Alcohol misuse: tackling the UK epidemic - London

BMA Board of Science 

Alcohol misuse: tackling the 

UK epidemic 

February 2008


Alcohol misuse: tackling the 

UK epidemic 

February 2008 

Alcohol misuse: tackling the UK epidemic i

ii 


Editorial board 

A publication from the BMA Science and Education department and the Board of Science. 

Chair, Board of Science Professor Sir Charles George 

Director of Professional Activities Professor Vivienne Nathanson 

Head of Science and Education Dr Caroline Seddon 

Project manager Nicky Jayesinghe 

Research and writing George Roycroft 

Editorial secretariat Thomas Ellinas 

Luke Garland 

Darshna Gohil 

Joseph Kirkman 

Joanna Rankin 

Andrea Ritson 

British Library Cataloguing-in-Publication Data. 

A catalogue record for this book is available from the British Library. 

ISBN: 978-1-905545-26-1 

Cover photograph: Getty Images Creative. 

© British Medical Association – 2008 all rights reserved. No part of this publication may be 

reproduced, stored in a retrievable system or transmitted in any form or by any other means that 

be electrical, mechanical, photocopying, recording or otherwise, without the prior permission in 

writing of the British Medical Association. 

Alcohol misuse: tackling the UK epidemic


Board of Science 

This report was prepared under the auspices of the Board of Science of the British Medical 

Association, whose membership for 2007/08 was as follows: 

HRH the Princess Royal President, BMA 

Dr Peter Bennie Chair of the Representative Body, BMA 

Dr Hamish Meldrum Chair of Council 

Dr David Pickersgill Treasurer, BMA 

Mr Tony Bourne Chief Executive, BMA 

Dr Kate Bullen Deputy Chair of Council 

Professor Sir Charles George Chair, Board of Science 

Dr Peter Maguire Deputy Chair, Board of Science 

Dr JS Bamrah 

Dr Peter Dangerfield 

Dr Lucy-Jane Davis 

Dr Greg Dilliway 

Dr Rajesh Rajendran 

Dr David Sinclair 

Dr Rafik Taibjee 

Dr Andrew Thomson 

Dr Dorothy Ward 

Dr David Wrigley 

Dr Chris Spencer-Jones (by invitation) 

Dr John Black (Co-optee) 

Dr Mohamed El-Sheemy (Co-optee) 

Dr Philip Steadman (Co-optee) 

Dr Joannis Vamvakopoulos (Co-optee) 

Dr Sally Nelson (Deputy member) 

Approval for publication as a BMA policy report was recommended by BMA Board of Professional 

Activities on 29 January 2008. 

Declaration of interest 

There were no competing interests with anyone involved in the research and writing of this 

report. For further information about the editorial secretariat or Board members please contact 

the BMA Science and Education department which holds a record of all declarations of 

interest: info.science@bma.org.uk 

Alcohol misuse: tackling the UK epidemic iii

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Acknowledgements 

The association is grateful for the help provided by the BMA committees and outside experts and 

organisations. We would particularly like to thank: 

Professor James Griffith Edwards CBE, Emeritus Professor of Addiction Behaviour, Addiction 

Research Unit, Institute of Psychiatry, King’s College London 

Professor Martin Plant, Professor of Addiction Studies and Co-Director of the Alcohol and 

Health Research Trust, University of the West of England 

Professor Robin Room, School of Population Health, University of Melbourne, and Director, 

AER Centre for Alcohol Policy Research, Turning Point Alcohol and Drug Centre, Victoria, Australia 



Abbreviations 

A&E accident and emergency 

AERC Alcohol Education Research Council 

ANARP Alcohol Needs Assessment Research Project 

ASA Advertising Standards Agency 

AUDIT Alcohol Use Disorders Identification Test 

BAC blood alcohol concentration 

BCS British Crime Survey 

CHD coronary heart disease 

CNS central nervous system 

DALY disability adjusted life year 

DCMS Department for Culture, Media and Sport 

DEFRA Department for Environment, Food and Rural Affairs 

DES direct enhanced service 

DH Department of Health 

DHSSPS Department of Health, Social Services and Public Safety 

DSD Department for Social Development 

ESPAD European School Survey Project on Alcohol and other Drugs 

EU European Union 

FASD fetal alcohol spectrum disorders 

FAST Fast Alcohol Screening Test 

FCAC Framework Convention on Alcohol Control 

FCTC Framework Convention on Tobacco Control 

GHS General Household Survey 

GP general practitioner 

ICD-10 International Classification of Diseases (Tenth revision) 

LGB lesbian, gay and bisexual 

MAST Michigan Alcoholism Screening Test 

NES national enhanced service 

GMS general medical services 

NHSS national healthy school standard 

NICS Northern Ireland Crime Survey 

NWPHO North West Public Health Observatory 

OCJS Offending Crime and Justice Survey 

ONS Office for National Statistics 

PAT Paddington Alcohol Test 

PCT primary care trust 

PMSU Prime Minister’s Strategy Unit 

PND penalty notices for disorder 

POST Parliamentary Office for Science and Technology 

PSHE personal, social and health education 

QOF quality outcomes framework 

RASG Retail of Alcohol Standards Group 

SALSUS Scottish Adolescent Lifestyle and Substance Use Survey 

SCS Scottish Crime Survey 

SEHD Scottish Executive Health Department 

SHS Scottish Health Survey 

SIGN Scottish Intercollegiate Guidelines Network 

UK United Kingdom 

USA United States of America 

WHO World Health Organisation 

Alcohol misuse: tackling the UK epidemic v

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Glossary 

Note 

An alcoholic beverage is a drink containing ethanol (ethyl alcohol). For this report, the term 

alcohol refers to ethanol rather than the broader definition of alcohol that incorporates other 

compounds including methanol, propanol and butanol. 

Alcohol abuse 

A term in wide use but of varying meaning. The Diagnostic and Statistical Manual of Mental 

Disorders, 4th edition (DSM-IV) defines psychoactive substance abuse as a maladaptive pattern of 

substance use leading to clinically significant impairment or distress, as manifested by one (or 

more) of the following, occurring within a 12-month period: 

recurrent substance use resulting in a failure to fulfil major role obligations at work, school, 

home (eg repeated absences or poor work performance related to substance use; 

substance-related absences, suspensions, or expulsions from school; neglect of children or 

household) 

recurrent substance use in situations in which it is physically hazardous (eg driving an 

automobile or operating a machine when impaired by substance use) 

recurrent substance-related legal problems (eg arrests for substance-related disorderly 

conduct) 

continued substance use despite having persistent or recurrent social or interpersonal 

problems caused or exacerbated by the effects of the substance (eg arguments with spouse 

about consequences of intoxication, physical fights). 1 

The term is not used in the World Health Organisation (WHO) International Classification of 

Diseases 10th revision (ICD-10), where harmful and hazardous use are the equivalent terms. In 

common usage, the term ‘abuse’ is sometimes used to refer to any use at all, particularly of illicit 

drugs. In other contexts, abuse refers to persistent or sporadic excessive drug use inconsistent with 

or unrelated to acceptable medical practice. 2 

The term alcohol abuse is used predominantly in the 

United States of America (USA). 

Alcohol misuse 

The use of alcohol for a purpose not consistent with legal or medical guidelines. 2 

Alcohol dependence syndrome 

Alcohol dependence syndrome is classified by the ICD-10 as a cluster of behavioural, cognitive, 

and physiological phenomena that develop after repeated alcohol use and that typically include a 

strong desire to consume alcohol, difficulties in controlling its use, persisting in its use despite 

harmful consequences, a higher priority given to its use than to other activities and obligations, 

increased tolerance, and sometimes a physical withdrawal state. 2 

Alcoholism 

A term of common use and variable meaning, generally taken to refer to chronic continual 

drinking or periodic consumption of alcohol which is characterised by impaired control over 

drinking, frequent episodes of intoxication, preoccupation with alcohol, and the use of alcohol 

despite adverse consequences. 2 

Alcoholism is not included as a diagnostic term in ICD-1O. 



Alcohol use disorders 

A generic term used to denote mental, physical, and behavioural conditions of clinical relevance 

and associated with the use of alcohol. The disorders include acute intoxication, harmful use, 

dependence syndrome, withdrawal syndrome (with and without delirium), psychotic disorders, and 

amnesic syndrome. 2 

Binge drinking 

The terms ‘binge drinking’ or ‘binge’ have no standard definition. Traditionally, a ‘binge’ has been 

used to describe a pattern of heavy drinking occurring over a prolonged period set aside for the 

purpose. Recent common use of the term ‘binge’ refers to a single drinking session intended to, 

or actually leading to, intoxification. A pattern of repeated ‘binge’ sessions is commonly therefore 

referred to as ‘binge drinking’ or ‘heavy episodic drinking’. Alternative definitions of a ‘binge’ 

focus on specific and objective quantities of alcohol; for example, the UK Prime Minister’s Strategy 

Unit (PMSU) defines a ‘binge’ as drinking over twice the recommended guidelines for daily 

drinking (see separate definition for recommended drinking guidelines). 3 

Blood alcohol concentration 

Blood alcohol concentration (BAC) is the concentration of alcohol in blood. It is measured either as 

a percentage by mass, by mass per volume, or a combination. In the United Kingdom (UK), BAC is 

reported as milligrams of alcohol per 100 millilitres of blood (eg 80mg per 100ml). In many 

countries, BAC is measured and reported as grams of alcohol per 1,000 millilitres (1 litre) of blood 

(g/1,000 ml). For purposes of law enforcement, BAC is used to define intoxication and provides a 

rough measure of impairment. Most countries disallow operation of motor vehicles, boats, aircraft 

and heavy machinery above prescribed levels of BAC. Blood alcohol concentration is commonly 

referred to as blood alcohol content. 

Harmful drinking 

Harmful drinking is a pattern of alcohol use that causes damage to physical and/or mental health. 2 

Harmful use commonly, but not invariably, has adverse social consequences. Social consequences 

on their own, however, are not sufficient to justify a diagnosis of harmful use. 2 

Harmful drinking is 

included as a diagnostic term in the ICD-I0. 

Hazardous drinking 

Hazardous drinking is a pattern of alcohol use that increases the risk of harmful consequences for 

the individual. 2 

In contrast to harmful use, hazardous drinking refers to patterns of use that are of 

public health significance despite the absence of any current disorder in the individual user. 2 

Hazardous drinking is not included as a diagnostic term in the ICD-10. 

Heavy drinking 

A pattern of drinking that exceeds some standard of moderate drinking. In the UK, heavy drinking 

is defined as consuming eight or more units for men and six or more units for women on at least 

one day in the week. 3 

Moderate drinking 

An inexact term for a pattern of drinking that is by implication contrasted with heavy drinking. It 

denotes drinking that is moderate in amount and does not cause problems. 2 

Alcohol misuse: tackling the UK epidemic vii

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Recommended drinking guidelines 

Guidelines set by the UK Government that provide advice on daily and weekly maximum alcohol 

consumption levels. The guidelines recommend that men should not regularly drink more than 

three to four units of alcohol per day, and women should not regularly drink more than two to 

three units of alcohol per day. In terms of weekly limits, men are advised to drink no more than 

21 units per week and women no more than 14 units per week. These guidelines are commonly 

referred to as ‘sensible drinking guidelines’. 

Unit 

In the UK, alcoholic drinks are measured in units and each unit corresponds to 7.9 grams (g) or 

10 millilitres (ml) of ethanol. The value of one UK unit does not necessarily correspond to a typical 

serving size. For example, one unit of alcohol approximates to half a pint of ordinary strength beer, 

lager, or cider (3-4% alcohol by volume), or a small pub measure (25ml) of spirits (40% alcohol 

by volume). There are one and a half units of alcohol in a small glass (125ml) of ordinary strength 

wine (12% alcohol by volume), or a standard pub measure (35ml) of spirits (40% alcohol by 

volume). There is also substantial variation in the standard measures used in bars and restaurants 

as well as measures poured in the home. Different methods are used to define standard 

measurements internationally none of which correspond to the UK unit. 



Foreword 

Alcoholic beverages consumed in moderation are enjoyed by many. Although socially accepted, 

alcohol can be an addictive drug. Alcohol misuse can be harmful foremost to the individual but 

also places a substantial burden on families and society. The levels of alcohol-related disorder, 

crime, morbidity and premature mortality in the UK are unacceptably high. Despite this, the 

strategy to reduce alcohol-related harm in the UK has seen an over-reliance on popular but 

ineffective policies, as well as liberalisation of the major drivers of alcohol consumption: availability 

and price. This represents a significant shortcoming in the political drive to improve public health 

and order. 

It is essential that the UK Governments implement alcohol control policies that are evidence-based 

and proven to reduce alcohol-related harm. This includes policies that limit access to alcohol, as 

well as enforcement of responsible retailing and a move away from self-regulation by the alcohol 

industry. Targeted approaches are vital, including measures to reduce alcohol consumption by 

young people and children, and a greater emphasis on the provision of treatment for individuals 

who misuse alcohol. 

The BMA has developed comprehensive policy on alcohol, and this report unifies its work and 

identifies effective, evidence-based policies for reducing the burden of alcohol misuse in the UK. 

It continues the work of the Board of Science on alcohol and health promotion which has resulted 

in a number of publications including Fetal alcohol spectrum disorders – a guide for healthcare 

professionals (BMA, 2007), Binge drinking (2005), and Adolescent health (2003) (see Appendix 1). 

The aim of this report is to tackle alcohol misuse and not to assail those who enjoy consuming 

alcohol sensibly. It proposes polices that promote a culture where alcohol is enjoyed safely. As with 

other BMA Board of Science publications, this report is intended for policy makers with strategic or 

operational responsibility for public health and health promotion in the UK. 

Professor Sir Charles George 

Chair, Board of Science 

The Board of Science, a standing committee of the BMA, provides an interface between the 

medical profession, the Government and the public. The Board produces numerous reports 

containing policies for national action by government and other organisations, with specific 

recommendations affecting the medical and allied professions. 

Alcohol misuse: tackling the UK epidemic ix

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Contents 

Executive summary 1 

Recommendations 7 

Introduction 10 

Alcohol consumption in the UK 11 

Per capita alcohol consumption 11 

Prevalence of alcohol consumption 13 

Patterns of alcohol misuse 14 

Socio-economic factors and alcohol consumption 17 

National and regional variations in alcohol consumption in the UK 19 

Trends in alcohol misuse 19 

Alcohol consumption and young people 22 

Why do individuals misuse alcohol? 24 

Where is alcohol consumed? 25 

The burden of alcohol on society 27 

Alcohol and health outcomes 27 

Alcohol consumption and health 27 

Alcohol-related morbidity, mortality and disability 31 

Causes of alcohol-related mortality 36 

Alcohol-related hospital admissions 37 

Alcohol-related crime, disorder and anti-social behaviour 38 

The social effects of alcohol misuse on individuals and families 41 

Driving and road safety 42 

The cost of alcohol misuse and alcohol-related harm 44 

Effective policies to reduce alcohol-related harm in the UK 47 

Access to alcohol – controlling price and availability 48 

Taxation and traveller’s allowances 48 

Licensing reforms 50 

Legal age of consumption and age of purchase 52 

Responsible retailing and industry practices 52 

Enforcing responsible serving practices 52 

Marketing and advertising 54 

Measures to reduce drink-driving 57 

Education and health promotion 59 

Educational programmes 59 

Understanding recommended drinking guidelines 60 

Health promotion and advice from healthcare professionals 61 

Early intervention and treatment of alcohol misuse 62 

Screening and brief interventions for alcohol misuse 62 

Specialist alcohol treatment services 65 

International cooperation on alcohol control 68 

Appendix 1 – summary of previous BMA publications on alcohol 71 

Appendix 2 – UK alcohol control policies 72 

Appendix 3 – excise duty rates in the European Union 75 

Appendix 4 – school-based alcohol education in the UK 76 

Appendix 5 – World Health Organisation European Charter on Alcohol 77 

Appendix 6 – Framework Convention on Tobacco Control 78 

References 79 

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Executive summary 

This report considers a range of evidence-based policies to tackle the problematic levels of alcohol 

misuse in the UK and is not intended to assail those who enjoy consuming alcohol in moderation. 

