocque K. Alcohol
attributable fractions for England; alcohol attributable mortality
and hospital admissions. North-West Public Health Observatory
and Dept of Health; 2008, p 26.. Back
Ibid., p 27. Back
Prime Ministers Strategy Unit. Interim Analytical Report. 2003. Back
Key J, Hodgson S, Omar RZ, Jensen TK, Thompson SG, Boobis AR,
et al. Meta-analysis of studies of alcohol and breast cancer with
consideration of the methodological issues. Cancer Causes Control
2006 Aug;17(6):759-70. Back
Tatsuo A, Iwasaki M, Uchitomi Y, et al, Alcohol consumption and
suicide among middle-aged men in Japan, British Journal of Psychiatry,
2006, 188: 231-236 Back
Prime Minister's Strategy Unit. Strategy Unit Alcohol Harm Reduction
Project: Interim Analytical Report. London. Cabinet Office, 2003 Back
Gupta S & Warner J, Alcohol-related dementia: a 21st century
silent epidemic, British Journal Psychiatry, 2008, 193: 351-353 Back
Ev 156 Back
Ev 2 Back
Ev 25 Back
Ev 2 Back
Ev 21 Back
Ev 26 Back
Ev 108 Back
Ev 44 Back
Ev 28 Back
Ev 156 Back
Q 5 Back
The disability-adjusted life year (DALY) is a measure of overall
disease burden, originally developed by the World Health Organization.
It is designed to quantify the impact of premature death and disability
on a population by combining them into a single, comparable measure.
In so doing, mortality and morbidity are combined into a single,
common metric Back
J, Room R, Monteiro M et al, 2003, Alcohol as a risk factor
for global burden of disease. European Addiction Research;
9(4), 157-164 Back
Q 4 Back
Office of National Statistics, Health Statistics Quarterly
33 (Spring 2007) Back
Becker U, Deis A, Sørensen TI, et al. 1996. Prediction
of risk of liver disease by alcohol intake, sex, and age: a prospective
population study. Hepatology. 1996 May,1025-9 Back
Q 14 Back
Ev 40 Back
Q 109 Back
Ev 24 Back
Ev 24 Back
Q 254 Back
NHS Information Centre for Health and Social Care, Statistics
on Alcohol: England, 2009, p 8. Back
Ev 2 Back
Ev 157 Back
Ev 66 Back
Ev 157 Back
British Liver Trust analysis of Office for National Statistics
mortality statistics covering all deaths related to liver dysfunction
covering ICD K70-76 and other codes including C22-24 (liver cancer),
and B15-B19 (viral hepatitis), January 2009 Back
Ev 65 Back
Ev 2 Back
National Audit Office, Reducing Alcohol Harm: Health Services
in England for Alcohol Misuse, 2008, p 12. Back
Ibid., p 12. Back
Prime Minister's Strategy Unit. Strategy Unit Alcohol Harm Reduction
Project: Interim Analytical Report, London, Cabinet Office, 2003 Back
The £7.3 billion Includes £3.5 billion to services as
a consequence of alcohol-related crime, £1.7-2.1 billion
to services related to crime, for example extra security staff
to prevent disorder, burglary alarms, shops spending on extra
security, £1.8 billion to the criminal justice system and
£0.5 billion from drink-driving Back
Lister G, Evaluating social marketing for health-the need
for consensus. Proceedings of the National Social Marketing
Centre, 2007. Back