Alcohol consumption represents an integral part of modern culture in the UK and internationally. 

Alcohol is a psychoactive substance and its consumption in moderation can lead to feelings of 

relaxation and euphoria. It is also an addictive drug and its misuse is associated with a wide range 

of dose-related adverse sequelae that can lead to significant harm to the individual and society. 

Since 1950, alcohol consumption in the UK has risen from 3.9 litres pure alcohol per capita per 

year to a peak of 9.4 litres in 2004. Despite a recent fall to 8.9 litres, per capita consumption in 

the UK has remained consistently above 7 litres pure alcohol per year since 1980. The UK is among 

the heaviest alcohol consuming countries in Europe. The vast majority of the UK adult population 

consumes alcohol. The prevalence of alcohol consumption varies considerably by ethnic group. 

Only nine per cent of the White British population are non-drinkers, whereas 48 per cent of Black 

African origin and 90 per cent or more among those of Pakistani and Bangladeshi origin abstain 

from alcohol. There are also differences in alcohol consumption between men and women with 

men drinking twice as much alcohol as women on average per week. Individuals in employment 

are more likely to drink frequently compared to those who are unemployed. 

A similar pattern is also seen for socio-economic classification. Individuals in managerial and 

professional occupations are more likely to drink more frequently than those in routine and 

manual occupations. 

A large majority of the individuals in the UK who consume alcohol, do so in moderation. Analysis of 

the patterns of alcohol consumption, however, reveals that a significant proportion misuse alcohol by 

drinking above the UK recommended guidelines. Of particular concern is the pattern of drinking 

among adolescents, and the high level of binge drinking and heavy drinking among men and women 

in the 16 to 24 and 25 to 44 age groups. UK teenagers are among the most likely in Europe to report 

heavy consumption of alcohol, being intoxicated and experiencing adverse effects of drinking. 

During the 1990s, the prevalence of alcohol misuse increased among both men and women, and in 

particular in the 16 to 24 age group. This upward trend was particularly marked among young women 

to the extent that consumption among this group is now the highest in Europe. The upward trend 

may have peaked, however. In the 16 to 24 age group, there has been a downward trend since 2003 

in the proportion of men drinking above recommended daily guidelines and drinking heavily. A similar 

downward trend has occurred among women aged 16 to 24 since 2002. Data on average weekly 

consumption show a similar downward trend in recent years. It is not yet possible to determine 

whether these recent trends in alcohol consumption are genuine long-term changes in drinking habits. 

Recent years have seen an increasing trend among UK adults toward home-based alcohol 

consumption. This trend toward home-based alcohol consumption most likely reflects the lower cost 

of alcohol in off-licences compared to licenced premises in the UK. Among younger adults, there is 

also an increased tendency to consume alcohol at home prior to going out. 

Alcohol consumption has been shown to be causally related to over 60 different medical 

conditions and is a significant cause of morbidity and premature death worldwide. In the majority 

of cases there is a dose-response relation, with risk increasing with the amount of alcohol 

consumed. Moderate alcohol consumption is not usually harmful to health. Indeed, consumption 

at moderate levels or below in older men and women is associated with a lower risk of coronary 

heart disease (CHD), ischaemic stroke and diabetes mellitus, compared to individuals who abstain 

from alcohol. Drinking heavily, however, can result in significant health problems through either 

acute or chronic misuse. In the UK, the burden of alcohol-related morbidity and mortality is 

Alcohol misuse: tackling the UK epidemic 1

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shifting to younger age groups in both men and women, and toward the most socially deprived 

groups. The pattern of consumption is important in determining the impact of alcohol misuse on 

health. Binge drinking is a particularly harmful form of alcohol consumption and significantly 

increases the risk of alcohol dependence in men and women. The frequency of heavy drinking by 

the pregnant mother is also associated with the occurrence of a range of completely preventable 

mental and physical birth defects collectively known as Fetal Alcohol Spectrum Disorders (FASD). 

Alcohol misuse can lead to many harmful consequences for the individual drinker, their family and 

friends. It significantly impacts on family life and is also a significant contributory factor in domestic 

violence incidents in about 50 per cent of cases. Parental alcohol misuse is also correlated with 

child abuse and impacts on a child’s environment in many social, psychological and economic 

ways. Driving under the influence of alcohol is a significant cause of death and serious injury from 

road traffic crashes in the UK. In 2006, six per cent of all road casualties and 17 per cent of road 

deaths were due to alcohol intoxication. Alcohol consumption by other road users such as cyclists 

and pedestrians is also associated with fatalities and injuries. The levels of alcohol-related crime 

and disorder vary with age and pattern of drinking, with alcohol-related offences particularly 

common among binge drinkers in the 18 to 24 age group compared to other regular drinkers. 

Drinking alcohol, especially frequent drinking, is also a significant factor in criminal and disorderly 

behaviour in young people aged under 18. 

The cost of alcohol misuse in the UK is substantial, both in terms of direct costs (eg costs to 

hospital services and the criminal justice service) and indirect costs (eg loss of productivity and the 

impact on family and social networks). The control of alcohol at a national and international level 

is therefore essential. This requires the implementation of strategies that are effective at reducing 

overall alcohol consumption levels in a population, as well as targeted interventions aimed at 

specific populations who misuse alcohol, or individuals who are dependant on alcohol. 

Effective policies to reduce alcohol-related harm in the UK 

There is a substantial body of evidence demonstrating that targeted and population-wide alcohol 

control policies can reduce alcohol-related harm. Historically, changes in alcohol control policies in 

the UK have been accompanied by fluctuations in alcohol consumption levels and associated 

problems. Since the Second World War, there has been considerable deregulation and liberalisation 

of alcohol control policies in the UK, which have been accompanied by an increase in consumption 

levels and alcohol-related problems. Current UK governmental alcohol control strategies have been 

the subject of much criticism due to the lack of commitment to evidence-based harm reduction 

policies. Lessening the burden of alcohol misuse in the UK requires strong leadership and the 

implementation of effective alcohol control policies that reduce overall consumption levels and 

minimise the harm to the public and the individual. Developing comprehensive alcohol control 

policies requires partnership between governmental agencies and organisations throughout the UK. 

Access to alcohol – controlling price and availability 

Access to alcohol is an important determinant of alcohol use and misuse. This incorporates the 

implementation of policies that regulate the affordability of alcohol as well as the introduction and 

enforcement of strict controls on the availability of alcohol to adults and young people. In the UK, 

the affordability of alcohol increased by 65 per cent between 1980 and 2006. Over the 

corresponding time period, per capita alcohol consumption aged 15 and over increased from 

9.4 to 10.9 litres pure alcohol. Since 1997, excise duties on wine and beer in the UK have only 

increased in line with inflation while the duty on spirits has not increased. There is strong and 

consistent evidence that increases in price have the effect of reducing consumption levels, and the 

rates of alcohol problems including alcohol-related violence and crime, deaths from liver cirrhosis, 



and drink-driving deaths. Increases in the price of alcohol not only affect consumption at a 

population level, but there is evidence that particular types of consumers (eg heavy drinkers and 

young drinkers) are especially responsive to price. Studies have also reported that price increases 

have the effect of reducing rates of alcohol problems including alcohol-related violence and crime. 

As part of a range of measures to reduce alcohol misuse, it is essential that the level of excise paid 

on all alcoholic beverages is increased at higher than inflation rates and that this increase is 

proportionate to the amount of alcohol in the product. This increased taxation would reduce 

alcohol consumption and its related harms, and would also contribute to providing the necessary 

funding to meet the social and economic costs of these harms. 

Licensing interventions are one of the most influential methods for controlling alcohol 

consumption and misuse through regulation of where, when and to whom alcohol can be sold. 

There is strong evidence that increased opening hours are associated with increased alcohol 

consumption and alcohol-related problems. Conversely, reductions in opening hours and the 

number of outlets are associated with reductions in alcohol use and related problems. The 

Licensing Act 2003 now permits 24-hour opening in England and Wales. Of particular note, is the 

fact that public health was not considered as one of the licensing objectives in the 2003 Licensing 

Act. The proposed changes to licensing in Scotland and Northern Ireland will permit more modest 

extensions in opening hours. A high density of alcohol outlets is associated with increased alcohol 

sales, drunkenness, violence and other alcohol-related problems. Consumers are likely to be 

deterred from purchasing alcohol when there is a lower density of outlets due to the increased 

time and inconvenience involved in purchasing it. 

Responsible retailing and industry practices 

Numerous factors contribute to the culture of drinking to excess and the rise in underage age 

drinking and alcohol-related harm in the UK. Key areas are the supply and promotion of alcohol to 

consumers. Active enforcement of laws regulating licensing hours and prohibiting the sale of alcohol 

to individuals who are intoxicated or those underage have been shown to be effective at increasing 

compliance with legislation. The layout, design and internal physical characteristics of licensed 

premises are also important considerations for strategies to reduce alcohol-related crime and disorder. 

Irresponsible promotional activities are common in licensed premises and off-licences (including 

supermarkets and local convenience stores) throughout the UK, so it is essential that these forms 

of promotional activity are strictly regulated; thus prohibiting price promotions on alcoholic 

beverages, and by establishing minimum price levels. Repeated exposure to high-level alcohol 

promotion influences young people’s perceptions, encourages alcohol consumption and increases 

the likelihood of heavy drinking. Specific advertising strategies such as sponsorship of sporting and 

music events, as well as advertisements using celebrity endorsements all serve to reinforce the 

image of alcohol among young people and predispose them to drinking well below the legal age 

to purchase alcohol. It is essential that there is statutory regulation of the marketing of alcoholic 

beverages in the UK. This includes prohibiting the broadcasting of alcohol advertising at any time 

that is likely to be viewed by young people, with specific provisions banning alcohol advertising 

prior to 9pm and in cinemas for films with a certificate below age 18. 


4 


Consideration also needs to be given to prohibiting alcohol industry sponsorship of sporting and 

music events aimed mainly at young people. 

Measures to reduce drink-driving 

Considerable reductions in the incidence of drink-drive road incidents and related deaths have 

occurred in the UK since 1980. The number of fatalities and serious injuries resulting from 

drink-drive road crashes, however, remains significantly high. In the UK, the BAC limit is 

80mg/100ml which is among the highest in Europe, yet there is a marked deterioration in driving 

performance between a BAC of 50mg/100ml and 80mg/100ml. Drinking by drivers with a BAC 

between 50mg/100ml and 80mg/100ml is a significant but largely hidden cause of road traffic 

crashes and has been estimated to account for 80 road deaths a year in England. Newly qualified 

drivers are felt to be particularly at risk of alcohol-related road crashes as a result of their limited 

driving experience. It is essential that further measures are implemented to build on progress 

achieved over recent years in reducing the levels of drink-driving in the UK. This includes a 

reduction in the legal BAC limit from 80mg/100ml to 50mg/100ml, and consideration for further 

reductions for all newly qualified drivers. 

Education and health promotion 

The use of public information and educational programmes is a common theme for alcohol control 

policies in the UK and internationally. Such approaches are politically attractive but have been found 

to be largely ineffective at reducing heavy drinking or alcohol-related problems in a population. In 

the UK, mass media campaigns, public service messages and school-based educational programmes 

are used as key alcohol control measures. While these may be effective at increasing knowledge and 

modifying attitudes, they have limited effect on drinking behaviour in the long term. It is essential 

that the disproportionate focus upon, and funding of, such measures is redressed. 

Much of the strategy to reduce alcohol-related harm in the UK focuses on recommended drinking 

guidelines. While the majority of people are aware of the existence of these guidelines, few can 

accurately recall them, understand them, or appreciate the relationship between units and glass 

sizes and drink strengths. Labelling of alcoholic beverage containers would be a useful method for 

explaining recommended drinking guidelines and for supporting other alcohol control policies. In 

the UK, recent voluntary agreements with the alcohol industry have led to the inclusion of 

information on unit content on some alcoholic beverages. The recommended guidelines, however, 

may only be one of the sources that inform individual decision-making with respect to alcohol 

consumption. Other influences include intrapersonal factors such as prior drinking experiences and 

interpersonal reasons such as peer influence. 

Early intervention and treatment of alcohol misuse 

Preventing alcohol-related harm requires the accurate identification of individuals who misuse alcohol, 

and the implementation of evidence-based interventions to reduce alcohol consumption. At present 

there is no system for routine screening and management of alcohol misuse in primary or secondary 

care settings in the UK. Screening and management occur opportunistically and where clinically 

appropriate in both settings. Identification of alcohol misuse among people not seeking treatment for 

alcohol problems can be achieved via alcohol screening questionnaires, detection of biological markers 

and detection of clinical indicators. The use of alcohol screening questionnaires is an efficient and costeffective 

method for detecting alcohol misuse. Biological markers can be used as adjuncts to 

questionnaires for the screening process. Primary care, general hospital and accident and emergency 

(A&E) settings provide useful opportunities for screening for alcohol misuse and the delivery of brief 

interventions. It is essential that systems are developed in order to encourage this activity on a regular 

basis. Effective operation of such systems requires adequate funding and resources, and 



comprehensive training and guidance on the use of validated screening questionnaires as well as the 

provision of brief interventions. Routine screening in primary care could be facilitated by the 

implementation of a directed enhanced service (DES). 

Brief interventions (behavioural modification techniques) provide prophylactic treatment and 

produce clinically significant effects on drinking behaviour and related problems in non-alcohol 

dependent individuals. For individuals with more severe alcohol problems and levels of dependence, 

specialised alcohol treatment services can effect significant reductions in alcohol use and related 

problems. It is essential that individuals identified as having severe alcohol problems or as being 

alcohol dependent are offered referral to specialised alcohol treatment services. Not all individuals 

however, with severe alcohol problems will recognise or agree that they have an alcohol misuse 

problem, or that they require treatment. 

The inadequate provision of specialised alcohol treatment services in the UK is a significant area 

of concern. It is essential that specialised alcohol treatment services are provided consistently 

throughout the UK, adequately resourced and funded, and that this funding is ring-fenced. 

High-level commitment is also required to ensure that the alcohol treatment services frameworks are 

prioritised when commissioning services. The need for, and provision of, alcohol treatment services 

throughout the UK must also be continually reviewed and assessed. 

International cooperation on alcohol control 

Different countries have adopted markedly varied policies for reducing the burden of alcohol 

misuse. International cooperation on alcohol control is essential for several reasons including the 

considerable global burden of alcohol, and trans-border factors such as global advertising and 

production, formal and informal trading and smuggling. Reducing alcohol-related harm across the 

European Union (EU) has been facilitated by the 2000 World Health Organisation (WHO) European 

Alcohol Action Plan, the 2006 EU Alcohol Strategy, and the establishment of the EU Alcohol and 

Health Forum. It is vital that the UK Government strongly supports EU initiatives and policies aimed 

at reducing alcohol-related harm to individual and public health. 

While the introduction of agreements such as the WHO European Alcohol Action Plan and the EU 

Alcohol Strategy provide a useful platform for action, their effectiveness has been questioned due 

to the influence of the alcohol industry on their development. A further drawback of EU-level 

action and agreements is the fact that they are non-binding. An alternative approach would be to 

introduce a legally binding treaty similar to the WHO Framework Convention on Tobacco Control 

(FCTC). This would serve to support governments in developing and implementing effective 

alcohol control policies, foster collaboration between countries, counter the international trade 

agreements that currently restrict governments from introducing stricter alcohol control policies, 

and effectively engage non-governmental organisations. 


6 




Recommendations 

As the leading professional organisation representing doctors in the UK, the BMA through this 

report, aims to promote the development of comprehensive and effective alcohol control 

policies in the UK. The recommendations are for action by the UK Government. They form a 

range of evidence-based policies that must be collectively implemented in order to effectively 

tackle alcohol misuse and its associated harms. 


Taxation on all alcoholic beverages should be increased at higher than inflation rates and 

this increase should be proportionate to the amount of alcohol in the product. 

The availability of alcoholic products should be regulated through a reduction in licensing 

hours for on- and off-licensed premises. 

Town planning and licensing authorities should ensure they consider the local density of 

on-licensed premises and the surrounding infrastructure when evaluating any planning or 

licensing application. Legislative changes should be introduced where necessary to ensure 

these factors are considered in planning or licensing applications for licensed premises. 


Licensing legislation in the UK should be strictly and rigorously enforced. This includes the 

use of penalties for breach of licence, suspension or removal of licences, the use of test 

purchases to monitor underage sales, and restrictions on individuals with a history of 

alcohol-related crime or disorder. 

Enforcement agencies should be adequately funded and resourced so that they can 

effectively carry out their duties. Consideration should be given to the establishment of a 

dedicated alcohol licensing and inspection service. 

Legislation should be introduced throughout the UK to: 

prohibit irresponsible promotional activities in licensed premises and by off-licences 

set minimum price levels for the sale of alcoholic beverages. 

A statutory code of practice on the marketing of alcoholic beverages should be introduced 

and rigorously enforced. This should include a ban on: 

broadcasting of alcohol advertising at any time that is likely to be viewed by young 

people, including specific provisions prohibiting advertising prior to 9pm and in cinemas 

before films with a certificate below age 18 

alcohol industry sponsorship of sporting, music and other entertainment events aimed 

mainly at young people 

marketing of alcoholic soft drinks to young people. 


8 



The legal limit for the level of alcohol permitted while driving, attempting to drive, or being 

in charge of a vehicle should be reduced from 80mg/100ml to 50mg/100ml throughout the 

UK. 

Legislation permitting the use of random roadside testing without the need for prior 

suspicion of intoxication should be introduced throughout the UK. This requires appropriate 

resourcing and public awareness campaigns. 


There should be further qualitative research examining attitudes to alcohol misuse in the UK. 

Public and school-based alcohol educational programmes should only be used as part of a 

wider alcohol-related harm reduction strategy to support policies that have been shown to 

be effective at altering drinking behaviour, to raise awareness of the adverse effects of 

alcohol misuse, and to promote public support for comprehensive alcohol control measures. 

It should be a legal requirement to: 

a) prominently display a common standard label on all alcoholic products that clearly states: 

alcohol content in units 

recommended daily UK guidelines for alcohol consumption 

a warning message advising that exceeding these guidelines may cause the individual 

and others harm. 

b) include in all printed and electronic alcohol advertisements information on: 




It should be a legal requirement for retailers to prominently display at all points where 

alcoholic products are for sale: 

information on recommended daily UK guidelines for alcohol consumption 




The detection and management of alcohol misuse should be an adequately funded and 

resourced component of primary and secondary care in the UK to include: 

formal screening for alcohol misuse 

referral for brief interventions and specialist alcohol treatment services as appropriate 

follow-up care and assessment at regular intervals. 

A system for the detection and management of alcohol misuse in primary care should occur 

via the implementation of a direct enhanced service by the UK health departments. This 

must be adequately funded and resourced. 



Systems for the detection and management of alcohol misuse should be developed for A&E 

care and the general hospital setting throughout the UK. These must be adequately funded 

and resourced. 

Comprehensive training and guidance should be provided to all relevant healthcare 

professionals on the identification and management of alcohol misuse. 

Funding for specialist alcohol treatment services should be significantly increased and ringfenced 

to ensure all individuals who are identified as having severe alcohol problems or who 

are alcohol dependent are offered referral to specialised alcohol treatment services at the 

earliest possible stage. 

There should be continual assessment of the need for and provision of alcohol treatment 

services in the UK, building on the 2004 Alcohol Needs Assessment Research Project in 

England, and ensuring similar assessment is undertaken throughout the UK. 


There should be strong support for European Union, World Health Organisation and World 

Health Assembly initiatives and policies aimed at reducing alcohol-related harm to individual 

and public health. 

Lobby for, and support the World Health Organisation in developing and implementing a 

legally binding international treaty on alcohol control in the form of a Framework 

Convention on Alcohol Control. This should include provisions for: 

regulation of the availability of alcohol through licensing 

increased taxation on alcoholic beverages 

statutory regulation of alcohol advertising, promotion and sponsorship 

programmes aimed at educating the public of the harms associated with alcohol misuse 

legislation to discourage drink-driving 

appropriately funded and resourced treatment services 

enforcement of the legal responsibility of retailers to sell alcoholic beverages in 

accordance with legislation 

promoting research and the exchange of information among countries 

establishing a priority for public health considerations in the regulation of international 

alcohol commerce 

international cooperation to combat illegal production and trade in alcohol. 

“” 

Death rates of most preventable diseases are falling, supported by government 

action. There is a tragedy unfolding with the rising levels of alcohol-related deaths, 

which could be addressed through the application of simple effective measures. 

These deaths signal a very disturbing change in drinking habits, which affect rates 

of crime, violence, divorce, abuse, productivity and mental health. There is an 

increasingly strong case for government to act. 

BMA member 


10 


Introduction 

Alcohol consumption represents an integral part of modern culture in the UK and internationally. 

The production of alcoholic beverages such as beer, wine and spirits occurs on a vast scale as part 

of a multi-billion pound global industry. Alcohol is a psychoactive substance and its consumption in 

moderation can lead to feelings of relaxation and euphoria, causing it to be consumed widely in 

many social scenarios and across the socio-economic spectrum. Alcohol is also an addictive drug, 

however, and its misuse is associated with a wide range of dose-related adverse consequences that 

can lead to significant harm to the individual and society. 

Recent years have seen increasing interest in the levels of alcohol misuse in the UK, and in 

particular the pattern of binge drinking and heavy drinking. Alcohol consumption is causally 

associated with a wide range of medical conditions and is a significant cause of morbidity and 

premature death worldwide. It contributes to a range of acute and chronic health consequences, 

from alcohol poisoning and injuries resulting from traffic crashes to cancer and cardiovascular 

disease. The more an individual consumes, the greater the risk of harm. Alcohol misuse is 

associated with crime, violence and anti-social behaviour, and can impact significantly on family 

and community life. The cost of alcohol misuse in the UK is substantial, both in terms of direct 

costs (eg costs to hospital services and the criminal justice service) and indirect costs (eg loss of 

productivity and the impact on family and social networks). The control of alcohol at a national 

and international level is therefore essential. This requires the implementation of strategies that are 

effective at reducing overall alcohol consumption levels in a population, as well as targeted 

interventions aimed at specific populations such as young people or individuals who are dependant 

on alcohol. Tackling alcohol misuse also requires greater personal responsibility from individuals 

who consume alcohol in a manner that is harmful to themselves and those around them. 

This report considers the problematic levels of alcohol misuse in the UK and is not aimed at those 

who enjoy consuming alcohol in moderation. It examines the patterns and trends of alcohol 

consumption and goes on to review the range of adverse effects both on the individual and 

society that are associated with its misuse. The report concludes by considering the evidence 

for effective alcohol control policies and discusses the current approaches in the UK. The 

recommendations are for action by the UK Government and are evidence-based policies that 

need to be adopted in order to tackle alcohol misuse and its associated harms. 

“” 

The parallels between the smoking habits of old and the drinking habits of the 

present are stark. I sincerely hope that the current evidence of medical and societal 

harm is enough for the government to act on alcohol now, rather than waiting for 

the imminent epidemic of cirrhosis and cancer. 

BMA member 



Alcohol consumption in the UK 

Per capita alcohol consumption 

Alcohol consumption in the UK has varied considerably over the past century (see Figure 1). 4 

At the 

beginning of the 20th century, national per capita alcohol consumption a 

was higher than at any 

point in the subsequent years. The level of consumption declined significantly during the First World 

War and remained relatively low during the inter-war period and the Second World War. Since 

1950, consumption rose from 3.9 litres per capita per year to a peak of 9.4 in 2004. 5 

Per capita 

consumption subsequently fell to 8.9 litres in 2006. 5 

Despite this recent decline, per capita 

consumption in the UK has remained consistently above 7 litres per capita per year since 1980, 

while consumption in other European countries including France, Italy and Spain has fallen steadily 

over the same period. 6 

Comparison of per capita consumption among adults aged 15 and over 

shows the UK to be among the heaviest alcohol consuming countries in Europe (see Figure 2). 

Data on per capita consumption are not available for the devolved UK nations. 

It is important to note that data on per capita consumption are based on tax-paid sales and do not 

account for unrecorded alcohol consumption resulting from legal or illegal home-made production, 

imported alcohol (including small-scale and large-scale smuggling and legally imported alcohol for 

personal use), and alcohol consumed by foreign visitors. It is likely that per capita consumption data are 

reasonably accurate for countries such as Australia and the USA where such factors are negligible. 

Nonetheless, cross border regulations in the EU and the relative ease of travel within Europe means that 

per capita data for European countries are likely to be less accurate. 7 

It has been estimated that the 

approximate level of unrecorded consumption in Norway, Finland, Sweden, Denmark and the UK is two 

litres of 100 per cent alcohol per inhabitant aged 15 or over. 7 

There is a need to improve data on per 

capita consumption to include not only tax-paid data for all the countries in the UK, but also regular 

published estimates of the amount of alcohol being imported outside of the tax regime. 

Figure 1 – per capita alcohol consumption in the UK (litres of pure alcohol) 

Litres of pure alcohol per head 

11 

10 

9 

8 

7 

6 

5 

4 

3 

2 

1 

0 

1900 

1905 

1910 

1915 

1920 

Source: Statistical handbook 2007 (British Beer and Pub Association, 2007) 

1925 

1930 

1935 

1940 

1945 

1950 

1955 

Year 

Ready-to-drink 

drinks (alcopops) 

Wine 

Spirits 

Cider 

Beer 

a Per capita alcohol consumption refers to the number of litres per head of pure (100%) alcohol. 

Alcohol misuse: tackling the UK epidemic 11 

1960 

1965 

1970 

1975 

1980 

1985 

1990 

1995 

2000 

2005

Litres of pure alcohol per inhabitant 

12 

18 

16 

14 

12 

10 

8 

6 

4 

2 

0 


There has been considerable variation in the levels of consumption of different types of beverage 

in the UK since 1970. While the proportion of alcohol consumed in the form of beer has fallen 

from 70.9 per cent in 1970 to 43.1 per cent (92.1 litres of beer per head of total population) in 

2006, it remains the most popular alcoholic beverage in the UK. 5 

Over the same period the 

proportion of spirits consumed rose from 17.1 per cent to 19.4 per cent (1.7 litres of spirits per 

head of total population), and cider from 2.0 per cent to 7.0 per cent (12.4 litres of cider per head 

of total population). 5 

There has been a significant rise in the proportion of wine consumed, 

increasing from 10 per cent in 1970 to 28.8 per cent (21.5 litres of wine per head of total 

population) in 2005, with an additional 2 per cent (4 litres per head of total population) in the 

form of wine-based coolers and flavoured alcoholic beverages (alcopops). 5 

While these data on per 

capita alcohol consumption provide useful information on trends, they do not provide information 

on the patterns of alcohol consumption. 

Figure 2 – per capita alcohol consumption in selected European and other countries 

(litres of pure alcohol per inhabitant) among adults (> – 15 years), 2003 

Luxembourg 

Ireland 

Hungary 

Republic of Moldova 

Czech Republic 

Croatia 

Germany 

United Kingdom 

Denmark 

Spain 

Portugal 

France 

Austria 

Switzerland 

Belgium 

Slovakia 

Russian Federation 

Finland 

Lithuania 

Romania 

Netherlands 

Latvia 

Bosnia and Herzegovina 

Greece 

Australia 

Estonia 

USA 

Serbia and Montenegro 

Poland 

Italy 

Canada 

Iceland 

Slovenia 

Ukraine 

Sweden 

Bulgaria 

Macedonia 

Belarus 

Norway 

Azerbaijan 

Albania 

Armenia 

Georgia 

Source: WHO Global Alcohol Database 

Alcohol misuse: tackling the UK epidemic 

Country


Prevalence of alcohol consumption 

In the UK, alcohol consumption is commonplace; however, there is significant variation in the level 

and pattern of consumption between particular groups. Information on which people consume 

alcohol and on the level and pattern of their consumption is only available from surveys of 

individuals about their alcohol use. It is important to note that these surveys are subject to 

under-reporting and are therefore likely to be underestimates. 

The vast majority of the UK adult population consume alcohol. The proportion of adults who 

consume alcohol has been estimated to be 90 per cent in England, 8 

and 75 per cent in Northern 

Ireland. 9 

A significant proportion of the UK adult population, however, abstains from alcohol 

consumption for religious, cultural and other reasons. The prevalence of alcohol consumption 

varies considerably by ethnic group. According to the General Household Survey (GHS) 2005, 

only 9 per cent of the White British population are non-drinkers, but the proportion is higher 

among every ethnic minority group, rising to 90 per cent or more among those of Pakistani and 

Bangladeshi origin. 10 

Individuals of Mixed origin are less likely to be non-drinkers than those in 

other ethnic minority groups. Twenty-two per cent of those of Mixed White and Black African 

origin were found to be non-drinkers compared to 48 per cent of those of Black African origin. 10 

According to the GHS 2006 b 

and the Scottish Health Survey (SHS) 2003, men were more likely 

than women to have had an alcoholic drink in the previous week, and to have drunk on more days 

of the week, and were much more likely to have drunk alcohol every day during the previous 

11, 12 

week. Individuals in the 16 to 24 and 65 and over age groups were less likely than those in the 

middle age range to report drinking alcohol during the previous week; however, although they 

were less likely to have had a drink at all in the previous week, men and women aged 65 and over 

drank more frequently than those in younger age groups. 11 

Individuals from ethnic minority groups 

are least likely to have drunk alcohol in the previous week. The GHS 2005 found that respondents 

of Pakistani or Bangladeshi origin were least likely to have drunk in the week prior to interview 

(5% and 4% respectively) compared to 68 per cent of those of White British origin and 67 per 

cent of those recording their ethnicity as ‘Other White’. 10 

Individuals from White British (18%) and 

‘Other White’ (17%) ethnic groups were most likely to drink on five or more days of the week, 

while only 1 per cent of individuals of Pakistani or Bangladeshi origin reported doing so. 10 

b Methods for calculating alcohol consumption for the GHS were revised in the 2006 edition to reflect the trend towards 

larger measures and stronger alcoholic drinks, especially wine. It should be noted, however, that changing the way in which 

alcohol consumption estimates are derived does not in itself reflect a real change in drinking among the adult population. 

For further information see General household survey 2006 (Office for National Statistics, 2008). 


14 


Patterns of alcohol misuse 

For the most part, adults in the UK consume alcohol in moderation. In 2004, the PMSU report estimated that 

26.3 million adults in Great Britain consume less than the recommended UK guidelines (14 units per week or 

less for women and 21 units per week or less for men), of whom 4.7 million abstain from all alcohol use. 8 

The GHS 2006 found the average weekly consumption for men to be 18.7 units and women 9.0 units. 11 

Various estimates have been made for the number of individuals who misuse alcohol in the UK (see Box 1). 

While these estimates do not provide a definitive picture of consumption patterns, it is clear that a significant 

proportion of individuals in the UK misuse alcohol by drinking above recommended UK guidelines. 

Box 1 – estimates of the number of individuals in the UK who misuse alcohol 

These estimates vary due to different methods of data collection and analysis, and as a result of 

differences in the categorisation of consumption levels and patterns of consumption. They are not 

therefore, directly comparable but provide an indication of the levels of alcohol misuse in the UK. 

The 2003 PMSU interim analytical report estimated that in Britain: 

6.4 million people consume alcohol at moderate to heavy levels (between 14 and 35 units per 

week for women and 21 and 50 units per week for men) 

1.8 million people consume alcohol at very heavy levels (over 35 units a week for women and 

50 units a week for men) 

5.8 million people exceed recommended daily guidelines (between 4-8 units per day for men and 

3-6 units for women) 

5.9 million people engage in binge drinking (8 or more units per day for men and 6 or more 

units per day for women) 

2.9 million (7%) of the adult population are alcohol dependent. 3 

The 2004 Alcohol Needs Assessment Research Project (ANARP) estimated that, for adults in England 

aged 16-64: c 

38 per cent of men and 16 per cent of women have an alcohol use disorder, corresponding to 

26 per cent overall (8.2 million people) 

of the 26 per cent with an alcohol use disorder, 23 per cent (7.1 million) consume alcohol at 

hazardous or harmful levels (32% of men and 15% of women), and 3.6 per cent (1.1 million) 

are alcohol dependent (6% of men and 2% of women) 

21 per cent of men and 9 per cent of women are binge drinkers. 13 

The Parliamentary Office for Science and Technology (POST) estimated that: 

5.9 million adults in the UK engage in binge drinking, 23 per cent of men and 9 per cent 

of women. 14 

A 2007 report from the North West Public Health Observatory (NWPHO) estimated that: 

1.55 million people in England consume alcohol at harmful levels (over 50 units per week for men 

and over 35 units per week for women) and a further 6.3 million drink at hazardous levels 

(between 22 and 50 units per week for men and between 15 and 35 units per week for women). 15 

c The 2004 ANARP definition of alcohol use disorders includes harmful drinking, hazardous drinking and alcohol dependence. 

Hazardous drinking is not included as part of the WHO definition of alcohol use disorders. Please see the glossary for an 

explanation of terms. 



Data from various alcohol use surveys provide a more detailed picture of alcohol consumption 

patterns and trends. In the UK, men are more likely to exceed recommended UK guidelines and to 

drink heavily compared to women. The GHS 2006 found that 40 per cent of men and 33 per cent 

of women in Britain exceeded recommended daily guidelines (4 units per day for men and 3 units 

per day for women) on at least one day in the previous week. 11 

The proportion of men who drank 

heavily (8 or more units per day for men and 6 or more units per day for women) on at least one 

day during the previous week was 23 per cent compared to 15 per cent of women. 11 

The Health 

and Social Wellbeing Survey 2001 found that in Northern Ireland, men were almost twice as likely 

as women to drink above the recommended weekly guidelines (25% and 14% respectively). 16 

A noteworthy pattern of consumption in the UK is the high level of heavy drinking and binge 

drinking among men and women in the 16 to 24 and 25 to 44 age groups. In 2006, 42 per cent 

of British men and 39 per cent of British women exceeding recommended daily guidelines on at 

least one day in the previous week were aged 16 to 24, while the corresponding figures for the 

25 to 44 age group were 48 per cent and 40 per cent respectively (see Figure 3). 11 

A similar 

pattern was found for the proportion of British men and women who drank heavily on at least 

one day during the previous week (see Figure 4). 11 

In Northern Ireland, men aged 16 to 24 were 

almost three times as likely to drink above recommended guidelines compared to those aged 65 to 

74, while women aged 16 to 24 were five times as likely compared to those aged 65 to 74. 16 

In Scotland, 62 per cent of men and 56 per cent of women who consumed more than the 

recommended daily amount on their heaviest drinking day were in the 16 to 24 age group. 12 

Thirty-one per cent of Scottish men and 23 per cent of Scottish women drinking in excess of 

weekly recommended guidelines were found to be in the 16 to 24 age group. 12 

Approximately 

10 per cent of drinkers aged 16 to 24 were found to consume alcohol at these levels in Northern 

Ireland compared to 3 per cent aged over 25. 16 

“” 

It is not infrequent to find patients with fatty liver in their 30s and 40s, and when 

asked about previous alcohol consumption often describe heavy or binge drinking 

when a student in their 20s. 

BMA member 


16 


Figure 3 – proportion of men and women exceeding daily benchmarks on at least one 

day in the previous week: Great Britain, 2006 

Percentage 

60 

50 

40 

30 

20 

10 

0 

Source: General household survey 2006 (Office for National Statistics, 2008) 

Figure 4 – proportion of men and women drinking heavily on at least one day in the 

previous week: Great Britain, 2006 

Percentage 

35 

30 

25 

20 

15 

10 

5 

0 



16-24 25-44 45-64 65 and over Total 

Age Group 

Age Group 

Men 

Women 

Men 

Women 

16-24 25-44 45-64 65 and over Total


In relation to ethnicity, alcohol consumption above recommended daily guidelines occurs most 

commonly among individuals of White origin and those of mixed origin. According to the GHS 

2005, drinking above recommended daily guidelines on at least one day in the previous week was 

found to be most common among individuals of Mixed White and Asian origin (35%), Mixed 

White and Black Caribbean origin (33%), White British origin (31%) and the Other White ethnic 

groups (28%). 10 

Individuals of Pakistani (3%) and Bangladeshi (1%) origin were least likely to have 

drunk above recommended daily guidelines on at least one day in the previous week. 10 

A similar 

pattern was observed with heavy drinking. The proportion of individuals reporting drinking in excess 

of recommended guidelines on one day in the previous week was highest among individuals of 

White and Asian mixed ethnicity (21%), those of White and Black Caribbean mixed ethnicity (18%), 

and those from the White British (16%) and the Other White (14%) ethic groups. 10 

Patterns of alcohol misuse among lesbian, gay and bisexual (LGB) people are complex and varied. 

Surveys such as the GHS and the SHS do not incorporate questions relating to sexual orientation 

making it difficult to analyse patterns and trends of alcohol misuse among LGB people in the UK. 

International evidence provides a mixed picture for the relationship between sexual orientation and 

the risk of alcohol problems. Several studies have found lesbians and gay men to be more likely to 

use and misuse alcohol compared to heterosexual men and women; 17-26 

however, other studies 

have not found differences by sexual orientation. 27-32 

Results from a number of small-scale studies 

in the UK have found higher levels of alcohol use and misuse among LGB people. 33-36 

As with 

sexual orientation, the relationship between patterns of alcohol consumption and disability is not 

considered within surveys such as the GHS and SHS. People with mental health problems are at an 

increased risk of alcohol misuse problems and vice versa. A number of psychiatric conditions are 

associated with alcohol dependence d 

including major depression, dysthymia, mania, hypomania, 

panic disorder, phobias, generalised anxiety disorder, personality disorders, any drug-use disorder, 

schizophrenia, and suicide. 37 

There has been very little research into the prevalence of alcohol use 

and misuse among people with learning disabilities. There is some evidence that alcohol-related 

health problems are uncommon in people with learning disabilities, 38 

and they are less likely to drink 

alcohol than people without learning disabilities. 39 

Socio-economic factors and alcohol consumption 

The link between alcohol consumption and socio-economic factors is an important consideration. 

Individuals in employment are more likely to drink frequently compared to those who are 

unemployed. The GHS 2006 found that among men aged 16 to 64, those in employment were 

most likely to have drunk alcohol during the previous week (76%) compared with those who were 

unemployed (54%) and those who were economically inactive e 

(59%). 11 

For women aged 16 to 

64, 65 per cent who were working, 54 per cent of unemployed, and 47 per cent of those who 

were economically inactive had drunk alcohol in the previous week. 11 

The GHS 2006 found that 

working men (47%) were more likely than unemployed men (37%) and the economically inactive 

(32%) to have drunk more than the recommended amount of over four units on one day. 11 

For 

women, those in employment were almost twice as likely as those who were economically inactive 

to have drunk heavily on at least one day in the previous week. 11 

In Scotland, the SHS 2003 found 

that the proportion of men and women consuming more than the recommended daily guidelines 

d The terms alcohol dependence syndrome, alcoholism and alcohol abuse are often used interchangeably in common usage. 

Please refer to the glossary for an explanation of these terms. 

e ‘Economically inactive’ is defined according to the International Labour Organisation as individuals who are not in work, and 

who do not want a job, have not sought employment in the last four weeks and are not available to start employment in 

the next two weeks. 


18 


increased with each quintile of deprivation. 12 

In England, unemployed men were just as likely to 

binge drink as working men (22% and 23% respectively). 40 

A similar pattern is also seen for socio-economic classification. According to the GHS 2006, 

individuals in managerial and professional occupations are more likely to have drunk alcohol in the 

previous week, and to drink more frequently than those in routine and manual occupations; yet, 

there is little difference in drinking above the daily recommendations between these two groups 

(see Figure 5). 11 

In terms of weekly alcohol consumption, men in managerial and professional 

occupations were found to drink on average 19.9 units a week, compared to 16.7 units per week 

for men in the routine and manual group. 11 

In women, average weekly consumption for the 

managerial and professional group was 10.7 units, compared to 7.1 units among those in the 

routine and manual group. 11 

Figure 5 – adults (aged 16 and over) drinking in the last week by socio-economic 

classification, Great Britain, 2006 

Percentage 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Drank last week Drank on five or 

more days 


The level of earnings is also associated with variations in alcohol consumption. Men and women 

who are higher earners are more likely than the lower paid to have drunk alcohol at all, and to 

4, 11 

have drunk on five or more days. The GHS 2006 found that among full-time workers aged 16 

to 64 who were earning more than £800 per week, 29 per cent of men and 16 per cent of 

women had drunk on five or more days in the previous week, compared with 23 per cent of men 

and 10 per cent of women earning £200 or less per week. 11 

Men who are higher earners have 

been found to be more likely to consume above recommended daily guidelines compared to low 

earners, however, the reverse has been found among women. 4 

Average weekly alcohol 

consumption was also found to be higher among men and women in high income households. 11 

In households with a gross income exceeding £1,000 per week, men drank on average 22.1 units 


Drank over 4/3 units on 

at least one day 

Social-economic classification 

Managerial and professional 

Intermediate 

Routine and manual 

All adults 

Drank over 8/6 units on 

at least one day


per week, and women 12.2 units, compared with 17.8 units and 6.1 units respectively among 

those in households with an income of £200 or less. 11 

No significant variation in average weekly 

consumption according to earnings has been found among those in full-time employment. 11 

National and regional variations in alcohol consumption in the UK 

The patterns of alcohol consumption in the UK are comparable across the devolved nations; 

however, slight variations do exist between the different countries. According to the GHS 2006, 

average weekly consumption was higher in England (13.7 units) and Wales (13.5 units) than in 

Scotland (11.6 units). 11 

Consumption among men was lower in Scotland (16.3 units) than in 

England (18.9 units) and Wales (19.9 units). 11 

In women, consumption in both Wales (7.8 units) 

and Scotland (7.8 units) was lower than in England (9.2 units). 11 

In 2006, men and women in 

England and Wales were more likely to have drunk on at least five days in the previous week 

compared to those living in Scotland. 11 

There was no statistically significant difference in the 

proportions of men and women exceeding recommended UK guidelines or drinking heavily 

between the devolved nations. 11 

All national surveys have consistently found the highest levels of binge drinking and drinking 

above recommended guidelines to be in the northern regions of England – in particular in 

11, 15, 40 

Yorkshire and Humberside, the North East and the North West – and lowest in London. The 

relatively low levels of alcohol consumption in London are largely explained by its high proportion 

of people in ethnic minority groups who abstain from alcohol consumption due to an ascetic 

element, or an inherent belief, that is present in some religions. In Scotland, the SHS 2003 found 

there to be little variation in weekly consumption of alcohol between NHS Board areas. 12 

Trends in alcohol misuse 

Over the last decade there has been considerable media interest in the rising levels of alcohol 

misuse in the UK. During the 1990s, the prevalence of alcohol misuse increased among both men 

4, 10 

and women, and in particular in the 16 to 24 age group. This upward trend was particularly 

marked among young women to the extent that consumption among this group is now the highest 

in Europe. 4 

A 2000 survey found that eight per cent of women aged 18 to 24 had consumed at 

least 35 units of alcohol in the previous week. 4 

Another survey found that 38 per cent of women in 

their 20s in the UK had consumed six or more units on at least one day in the week. 41 

Analysis of recent data from alcohol use surveys suggests that while the proportion of individuals 

misusing alcohol remains high, the upward trend in alcohol misuse among men and women in the UK 

may have peaked. According to the GHS 2006 f 

, the proportion of men and women in Britain 

exceeding recommended daily guidelines on at least one day in the previous week remained relatively 

g, 11 

constant between 1998 and 2004 (see Table 1). Between 2004 and 2006, there was a fall among 

men from 39 per cent to 33 per cent, while the proportion of women remained at 20 per cent. 11 

A similar pattern of change was found in the proportions drinking heavily on at least one day in the 

previous week (see Table 2). 11 

These data vary considerably among the different age groups which 

makes it difficult to identify an overall trend. In the 16 to 24 age group, there has been a downward 

trend since 2003 in the proportion of men drinking above recommended daily guidelines and drinking 

heavily. 11 

A similar downward trend has occurred among women aged 16 to 24 since 2002. 11 

f For comparative purposes, the GHS 2006 data on trends discussed in this section are those derived using the original method of 

conversion to units. For further information see General household survey 2006 (Office for National Statistics, 2008). 

g Data on the proportion of individuals exceeding recommended daily guidelines are only available from 1998 onwards as questions 

relating to the maximum daily amount of alcohol consumed in the last week were not included in the GHS prior to this year. 


20 


Table 1 – proportion (%) of men/women in Great Britain drinking more than 4/3 units on 

at least one day in the previous week 

a) Men 

1998 2000 2001 2002 2003 2004 2005 2006 

16-24 52 50 50 49 51 47 42 39 

25-44 48 45 49 46 47 48 42 42 

45-64 37 38 37 38 41 37 35 33 

65+ 16 16 18 16 19 20 16 14 

Total 39 39 40 38 40 39 35 33 

b) Women 

1998 2000 2001 2002 2003 2004 2005 2006 

16-24 42 42 40 42 40 39 36 34 

25-44 28 31 31 31 30 28 26 27 

45-64 17 19 19 19 20 20 28 17 

65+ 4 4 5 5 4 5 4 4 

Total 21 23 23 23 23 22 20 20 


Table 2 – proportion (%) of men/women in Great Britain drinking more than 8/6 units on 

at least one day in the previous week 

a) Men 

1998 2000 2001 2002 2003 2004 2005 2006 

16-24 39 37 37 35 37 32 30 27 

25-44 29 27 30 28 30 31 25 25 

45-64 17 17 17 18 20 18 16 15 

65+ 4 5 5 5 6 7 4 4 

Total 22 21 22 21 23 22 19 18 

b) Women 

1998 2000 2001 2002 2003 2004 2005 2006 

16-24 24 27 27 28 26 24 22 20 

25-44 11 13 14 13 13 13 11 12 

45-64 5 5 5 5 5 6 4 4 

65+ 1 1 1 1 1 1 1 0 

Total 8 10 10 10 9 9 8 8 


Data on average weekly consumption show a similar downward trend in recent years. The GHS 

2006 found that the proportion of men drinking on average above recommended weekly drinking 

guidelines fell from 29 per cent in 2000 to 23 per cent in 2006, and for women fell from 17 per 

cent to 12 per cent respectively (see Figure 6). 11 

This decrease occurred among men and women 



in all age groups, but was most evident among those aged 16 to 24. 11 

The proportion of men 

aged 16 to 24 who drank more than 21 units a week fell from 41 per cent in 2000 to 26 per cent 

in 2006, while the proportion of women who drank more than 14 units a week fell from 33 per 

cent to 19 per cent respectively. 11 

Between 2002 and 2006, the average weekly consumption in 

the 16 to 24 age group fell from 21.5 to 16.4 units in men and from 14.1 to 9.0 units in 

women. 11 

Since 2002, there has been a slight decline in the proportion of men drinking more than 

50 units a week on average, but no significant change in the proportion of women drinking more 

than 35 units. 11 

According to the SHS 2003, the proportion of Scottish men aged 16 to 64 who 

drank over 21 units per week on average decreased from 33 per cent in 1995 to 29 per cent in 

2003. 12 

The number of Scottish women aged 16 to 24 drinking over 14 units per week on average 

increased from 13 per cent in 1995 to 17 per cent in 2003. 12 

Figure 6 – proportion of men drinking more than 21 units a week, and women drinking 

more than 14 units a week: Great Britain 1988 to 2006 h 

Percentage 

35 

30 

25 

20 

15 

10 

5 

0 

1988 1992 1994 1996 1998 2000 2001 2002 2005 2006 


It is important to note that it is not yet possible to determine whether these recent trends in 

alcohol consumption are genuine long-term changes in drinking habits. It may be that there is an 

increased tendency to under-report consumption due to the recent extensive publicity about binge 

drinking and the dangers of heavy consumption. Data from future years will provide a clearer 

indication of any long-term trends. 


Year 

h Data for 1988 to 1998 are unweighted; data for 1998 onwards are weighted. 

Men 

Women

22 


Alcohol consumption and young people 

Alcohol consumption in young people aged under 18 is a significant problem in the UK. The 2003 

BMA report Adolescent health examined the drinking habits of adolescents in the UK and found 

them to have one of the highest European levels of alcohol use, binge drinking and getting drunk. 42 

The 2003 European School Survey Project on Alcohol and other Drugs (ESPAD) found that in Europe, 

UK teenagers were among the most likely to report heavy consumption of alcohol, being intoxicated 

and experiencing adverse effects of drinking (eg delinquency). 43 

The highest proportion of teenagers 

who had consumed five or more drinks in a session on at least three occasions in the previous month 

were from Ireland (32%), the Netherlands (28%), and the UK and the Isle of Man (27% each). 43 

The 

survey also found that in the UK, girls were more likely than boys to have consumed five or more 

drinks in a session on at least three occasions in the previous month. 43 

This was also found in Ireland 

and the Isle of Man but not in the remaining 32 European countries surveyed. 43 

The ESPAD 2003 

showed that following an increase in the level of binge drinking in UK teenage boys between 1995 

and 1999, the number fell slightly by 2003. Binge drinking in UK teenage girls, however, increased 

significantly between 1995 and 2003 (see Figure 7). 44 

This increase in alcohol consumption in UK 

teenage girls mirrors the changes in young women in the UK discussed previously. 

“” 

Seeing young people drunk in the streets and then encountering individuals of the 

same age with liver disease is very depressing. 

BMA member 

Figure 7 – proportion (%) of UK teenage boys and girls aged 15 and 16 who had 

consumed five or more drinks in a session on at least three occasions in the previous 

month (1995-2003) 

Percentage 

35 

30 

25 

20 

15 

10 

5 

0 

Source: Plant MA & Plant ML (2006) Binge Britain: Alcohol and the national response. Oxford: Oxford University Press. 


1995 1999 2003 

Year 

Boys 

Girls


The high level of alcohol consumption among young people occurs throughout the UK and across 

the social spectrum. A 2006 survey found that 21 per cent of English pupils aged 11 to 15 

reported drinking alcohol in the last week, of which the proportions of boys (21%) and girls (20%) 

were similar. 45 

This is a fall from 26 per cent in 2001. In 2005, the proportion of pupils who had 

drunk alcohol in the last week increased with age from 3 per cent of 11-year-olds to 41 per cent 

of 15-year-olds. 45 

While the prevalence of alcohol consumption has declined in recent years the 

consumption rates have increased significantly. The average consumption among pupils aged 

11 to 15 who drank in the last seven days has increased from 5.3 units in 1990 to 11.4 units in 

2006 (see Figure 8). 45 

In 2006, the average level of consumption in the last seven days was higher 

among boys (12.3 units) compared with girls (10.5 units), and higher among older pupils 

compared to younger pupils. 45 

Figure 8 – mean alcohol consumption (units) in the last week, by sex in pupils aged 11 to 

15, England, 1990-2006 

Mean units of alcohol 

14 

12 

10 

8 

6 

4 

2 

0 

1990 1992 1994 1996 1998 2000 2001 2002 2005 2006 

Source: Smoking, drinking and drug use among young people in England in 2006: headline figures (Information Centre for 

Health and Social Care, National Centre for Social Research, National Foundation for Educational Research, 2007) 

The 2004 Scottish Adolescent Lifestyle and Substance Use Survey (SALSUS) found that 20 per cent 

of 13-year-old boys and girls reported drinking in the past week, and this rose to 40 per cent and 

46 per cent for 15-year-old boys and girls respectively. 46 

As in England, the prevalence of alcohol 

consumption has declined in recent years; however, the consumption rates remain 

disproportionately high. The average weekly consumption by pupils who drank in the last week 

was nine units for 13-year-olds and 12 units for 15-year-olds. 46 

More girls reported drinking over 

recommended guidelines, with 20 per cent of 15 year-old-boys reporting that they had drunk 

21 units or more in the past week, while 25 per cent of girls reported drinking more than 14 units 

in the past week. 46 

Eighty per cent of 15-year-olds and 57 per cent of 13-year-olds who reported 

drinking in the last week also reported that they had drunk more than five drinks on the same 

occasion at least once in the past. 46 

In Northern Ireland, 74 per cent of 11 to 15-year-olds surveyed 


Year 

Boys 

Girls 

All pupils

24 


in 1997/98 had consumed alcoholic drinks at some time. 47 

Among the youngest age group, 

5.6 per cent of boys reported drinking both weekly and monthly, while 2.5 per cent and 4.3 per 

cent of girls reported drinking weekly and monthly respectively. 47 

In the older age group, 43.6 per 

cent of boys and 39.9 per cent of girls reported drinking weekly, while 21.4 per cent of boys and 

23.3 per cent of girls reported drinking monthly. 47 

Of those who reported drinking regularly, 

31.5 per cent of boys and 23.2 per cent of girls reported having been drunk more than 10 times. 47 

Why do individuals misuse alcohol? 

There is comprehensive literature on why individuals use and misuse alcohol. Personal use of 

alcohol has been found to be associated by users with numerous positive consequences including 

enjoyment of the taste; feeling happier, more friendly and outgoing; having fun; feeling relaxed; 

and escaping and forgetting problems. 4 

Alcohol use is also seen as a social norm in many cultures 

and across the socio-economic spectrum. Peer pressure may also be an important factor in the 

decision to consume alcohol. 

Alcohol misuse has a complex aetiology. As with other alcohol consumers, individuals who misuse 

48, 49 

alcohol may do so due to social norms, peer pressure and the associated positive consequences. 

A 2002 study of British adults found there to be ambivalence about the positive effects of alcohol 

use and a range of adverse consequences of its misuse. 50 

These adverse consequences include 

feeling hungover and sick; having accidents; doing something regrettable; harmful health effects; 

not being able to stop drinking; and getting into trouble with the police. 4 

Many people therefore 

appear to be prepared to tolerate the adverse consequences of alcohol misuse in order to 

experience the associated positive aspects. Accordingly, while the negative effects are likely to be 

greater with the more alcohol that is consumed, there is also likely to be a greater level of positive 

effects. The prevailing culture and acceptability of various patterns of alcohol misuse are also 

important determinants of alcohol misuse. The desire to drink heavily and get drunk may therefore 

arise from a combination of the wish to experience the associated positive aspects of intoxification, 

the surrounding culture, the pharmacology of the drug, and an individual’s personal genetics and 

preferences. The situation is markedly different for individuals who are dependent on alcohol as a 

result of their need to overcome symptoms of withdrawal, and due to the development of 

tolerance (ie the need to increase alcohol consumption in order to achieve the desired effect). 

Alcohol dependence is of multifactorial origin and determined by complex interactions between 

individual (eg genetic predisposition) and environmental factors (eg availability). 51 

“” 

I remember one patient who being so desperate for alcohol, once the drinks had 

run out used to be reduced to drinking nail varnish or spraying hairspray into a glass 

to get at the alcohol. 

BMA member 



Where is alcohol consumed? 

Recent years have seen an increasing trend among UK adults toward home-based alcohol 

consumption. 4 

Data on UK household expenditure suggest that more alcohol is purchased in 

on-licenced premises (such as restaurants, bars, public houses) than off-licenced premises (such as 

supermarkets and shops). A 2007 report from the Department for Environment, Food and Rural 

Affairs (DEFRA) found that 58 per cent of total household expenditure on alcoholic drinks in the 

UK was spent on alcohol consumed outside the home in 2005/06. 52 

This was a decrease from 

60 per cent in 2002/03. 52 

Expenditure on alcoholic drinks consumed outside the home has fallen 

slightly each year from 2002/03 to 2005/06. 52 

The 2006 ONS survey Family spending found that 

alcohol bought and consumed on licensed premises accounted for slightly more than half (57%) of 

all expenditure on alcoholic drink (£14.80 per household per week), while the remaining £6.30 

was spent on alcohol bought at large supermarket chains or off-licence outlets. 53 

This trend toward home-based alcohol consumption most likely reflects the lower cost of alcohol 

in off-licences compared to licenced premises in the UK. Among younger adults, there is also an 

increased tendency to consume alcohol at home prior to going out. 4 

Alcohol consumption among 

teenagers and adolescents below the legal purchase age for alcohol is commonly home-based, but 

with increasing age, becomes more non-home-based (often outdoors or illegally in licenced 

4, 54 

premises) and away from parental supervision. 


26 




The burden of alcohol on society 

The relationship between alcohol consumption and health and social outcomes is complex and 

multifaceted. In the short term, the acute intoxicating effects of alcohol on cognitive and motor 

functioning impair an individual’s reactions, judgement, coordination, vigilance, vision, hearing and 

memory. This impairment is associated with many adverse outcomes for the individual and those 

around them as it can lead people to have accidents, misread situations and react aggressively. 

Alcohol consumption is linked to long-term health and social consequences through three main 

causal pathways: intoxication, dependence, and toxic (and beneficial) direct biological effects. 55 

These 

pathways are in turn affected by the volume of consumption and the pattern of drinking. Alcohol 

misuse is also frequently associated with drug abuse and other harmful behaviours such as smoking. 

Alcohol and health outcomes 

Alcohol consumption and health 

Moderate alcohol consumption is not usually harmful to health. 4 

Drinking heavily, however, can 

result in significant health problems. These may occur after heavy alcohol consumption over a short 

period (eg intoxification or poisoning) or may develop more gradually (eg cirrhosis of the liver). 

“” 

The most upsetting (disturbing) memory relating to my clinical practice was 

watching a young patient in her 40s with multi-organ failure bid farewell to her 

children prior to dying a couple of days later. Her multiple medical problems were 

due to chronic alcoholism. 

BMA member 

Ethanol is a highly toxic compound that can affect the body in a variety of ways. The toxic effect 

on basic cell functions is produced by ethanol and its oxidation product, acetaldehyde, which 

accounts for much of the acute and delayed effects of ethanol toxicity. 56 

Principally, ethanol affects 

the central nervous system (CNS), mainly through stimulation of opiate and benzodiazepine 

receptors as well as several neurotransmitters. The effects of alcohol on an individual are 

dependent on various factors including age, weight, type of drink, level of dehydration, previous 

exposure to alcohol, level and timing of food intake, and gender of the drinker. Table 3 outlines 

the possible effects of alcohol at different levels. 


28 


Table 3 – progressive effects of blood alcohol concentration 

BAC (mg/100ml) Effect Impairment (continuum) 

10 - 50 Relaxation Alertness 

Sense of well being Judgement 

Loss of inhibition 

60 - 100 Pleasure Coordination (especially fine motor skills) 

110 - 200 Mood swings 

Numbing of feelings Visual tracking 

Nausea, Sleepiness 

Emotional arousal Reasoning and depth perception 

Anger 

Sadness 

210 - 300 Aggression 

Mania Slurred speech 

Reduced sensations Lack of balance 

Depression 

310 - 400 Unconsciousness 

Stupor Loss of temperature regulation 

Death possible Loss of bladder control 

Coma Difficulty breathing 

> 410 Death Slowed heart rate 

Source: National Institute on Alcohol Abuse and Alcoholism 

Alcohol has been shown to be causally related to over 60 different medical conditions (see 

Box 2), and in the majority of cases there is a dose-response relation to the volume of alcohol 

55, 57 

consumption, with risk of disease increasing with higher volume. Alcohol consumption above 

recommended daily guidelines significantly increases the risk of various diseases and it has been 

suggested to be a significant contributory factor to a range of chronic conditions (see Table 4 and 

Table 5). 54 

The disease conditions related to alcohol consumption fall into three categories that 

reflect the nature of the conditions and the nature of the aetiologic influence of alcohol on the 

conditions: 

wholly alcohol-attributable conditions which include alcoholic psychoses, alcohol-dependence 

syndrome, alcoholic polyneuropathy, alcoholic cardiomyopathy, alcoholic gastritis, alcoholic 

liver cirrhosis, and ethanol toxicity 

chronic conditions where alcohol is a contributory cause which include lip, oropharyngeal, 

oesophageal, liver, laryngeal, and breast cancer, epilepsy, hypertension, cardiac arrhythmias, 

stroke, oesophageal varices, gastro-oesophageal haemorrhage, liver cirrhosis, acute and 

chronic pancreatitis, spontaneous abortion, low birth weight, and psoriasis 

acute conditions where alcohol is a contributory cause which include road injuries, injuries 

from falls, fires, drowning, occupational and machine injuries, other accidents, suicide, 

assault, and child abuse. 55 



“” 

One image that sticks in my mind was the patient who had such severe memory 

problems secondary to alcohol that he came out of his room every few minutes 

asking where his jacket was, not realising that he was doing this about 15 times per 

hour – and what I also remember is the sustained patience of the nursing staff! 

BMA member 

The evidence that alcohol consumption is a contributory cause of a number of cancers has 

58, 59 

strengthened in recent years. A 2007 review concluded that there is convincing evidence that 

alcoholic drinks are a contributory cause of cancers of the mouth, pharynx, and larynx, 

oesophagus, colorectum (men), and breast, and a probable cause of colorectal cancer in women 

and of liver cancer. 59 

The review also concluded that there is no safe threshold below which no 

effect on cancer risk is observed. 59 

The adverse effects of alcohol on health outlined in Box 2 are 

most notable in individuals who are alcohol dependent. Alcohol dependence syndrome is strongly 

associated with neurologic impairment, cardiovascular disease, liver disease, malignant neoplasms, 

and an increased risk of injury. 37 

While the majority of effects from alcohol are detrimental to health, consumption at moderate 

levels or below is associated with a lower risk of CHD, ischaemic stroke and diabetes mellitus 

55, 57, 58, 60-62 

compared to individuals who abstain from alcohol. These positive effects on the risk of 

CHD appear to be confined to males over the age of 45 years and females past the menopause. 63 

As consumption increases above moderate levels, however, the risk relation reverses. 

“” 

Unfortunately, us doctors, journalists and politicians have supported the concept 

that alcohol is good for you (raises HDL cholesterol, the good cholesterol), but of 

course not for all, and only in small amounts. 

BMA member 


30 


Box 2 – major disease and injury conditions related to alcohol and proportions 

attributable to alcohol worldwide (%) i 

Men Women Both 

Malignant neoplasms 

Mouth and oropharynx cancers 22 9 19 

Oesophageal cancer 37 15 29 

Liver cancer 30 13 25 

Breast cancer 

Neuropsychiatric disorders 

N/A 7 7 

Unipolar depressive disorders 3 1 2 

Epilepsy 23 12 18 

Alcohol use disorders 100 100 100 

Diabetes mellitus 

Cardiovascular diseases 

-1 -1 -1 

Ischaemic heart disease 4 -1 2 

Haemorrhagic stroke 18 1 10 

Ischaemic stroke 

Gastrointestinal diseases 

3 -6 -1 

Cirrhosis of the liver 

Unintentional injury 

39 18 32 

Motor vehicle accidents 25 8 20 

Drownings 12 6 10 

Falls 9 3 7 

Poisonings 

Intentional injury 

23 9 18 

Self-inflicted injuries 15 5 11 

Homicide 26 16 24 

Source: Room R, Babor T & Rehm J (2005) Alcohol and public health. Lancet 365: 519-30. 

Table 4: Increased risks of ill health to harmful drinkers 

Condition Men (increased risk) Women (increased risk) 

Hypertension (high blood pressure) Four times Double 

Stroke Double Four times 

Coronary heart disease 1.7 times 1.3 times 

Pancreatitis Triple Double 

Liver disease 13 times 13 times 

Source: Safe. Sensible. Social: the next steps in the national alcohol strategy (HM Government, 2007) 

i This table only summarises the major disease and injury categories and does not include diseases where there is currently 

insufficient epidemiological evidence to allow meta-analysis studies to be carried out. The negative percentages for diabetes 

mellitus, ischaemic heart disease and ischaemic stroke relate to the beneficial effect of alcohol consumption at moderate 

levels or below for these specific conditions. 



Table 5: Those with chronic conditions who are drinking above recommended daily 

guidelines on a regular basis 

Condition Men (%) Women (%) 

Hypertension 42 10 

Coronary heart disease 34 6 

Stroke 33 7 

Diabetes 35 8 

Kidney disease 26 6 

Depression 42 16 

Source: Safe. Sensible. Social: the next steps in the national alcohol strategy (HM Government, 2007) 

The pattern of consumption is an important determinant in assessing the impact of alcohol on 

health. Binge drinking is a particularly harmful form of alcohol consumption and significantly 

increases the risk of alcohol dependence in men and women. 64 

The frequency of heavy drinking by 

the mother is also associated with the occurrence of a range of completely preventable mental and 

physical birth defects collectively known as Fetal Alcohol Spectrum Disorders (FASD). 65 

FASD are 

lifelong conditions resulting from maternal alcohol consumption during pregnancy that can 

significantly impact on the life of the individual and those around them. The rate of teenage 

pregnancies in the UK is the highest in Western Europe 66 

and with recent evidence suggesting that 

67, 68 

unplanned pregnancies are common, not only in young women but in women throughout their 

childbearing years. 69 

The BMA recommends that the only sensible message for women who are 

pregnant or planning a pregnancy must be complete abstinence from alcohol. Further information 

on the risks of alcohol consumption during pregnancy can be found in the 2007 BMA Board of 

Science report Fetal alcohol spectrum disorders – a guide for healthcare professionals. 

Alcohol-related morbidity, mortality and disability 

Alcohol is a significant cause of morbidity, mortality and disability in the UK and internationally. 

Information on alcohol-related morbidity alone is limited because of difficulties in assessing this in 

an objective and standardised way. There is also no standard measure for quantifying the burden 

of alcohol consumption where it is a contributory factor in illnesses such as cancer and CHD. There 

is a need to improve data on alcohol-related morbidity and mortality through the use of alcoholspecific 

code categories as in the ICD-10. This could be extended to include systems for routinely 

recording alcohol involvement in injuries based on categories Y-90 (evidence of alcohol 

involvement determined by blood alcohol level) and Y-91 (evidence of alcohol involvement 

determined by level of intoxication) in the ICD-10. 

Worldwide, alcohol causes 3.27 per cent of all deaths (1.8 million) and 4 per cent of disability 

adjusted life years (DALYs) lost. 70 

The burden is not equally distributed among countries. Alcohol 

consumption is the leading risk factor for disease burden in low mortality developing countries 

(accounting for 6.2% of DALYs lost) and the third largest risk factor in developed countries 

(accounting for 9.2% of DALYs lost compared to 10.9% and 12.2% for blood pressure and 

tobacco respectively). 71 

In the UK, and internationally, alcohol-related mortality is closely linked to 

the level of alcohol consumption. According to the ONS – which collects data on deaths directly 


32 


attributable to alcohol j 

– the alcohol -related death rate in the UK almost doubled from 6.9 to 

12.9 per 100,000 population between 1991-2005 (see Figure 9), and the number of alcohol-related 

deaths more than doubled from 4,144 in 1991 to 8,386 in 2005. 72 

Death rates are much higher for 

males than females and the gap between the sexes has widened in recent years. 72 

In 2005, the male 

death rate (17.9 deaths per 100,000 population) was more than twice the rate for females (8.3 

deaths per 100,000 population) and males accounted for two-thirds of the total number of deaths. 72 

“” 

I had a patient, a few months ago, who had a bit too much to drink and while 

visiting his mother‘s grave – lay down next to it and choked to death on his vomit! 

BMA member 

Figure 9 – alcohol-related death rates by sex, United Kingdom, 1991-2005 

Age-standardised rate per 100,000 population 

20 

18 

16 

14 

12 

10 

8 

6 

4 

2 

0 

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 

Source: Office for National Statistics, General Register Office for Scotland, Northern Ireland Statistics and Research Agency (2006) 


Year 

Men 

Women 

All persons 

j The ONS definition of alcohol-related deaths is based on the ICD-10 and includes those causes regarded as most directly due to 

alcohol consumption: mental and behavioural disorders due to alcohol (F10), alcoholic cardiomyopathy (I42.6), alcoholic liver 

disease (K70), chronic hepatitis – not elsewhere specified (K73), fibrosis and cirrhosis of the liver (K74), alcoholic induced chronic 

pancreatitis (K86.0), alcoholic poisoning by and exposure to alcohol (X45). These data do not include deaths where alcohol is a 

contributory cause (eg in road incidents, deaths from falls or accidents etc) and do not therefore account for the total number of 

deaths attributable to alcohol in the UK.


The burden of alcohol-related mortality is shifting to younger age groups in both men and 

women, and toward the most socially deprived groups. For men the death rates in all age groups 

in the UK increased between 1991 and 2005 with the biggest increase in the 35 to 54 age group 

(see Figure 10). 72 

Rates in this age group more than doubled between 1991 and 2005, from 

13.4 to 29.9 deaths per 100,000. 72 

The highest rates in each year occurred in the 55 to 74 age 

group where the death rate reached 43.4 per 100,000 in 2005. 72 

The death rates by age group 

for females in the UK were consistently lower than rates for males; however the trends showed 

a broadly similar pattern by age (see Figure 11). 72 

The death rate for women aged 35 to 54 

increased from 7.2 to 14.2 per 100,000 population between 1991 and 2005, a larger increase 

than the rate for women in any other age group. 72 

The highest rates in each year were for women 

aged 55 to 74 where the death rate reached 19.2 per 100,000 population in 2005. 72 

Figure 12 

shows how the alcohol-related mortality rate in England and Wales between 1999 and 2003 was 

significantly higher in the most deprived areas compared to the least deprived. 

Figure 10 – male alcohol-related death rates by age group, United Kingdom, 1991-2005 


20 

18 

16 

14 

12 

10 

8 

6 

4 

2 

0 

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 



Year 

15-34 

35-54 

55-74 

75+

34 


Figure 11 – female alcohol-related death rates by age group, United Kingdom, 

1991-2005 


20 

18 

16 

14 

12 

10 

8 

6 

4 

2 

0 

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 



Year 

15-34 

35-54 

55-74 

75+


Figure 12 – age-standardised alcohol-related death rates by deprivation twentieth and 

sex, England and Wales, 1999-2003 


35 

30 

25 

20 

15 

10 

5 

0 

Least deprived Most deprived 

The overall rates for men and women in England and Wales were 14.1 and 6.9 respectively. 

Source: Office for National Statistics (2007) 

Men 

Women 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 

Deprivation twentieth (Carstairs deprivation index) 

An important measure of alcohol-related deaths is the rate of mortality due to liver cirrhosis. k 

In 

England, the rate of liver cirrhosis mortality approximately trebled between 1970 and 1998, while the 

rate in the EU decreased by 30 per cent. 73 

In the 35 to 44 years age group the death rate increased 

eight-fold in men and almost seven-fold in women, while there was a four-fold increase in 25 to 34 

year-olds. 73 

A study of liver cirrhosis mortality rates in Britain from 1950-54 to 2000-02 found that rates 

in men increased five-fold in England and Wales and six-fold in Scotland over this period. 74 

In women, 

there was a corresponding four-fold increase. 74 

This increase occurred in both the 15 to 44 years age 

group and the 45 to 64 years age group, although the absolute rates were much higher in the older 

group. 74 

In comparison to the rates in 12 other western European countries l 

over a similar period, these 

increases were found to be the steepest rise in western Europe where the rate of mortality has been 

declining since the early 1970s. 74 

The mortality rates for Scotland across both age-groups and sexes are 

now one of the highest in western Europe and while the absolute rates in England and Wales remain 

relatively low, the steep increase in recent years have seen the rates beginning to exceed the western 

European average. 74 

In Wales, the number of alcohol-related deaths more than doubled between 1992 

and 2005, increasing from 199 to 407. 95 

In 2005, 63 per cent (255) of these deaths were among males, 

of which 46 per cent were aged 45 to 74. 75 

Corresponding data are not available for Northern Ireland. 

k There are many different causes of liver cirrhosis of which sustained alcohol misuse and hepatitis C infection are the most 

common. 

l The 12 western European countries included in the study were Austria, Denmark, Finland, France, Germany, Ireland, Italy, 

Netherlands, Norway, Portugal, Spain and Sweden. 


36 


Causes of alcohol-related mortality 

Alcohol misuse can be directly associated with mortality from certain types of disease (eg liver 

cirrhosis). Table 6 compares the data for the deaths from causes linked directly to alcohol 

consumption in 2005 for England and Wales, Scotland and Northern Ireland. As Table 6 

demonstrates, alcoholic liver disease accounts for the majority (approximately two-thirds) of deaths 

directly linked to alcohol consumption in the UK. With the exception of chronic hepatitis, more 

men than women died from each of the alcohol-related causes of death. 

Table 6 – deaths from causes directly linked to alcohol consumption in the UK in 2005 as a 

percentage of the total number of deaths (based on the ICD-10) 

Cause of death (ICD-10 code) England and Wales Scotland Northern Ireland 

Male Female Male Female Male Female 

Mental and behavioural 8.9 6.2 25.0 17.9 33.7 27.4 

disorders due to alcohol (F10) (386) (137) (255) (88) (63) (23) 

Alcoholic cardiomyopathy 1.5 0.7 1.3 0 11.8 4.8 

(I42.6)* (64) (16) (13) (0) (22) (4) 

Alcoholic liver disease (K70) 64.3 61.6 62.5 68.7 42.2 45.2 

(2,789) (1,371) (638) (338) (79) (38) 

Chronic hepatitis – not 0.32 2.3 0 1.0 0 2.4 

elsewhere specified (K73) (14) (52) (0) (5) (0) (2) 

Fibrosis and cirrhosis 21.3 26.2 9.6 11.4 8.6 17.9 

of the liver (K74) (926) (584) (98) (56) (16) (15) 

Alcoholic induced chronic 1.0 0.5 1.4 0.8 2.7 2.4 

pancreatitis (K86.0)** (44) (11) (14) (4) (5) (2) 

Alcoholic poisoning by and 2.3 2.3 0 0 1.1 0 

exposure to alcohol (X45) (100) (51) (0) (0) (2) (0) 

Total 100 100 100 100 100 100 

(4,340) (2,227) (1,021) (492) (187) (84) 

Source: Statistics on alcohol: England 2007 (The Information Centre, 2007), General Register Office for Scotland (2007), 

Registrar General Northern Ireland Annual Report 2005 (Northern Ireland Statistics and Research Agency, 2006). 

* Data presented for Northern Ireland relate to the broader category of cardiomyopathy and not specifically for alcoholic 

cardiomyopathy (I42.6) for which data were not available. 

** Data presented for Northern Ireland relate to the broader category of other diseases of the pancreas (K86) and not 

specifically for alcoholic induced chronic pancreatitis K86.0) for which data were not available. 



The data in Table 6 do not include mortality associated with, but not directly linked to, alcohol 

consumption (eg deaths from chronic conditions such as ischaemic stroke, CHD, and various 

cancers, as well as acute conditions such as suicide, homicide, and deaths resulting from accidents 

or injuries). Information on the number of deaths associated with, but not directly linked to, 

alcohol consumption is based on estimates due to the difficulty in attributing causation. It has 

been estimated that alcohol misuse accounts for more than 22,000 premature deaths per year in 

England, of which 1,000 are suicides. 8 

Alcohol-related hospital admissions 

Alcohol misuse is a major cause of admission to hospital in both the Accident and Emergency 

(A&E) and non-emergency setting. Alcohol may be the direct cause of admission, or may increase 

the burden on hospital services by adversely affecting the course of illness following admission. 

The PMSU has estimated that 70 per cent of all admissions to A&E at peak times are alcoholrelated. 

8 

Recent years have seen a significant increase in the number of alcohol-related hospital 

admissions in the UK, with the most common cause for admission being mental and behavioural 

disorders due to alcohol consumption, followed by alcoholic liver disease and toxic effect of 

alcohol. m 

Box 3 summarises the available data for England and Scotland. Comparative data are not 

available for Wales and Northern Ireland. 

“” 

A&E particularly during the weekend is a nightmare. Staff are usually stretched to 

their limits with an over spilling waiting room which looks like a ‘war zone’ as 

patients wait, some with bloodstained clothes, to be seen. Staff trying to treat most 

of these intoxicated patients have to put up with a torrent of abuse, while clearing 

up vomit, urine etc. 

BMA member 

m Detailed information on the categories included within mental and behavioural disorders due to alcohol consumption, 

alcoholic liver disease and toxic effect of alcohol can be found in the ICD-10 at www.who.int 


38 


Box 3 – summary data on alcohol-related hospital admissions in England and 

Scotland 

England: 

the number of NHS hospital admissions of adults aged 16 and over with a primary or 

secondary diagnosis specifically related to alcohol more than doubled from 89,280 in 

1995/96 to 187,640 in 2005/06 

in 2005/06, the most common causes for admission for adults aged 16 and over, where 

alcohol was specifically related to the primary or secondary diagnosis, were mental and 

behavioural disorders due to alcohol consumption (139,680), alcoholic liver disease (39,180) 

and toxic effect of alcohol (25,210) 

the number of NHS hospital admissions of children under 16 with a primary or secondary 

diagnosis specifically related to alcohol rose from 3,870 in 1995/96 to 5,280 in 2005/06 

in 2005/06, the most common causes for admission for children aged under 16, where 

alcohol was specifically related to the primary or secondary diagnosis, were mental and 

behavioural disorders (4,360) and toxic effect of alcohol (940). 40 

Scotland: 

in 2005/06, there were 39,061 alcohol-related general hospital discharges, of which 

381 were children aged under 15 

there was an overall increase of 7 per cent in alcohol-related discharge rates from 

Scottish general hospitals between 2000/01 and 2005/06 

in 2005/06, mental and behavioural diagnoses accounted for 64 per cent (24,869) of all 

discharges, while alcoholic liver disease and toxic effect of alcohol accounted for 15 per 

cent (6,016) and 10 per cent (3,723) respectively 

in children under 15 years, the most common cause of alcohol-related discharge in 2005/06 

was mental and behavioural diagnoses (260), followed by toxic effect of alcohol (77). 12 

Alcohol-related crime, disorder and anti-social behaviour 

Alcohol misuse, particularly the pattern of binge drinking and the frequency of getting drunk, is 

associated with a wide range of crimes, disorders and anti-social behaviours. 54 

Alcohol-related 

crime and disorder significantly impacts on quality of life, both directly through the effects of 

physical or sexual assault, or indirectly through the impact on the urban infrastructure (eg broken 

glass, noise and litter). 8 

There are two main categories of offences associated with alcohol-related 

crime and disorder: 

alcohol-defined offences such as drunkenness offences or driving with excess alcohol (see 

page 42 for further information on driving and road safety) 

offences in which alcohol consumption was a contributory factor in the committing of an 

offence, usually where the offender was under the influence of alcohol at the time. 

Examples of offences which are often committed by people under the influence include 

physical and sexual assault, breach of the peace, criminal damage and other public order 

offences. 

Alcohol consumption is also strongly associated with anti-social behaviour, particularly at 

54, 76, 77 

weekends, in both urban and rural environments. Anti-social behaviour can be defined as 

acting ‘in a manner that caused or was likely to cause harassment, alarm or distress’ 78 

and includes 

activities such as nuisance and rowdy behaviour, noise disturbance, street drinking and begging, 

littering, and intimidation or harassment. 



The number of officially recorded drunkenness offenders has been declining since 1981 

throughout the UK (see Figure 13). These figures should be taken with caution as they most likely 

reflect changes in policy and police practice rather than changes in the actual incidence of 

drunkenness. 4 

The 2004 PMSU alcohol-harm reduction strategy noted that ‘Enforcement of 

legislation on drunk and disorderly behaviour has dropped sharply over the last 10 years. This 

reflects not only falling priority but also, crucially, the sheer practicalities of policing large numbers 

of drunk people’. 8 

In England and Wales, the recent downward trend coincides with the 

introduction of Penalty Notices for Disorder (PND) in 2003/04. In 2004 there were approximately 

3,000 penalty notices issued for drunkenness or consuming alcohol in a designated public place 

and 26,600 penalty notices issued for drunk and disorderly behaviour. 40 

Figure 13 – drunkenness offenders in the UK, 1964-2005 

Number of offenders 

140000 

120000 

100000 

80000 

60000 

40000 

20000 

0 

1965 

1967 

1969 

1971 


1973 

1975 

1977 

1979 

1981 

1983 

While statistics on alcohol-defined offences such as drunkenness and driving with excess alcohol 

are readily available, data on other offences where alcohol is a contributory factor are not collected 

per se due to the complexity in establishing causality. As a result, the involvement of alcohol in 

offences such as assault is not routinely investigated or recorded. This is compounded by the 

under-reporting in police statistics of violent crimes which is known to occur. 79 

Data on the levels 

of antisocial behaviour are also limited as this information is also not routinely collected. There is a 

clear need to improve the collection of data on alcohol-related crime and disorder through routine 

coding in police investigations and incident reports. 


1985 

Year 

1987 

Total number of offenders 

Rate per 10,000 (all ages) 

Rate per 10,000 (aged 15 and over) 

1989 

1991 

1993 

1995 

1997 

1999 

2001 

2003 

2005 

30 

25 

20 

15 

10 

5 

0 

Rate per 10,000 population

40 


Information on alcohol-related violent crime and disorder is available from crime surveys; however, 

these data are subjective as they are reliant on the victim’s perception of an offender’s alcohol use. 

According to the British Crime Survey (BCS) 2005-06, 44 per cent of violent offenders in England 

and Wales were perceived by their victims to be under the influence of alcohol. 80 

This corresponds 

to a decrease in the number of violent incidents where the victim believed the offender or 

offenders to be under the influence of alcohol from 1,659,000 in 1995 to 1,029,000 in 2005/06. 

The offender was judged to be under the influence of alcohol in 54 per cent of incidents of 

stranger violence, 44 per cent of incidents of acquaintance violence and 21 per cent of incidents 

of mugging. 80 

Eighteen per cent of violent offenders between the age of 10 and 25 reported being 

under the influence of alcohol only, and three per cent under the influence of drugs and alcohol, 

at the time of the offence. 81 

Thirty-two per cent of young people surveyed reported being under 

the influence of alcohol when committing criminal damage offences and 27 per cent were under 

the influence of drugs and alcohol while being involved in vehicle related thefts. 81 

The 2000 

Scottish Crime Survey (SCS) found that 72 per cent of victims of violent crime in Scotland reported 

that the assailant was under the influence of alcohol, and that male offenders were more likely to 

be under the influence (69%) than female (30%). 82 

Comparative data are not available for 

Northern Ireland. 

The levels of alcohol-related crime and disorder vary with age and pattern of drinking. The 2003 

Offending, Crime and Justice Survey (OCJS) found that binge drinkers were more likely to offend 

than other regular drinkers, and the number of offences was highest among binge drinkers aged 

18 to 24. 83 

While this age group accounted for only six per cent of the total adult survey sample, 

it was found to be responsible for 30 per cent of all crimes and 24 per cent of all violent incidents 

reported by adults in the preceding 12 months. 83 

Young binge drinkers aged 18 to 24 were found 

to account for a disproportionate level of criminal and disorderly behaviour (ie getting into an 

argument or fight, breaking or damaging property, and stealing). 83 

Drinking alcohol, especially 

frequent drinking, is also a significant factor in criminal and disorderly behaviour in young people 

aged under 18. The 2004 OCJS for England and Wales found that 10 to 17-year-olds who 

reported drinking alcohol once a week or more (14%) committed a disproportionate volume of 

crime, accounting for 37 per cent of all offences reported by the respondents. 84 

Those who had 

never drunk alcohol or had not drunk alcohol in the past year, comprised 45 per cent of 

respondents and only committed 16 per cent of all the offences reported. 84 



The social effects of alcohol misuse on individuals and families 

Alcohol misuse can lead to many harmful consequences for the individual drinker, their family and 

friends. In terms of the individual, alcohol misuse can be associated with many negative 

consequences including tobacco and illicit drug use; accidents and injuries; malnutrition and eating 

disorders; unemployment; social exclusion; memory loss; self-harm and suicide; unprotected and 

underage sex; unplanned pregnancy; and problems in relationships with friends and partners. 4 

There is a complex relationship between alcohol misuse and homelessness. Alcohol dependence 

can lead to homelessness, while for others, alcohol problems may develop as a result of being 

homeless. 3 

3, 85 

It has been estimated that around half of homeless people are dependent on alcohol. 

In contrast, a 1994 survey of 1,061 homeless people in hostels, night-shelters, day centres and 

86, 87 

private-sector leased accommodation in Britain found over 21 per cent to be alcohol dependent. 

Alcohol misuse can also significantly impact on family life. Marriages where there are alcohol 

problems are twice as likely to end in divorce. 88 

Parental alcohol misuse is correlated with child 

abuse and significantly impacts on a child’s environment in many social, psychological and 

economic ways. 89 

Single parent households, low income and parental unemployment are all 

significant risk factors for heavy alcohol use by children and young people. 4 

In 2004, it was 

estimated that between 780,000 and 1.3 million children were affected by parental alcohol 

problems in England. 8 

Drinking alcohol can impair performance as a parent, spouse or partner 

through negative effects on relationships with family members and through time spent away from 

the family and home. Alcohol use can significantly impact on family economic resources through 

direct expenditure on alcohol, increased medical and childcare expenses, reduced household 

income through alcohol-related morbidity and mortality, lost employment opportunities, legal costs 

of alcohol-related offences and decreased eligibility for loans. 90 

The economic consequences of 

expenditures on alcohol can perpetuate the effects of poverty on families and children by diverting 

scarce funds away from meeting basic needs. Alcohol misuse can also result in substantial mental 

health problems for family members. 70 

“” 

Alcoholism destroys individuals and slowly but inevitably pulls the family down on 

the back of “they like their drink”. Just imagine how different life would have been 

for people and public figures without the destruction by alcohol. 

BMA member 

In the workplace, alcohol misuse is associated with lower productivity through sickness-related 

8, 70, 91 

absence and poor performance, as well as resulting in shorter working lives. It has been 

estimated that alcohol misuse results in 17 million working days lost annually in England. 8 

Research 

has found that alcohol is a significant contributory factor in domestic violence incidents and that the 

risks of suffering domestic abuse rise with increasing levels of drinking for both male and female 

victims. 92 

The BCS 2005-06 found that 46 per cent of domestic abuse offenders were under the 

influence of alcohol. 80 

The Northern Ireland Crime Survey (NICS) 2005 found that 51 per cent of 

perpetrators of domestic violence were identified by their victims as under the influence of alcohol 

at the time of their worst incident. 93 

It has been found that domestic abuse characterised by the 

perpetrator’s pre-assault alcohol use is associated with more serious outcomes, with perpetrator 

alcohol use being associated with approximately 1.5 times greater risk of victim injury and receipt of 

medical attention. 94 

Victims of domestic abuse have also been found to have increased alcohol 

consumption compared with non-victims, 95 

and children who witness domestic abuse are more likely 

to display harmful drinking patterns later in life. 92 

Further information on domestic abuse and its 

association with alcohol misuse can be found in the 2007 BMA report Domestic abuse. 96 


42 


Driving and road safety 

The adverse short- and long-term effects of alcohol misuse on judgement, coordination and 

reactions are a common cause of road traffic crashes involving intoxicated drivers and other 

intoxicated road users such as cyclists. Driving under the influence of alcohol is a significant cause 

of death and serious injury from road traffic crashes in the UK. In Great Britain, there were an 

estimated 14,380 casualties resulting from drink-drive road crashes in 2006, of which 540 were 

estimated to be fatal and 1,960 serious. 97 

This corresponds to six per cent of all road casualties and 

17 per cent of road deaths in 2006. 97 

The number of people killed or seriously injured in drinkdrive 

crashes in Great Britain fell from over 9,000 in 1979 to less than 2,000 in 2006. 97 

Between 

1995 and 2006, there has been no overriding trend in the number killed or seriously injured 

despite year-to-year fluctuation. In Northern Ireland, consumption of alcohol or drugs by drivers or 

riders was responsible for 18 deaths and 115 seriously injured casualties in 2006, corresponding to 

10 per cent of all fatal and serious road traffic crashes. 98 

“” 

I have treated far too many casualties following drink-drive crashes, many of whom 

have been innocent victims due to an irresponsible motorist driving whilst over the 

legal limit. As a doctor I do my best to treat these patients but often they are left 

with permanent physical injuries and sometimes brain damage. These are tragic 

occurrences which occur all too frequently. 

BMA member 

In the UK, drink-driving is more common in men, and among those aged under 30. According to 

road casualty data for Great Britain, three per cent of all male car drivers involved in a personal 

injury road crash in 2006 failed a breath test compared to 1.2 per cent of women. 97 

In 2005, the 

highest rates of drink-drive crashes per 100,000 license holders were found in the 17 to 19 age 

group (74), followed by those in the 20 to 24 age group (71) and the 25 to 29 age group (48). 97 

Figure 14 and Figure 15 show the number of convictions for drinking and driving in England and 

Wales, and Scotland respectively between 1963 and 2005. In England and Wales, the number of 

people convicted of drink-driving decreased substantially between 1990 and 1994, and has 

fluctuated around 80,000 individuals per year since then. In Scotland, there has been a downward 

trend in the number of people convicted since the mid 1970s. In Northern Ireland, the total 

number of convictions for drink-driving increased from 1,890 in 2001 to 2,536 in 2005. 99 



Figure 14 – number of persons convicted of drinking and driving in England and Wales, 

1965-2005 

Number of convictions (thousands) 

120 

100 

80 

60 

40 

20 

0 

1965 

1967 

1969 

1971 

1973 


Figure 15 – number of persons convicted of drinking and driving in Scotland, 1965-2005 

Number of convictions (thousands) 

14 

12 

10 

8 

6 

4 

2 

0 

1965 

1967 

1969 

1971 

1973 


1975 

1975 

1977 

1977 

1979 

1979 

1981 

1981 

1983 

1983 


1985 

Year 

1985 

Year 

1987 

1987 

1989 

1989 

1991 

1991 

1993 

1993 

1995 

1995 

1997 

1997 

Men 

Women 

Total 

1999 

1999 

2001 

Men 

Women 

Total 

2001 

2003 

2003 

2005 

2005

44 


Pedestrian alcohol consumption is also associated with fatalities and injuries. In Great Britain, 

72 per cent n 

of pedestrians aged 16 and over killed between 10pm and 4am in 2005 were found 

to have a BAC in excess of 80mg/100ml. 97 

Research conducted by the Scottish Office Central 

Research Unit found that 31 per cent of all pedestrian casualties attending A&E departments in 

five large Scottish hospitals in 1996/97 had consumed alcohol, of which 87 per cent were male. 100 

In Northern Ireland, 12 per cent of fatal and serious pedestrian injuries in 2005 were due to 

pedestrian consumption of alcohol or drugs. 98 

The cost of alcohol misuse and alcohol-related harm 

The cost of alcohol misuse in the UK is substantial and can be divided into four broad categories: 

healthcare service costs – including costs to primary care services and hospital services (A&E, 

medical and surgical inpatient services, paediatric services, psychiatric services, and outpatient 

departments) of alcohol-related morbidity and mortality 

cost of alcohol-related crime, disorder and anti-social behaviour – including costs to the criminal 

justice system, costs to services (eg social work services), costs of drink-driving, and the human 

cost of alcohol-related harm (eg domestic abuse, assault) 

loss of productivity and profitability in the workplace – including costs to the economy from 

alcohol-related deaths and alcohol-related lost working days 

impact on family and social networks – including human and emotional costs such as 

breakdown of marital and family relationships, poverty, loss of employment, domestic and child 

abuse, homelessness and other drug use. 

Box 4 summarises various estimates of the costs of alcohol-related harm in the UK. 

n As blood alcohol levels were only available for 45 per cent of all pedestrian fatalities, these figures may overestimate the 

proportion of fatalities with a BAC in excess of 80mg/100ml. 



Box 4 – estimated annual costs of alcohol-related harm in the UK 

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). 101 

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 alcoholrelated 

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). 8 

Scotland 

In 2002/03, the overall annual cost of alcohol misuse in Scotland was estimated to be 

£1.13 billion including: 

£110.5 million for healthcare services provided by NHS Scotland 

£96.7 million for social work services 

£276.7 million for criminal justice and emergency services 

£417.8 million for wider economic costs associated with alcohol misuse including working 

days lost due to alcohol-related absenteeism 

£223.8 million for human costs (premature mortality in the non-working population). 102 

Northern Ireland 

The annual cost of alcohol-related harm in Northern Ireland has been estimated to be 

£743 million, of which £34 million is incurred in direct costs (eg healthcare costs and prison 

service costs). 9 


46 




Effective policies to reduce alcoholrelated 

harm in the UK 

There is a substantial body of evidence demonstrating that targeted and population-wide alcohol 

control policies can reduce alcohol-related harm. Historically, changes in alcohol control policies in 

the UK have been accompanied by fluctuations in alcohol consumption levels and associated 

problems. In the 18th century, a dramatic increase in the consumption of gin in the UK occurred 

following a reduction in taxation levels, leading to a period of widespread chronic mass 

intoxication, drunken violence, disease, alcohol dependence and premature mortality. 103 

It was not 

until 1743 that the ‘gin epidemic’ was brought under control through moderate taxation and 

strong enforcement. During the 19th century, deregulation of the sale of beer, ale and cider led to 

the proliferation of premises selling alcoholic drinks and an accompanying increase in drunkenness 

and alcohol-related problems. 4 

This in turn brought about the introduction of licensing controls in 

the late 19th century. During the First and Second World Wars and the inter-war period, 

restrictions on the sale of alcoholic beverages and increased taxation – together with the removal 

of large numbers of young men by wartime duty or premature death – led to dramatically reduced 

national per capita consumption and alcohol-related problems. 4 

“” 

I see more and more alcohol-attributable deaths. ‘There is nothing more we can do’ 

is a hard discussion to have with a patient and their family. Excessive drinking has a 

wide range of adverse effects – medical, personal and social. The government needs 

to take tougher action to address these problems and it needs to happen now. 

BMA member 

Since the Second World War, there has been considerable deregulation and liberalisation of alcohol 

control policies in the UK. This has been accompanied by an increase in consumption levels and 

alcohol-related problems as discussed earlier. Information on current UK governmental alcohol 

control strategies can be found in Appendix 2. These strategies have been the subject of much 

criticism due to the lack of governmental commitment to evidence-based harm reduction 

57, 104-111 

policies. The primary criticism is the focus of the UK Government on interventions that are 

popular (eg educational programmes and media campaigns) but argued to be ineffective, and the 

rejection of policies such as increased taxation and reduced availability that have been found to 

reduce alcohol consumption and related problems. These criticisms are supported by analysis and 

comparison of the strength of alcohol control policies internationally. A recent study of alcohol 

control policies among countries in Europe, Asia, North America, and Australia found the strongest 

alcohol control policies to be in Norway and Poland while the UK was ranked 20th out of the 

30 countries examined in the study. 112 

Lessening the burden of alcohol misuse in the UK requires strong leadership and the implementation 

of effective alcohol control policies that reduce overall consumption levels and minimise the harm to 

the public and the individual. It is worth noting that while the devolved UK nations have developed 

independent strategies, there is no overarching strategy for the UK. Developing comprehensive alcohol 

control policies therefore requires partnership between governmental agencies and organisations 

throughout the UK. A coordinated approach is also required to increase the popularity and acceptance 

of such policies among the general public. The UK Government’s emphasis on partnership with the 

alcohol industry and self-regulation has at its heart a fundamental conflict of interest that does not 

adequately address individual and public health. The alcohol industry clearly has a vested interest in the 

development of control policies. It is essential, that the UK Government moves away from partnership 

with the alcohol industry and looks at effective alternatives to self-regulation that will ensure there is a 

transparent policy development process that is based on reducing the harm related to alcohol misuse. 


48 


The sub-sections to follow set out a range of evidence-based policies that must be collectively 

implemented in order to effectively tackle alcohol misuse and its associated harms. 


Access to alcohol is an important determinant of alcohol use and misuse. This incorporates the 

implementation of policies that regulate the affordability of alcohol, as well as the introduction 

and enforcement of strict controls on the availability of alcohol to adults and young people. 

Taxation and traveller’s allowances 

In recent years, the affordability of alcohol in the UK has been increasing and this has played a 

significant role in the rise in alcohol consumption. 4 

Figure 16 shows how the affordability of alcohol in 

the UK increased by 65 per cent between 1980 and 2006. 40 

In the corresponding period, per capita 

alcohol consumption for those aged 15 and over increased from 9.4 to 10.9 litres of pure alcohol. 5 

Figure 16 – the affordability o 

of alcohol and consumption of alcohol per capita aged 15 

and over, UK, 1980-2006 

Affordability (100=1980 value) 

180 

160 

140 

120 

100 

80 

60 

Source: Statistics on alcohol: England 2007 (The Information Centre, 2007), Statistical handbook 2007 (British Beer and Pub 

Association, 2007) 


Year 

Affordability 

Consumption 

1980 

1981 

1982 

1983 

1984 

1985 

1986 

1987 

1988 

1989 

1990 

1991 

1992 

1993 

1994 

1995 

1996 

1997 

1998 

1999 

2000 

2001 

2002 

2003 

2004 

2005 

2006 

o The affordability of alcohol has been calculated by comparing the relative changes in the price of alcohol (relative alcohol 

price index) with changes in household’s disposable income (real household’s disposable income index) over the same period 

(with both allowing for inflation). The base year for these data is 1980. 

12 

11.5 

11 

10.5 

10 

9.5 

9 

8.5 

8 

Litres of pure alcohol per capita (aged 15 and over)


In the UK, taxation on alcohol is set centrally by Her Majesty’s (HM) Treasury. Since 1997, the 

duties on wine and beer have only increased in line with inflation and the duty on spirits has not 

increased. 113 

It is important to recognise that while the production, distribution and sale of 

alcoholic beverages is economically significant, the burden of alcohol misuse is equally important. 

There is strong and consistent evidence that alcohol consumption and rates of alcohol-related 

problems are responsive to price. 114-118 

It has been estimated that a 10 per cent increase in alcohol 

prices in the UK would lead to a 10 per cent fall in consumption. 4 

The price elasticity varies 

between types of alcoholic beverage. In the UK, price elasticises have been estimated as -0.48 for 

beer consumed on premises, -1.03 for packaged beer, -0.75 for wine, and -1.31 for spirits (ie 

spirits are most price elastic and beer consumed on premises least price elastic). 119 

Based on these 

estimates, a 10 per cent increase in the prices of alcoholic beverages across the board would lead 

to a reduction in consumption of beer consumed on premises of 4.8 per cent, and spirits by 13.1 

per cent. 57 

Increases in the price of alcohol not only affect consumption at a population level, but 

there is evidence that particular types of consumers (eg heavy drinkers and young drinkers) are 

57, 114, 120-123 

especially responsive to price. 

Studies have also reported that price increases have the effect of reducing rates of alcohol 

4, 114 

problems including alcohol-related violence and crime, deaths from liver cirrhosis, 124 

and drinkdriving 

deaths. 125 

A 2007 review found the 2004 reductions in alcohol taxation in Finland to be 

associated with an increase in the number of sudden deaths involving alcohol. 126 

A 2006 study 

examining the influence of the price of beer on violence-related injuries in England and Wales 

found that increased alcohol prices would result in substantially fewer violent injuries and reduced 

demand on trauma services. 127 

The study concluded that a one per cent rise in the real price of 

alcohol would equate to an economy-wide reduction in cases of assaults in emergency 

departments of 5,000 per year. 127 

In the UK, alcohol is relatively highly taxed compared to other EU countries (see Appendix 3). 5 

Furthermore, traveller’s allowance guidelines for the importation of alcohol for personal use from 

other EU countries are disproportionately high. HM Revenue and Customs guidelines advise that 

no more than 10 litres of spirits, 20 litres of fortified wine, 90 litres of wine, and 110 litres of beer 

can be brought into the UK for personal use. 128 

Any alcohol brought into the UK in excess of these 

guidelines may be seized by customs officers if the individual cannot provide satisfactory 

explanation that these quantities are for personal rather than commercial purposes. The 

combination of low alcohol taxation in the EU coupled with high traveller’s allowances mean large 

quantities of alcohol are regularly imported into the UK from continental Europe. As noted 

previously, it has been estimated that the approximate level of unrecorded annual consumption in 

the UK is two litres of 100 per cent alcohol per inhabitant aged 15 or over. 7 

Reducing the 

importation of alcohol from other EU countries, however, is unrealistic given current EU legislation 

and single market regulations. 

It is clear that the relationship between the affordability of alcohol and the level of consumption 

provides an effective tool for controlling levels of consumption and reducing levels of alcoholrelated 

harm. The UK Government, however, has consistently opted not to use taxation as an 

alcohol control policy. The proposal by the European Commission in 2006 to increase minimum 

levels of excise duty on alcoholic drinks across the EU was also rejected by the European 

Parliament. It is essential that there is an increase in the level of excise paid on alcohol in the UK 

and this should be relative to the number of units of alcohol. This increased taxation would not 

only reduce alcohol consumption and its related harms, but would also contribute to providing the 

necessary funding to meet the social and economic costs of these harms (eg police enforcement 

measures, healthcare service costs and treatment services). 


50 


Recommendation 

Taxation on all alcoholic beverages should be increased at higher than inflation rates and 

this increase should be proportionate to the amount of alcohol in the product. 

Licensing reforms 

Licensing interventions are one of the most influential methods for controlling alcohol consumption 

and misuse through regulation of where, when and to whom alcohol can be sold. There is strong 

evidence that increased opening hours are associated with increased alcohol consumption and 

4, 57, 114, 115, 117 

alcohol-related problems. 

A literature review conducted by the Scottish Executive in 2003 on the impact of licensing and other 

controls on public disorder found that, although there is inconsistent evidence relating to the impact 

of licensing controls in the UK, there is international evidence to support the idea that longer hours 

of alcohol sales may be linked to increased problems with alcohol-related crime and disorder. 129 

A study in 2002 noted that past increases in hours of alcohol sales in Michigan, Perth, New South 

Wales, Victoria, Tasmania, Brisbane, Finland and Sweden have been shown to result in increases in 

road deaths and injuries and/or violence. 130 

In a study in hotels in Perth, Australia, late trading was 

found to be associated with both increased violence and increased levels of alcohol consumption 

during the study period. 131 

It is suggested that greater numbers of patrons and increased levels of 

intoxication contributed to the observed increase in violence. 131 

Several controlled and uncontrolled studies in Nordic countries with State alcohol monopolies have 

shown that major relaxations in controls on beer strength or sales outlets were followed by 

increases in alcohol consumption, drunkenness and alcohol-related hospital admissions. 132 

The 

extension of licensing hours in Reykjavik, Iceland, was found to result in net increases in police 

work, in emergency room admissions, and in drink-driving cases. 123 

The extension of opening hours 

for pubs and clubs in the Republic of Ireland following the introduction of the 2000 Intoxicating 

Liquor Act was found to result in a number of negative consequences including a significant rise in 

binge drinking, especially among under-age drinkers. 4 

Conversely, reductions in the opening hours 

and the number of outlets are associated with reductions in alcohol use and related problems. 

Reductions in licensing hours in Norway, Finland and Sweden led to a decrease in the alcohol 

consumption of heavy drinkers. 133 

In the UK, access to alcohol has increased significantly due to the doubling in the number of onand 

off-licensed premises since the 1950’s. In 1953, there were 61,000 on-licensed premises and 

24,000 off-licensed premises in Great Britain. 134 

In 2001, the total number of on-licensed and offlicensed 

premises in England and Wales was estimated to be 110,000 and 44,700 respectively. 135 

Despite the evidence that increased opening hours and availability of alcohol are associated with 

greater consumption and alcohol-related problems, recent and proposed changes to licensing 

policies in the UK have favoured extended trading hours. The Licensing Act 2003 now permits 

24-hour opening in England and Wales, while proposed changes to licensing in Scotland and 

Northern Ireland will permit more modest extensions in opening hours. The licensing reforms in 

England and Wales were introduced in 2005 with the aim of altering the drinking culture, reducing 

binge drinking levels and reducing the tendency of drinkers to rush to consume alcohol immediately 

prior to closing time. 4 

Of particular note, however, is the fact that public health is not considered as 

one of the licensing objectives in the 2003 Act. 136 

By contrast, the Licensing (Scotland) Act 2005 

specifically mentions ‘protecting and improving public health’ as one of the licensing objectives. 137 



The decision to permit extended licensing hours in England and Wales has received considerable 

criticism in the medical community. 138-140 

In 2005, the Association of Chief Police Officers (ACPO) 

raised concerns that extended licensing hours would result in greater numbers of people under the 

influence of alcohol, and therefore lead to increased levels of crime and disorder, and associated 

demands on policing. 141 

It is essential that licensing reforms are based on the best available 

evidence on the effects of increased licensing hours. It is also important that any changes to 

licensing legislation are accompanied by a programme of post change research to evaluate the 

short, intermediate and long-term effects, including an assessment of any health impacts. A recent 

small-scale review of the effect of the new licensing laws in England and Wales found a statistically 

significant increase in alcohol-related overnight attendances in the emergency department in St 

Thomas’ hospital in London following the introduction of the new licensing legislation. 142 

The number 

of alcohol-related attendances increased from 79 (2.9% of all overnight attendances) in March 2005 

to 250 (8% of all overnight attendances) in March 2006. 142 

A 2007 Home Office report examining 

violent crime, disorder and criminal damage since the introduction of the Licensing Act 2003 

indicated that there had been an increase in offences of all types (criminal damage, harassment, 

assault with no injury, less serious wounding, serious violent crime) between 3am and 6am after the 

introduction of the 2003 Licensing Act in November 2005. 143 

The report concluded that the increase 

between 3am and 6am was likely to partly reflect the change to opening hours of licensed premises 

and the increased numbers of people in a public place at these times. 143 

A high density of alcohol outlets is also associated with increased alcohol sales, drunkenness, 

114, 144-149 

violence and other alcohol-related problems. A high density of outlets increases the 

likelihood of movement between bars which in turn increases noise and disturbance in the vicinity, 

complicates the assignment of responsibility to any one server or establishment to prevent 

intoxification, and makes it easier for customers to respond to price promotions in the area. 149 

Consumers are likely to be deterred from purchasing alcohol when there is a lower density of 

outlets due to the increased time and inconvenience involved in purchasing. It is therefore 

important that the density of alcohol outlets is taken into account when considering planning or 

licence applications, and where necessary, legislative changes are introduced to ensure these 

factors are considered. The surrounding infrastructure and availability of local amenities (eg taxi 

services and food outlets) are also important considerations. 


The availability of alcoholic products should be regulated through a reduction in licensing 

hours for on- and off-licensed premises. 

Town planning and licensing authorities should ensure they consider the local density of 

on-licensed premises and the surrounding infrastructure when evaluating any planning or 

licensing application. Legislative changes should be introduced where necessary to ensure 

these factors are considered in planning or licensing applications for licensed premises. 


52 


Legal age of consumption and age of purchase 

In the UK, the legal age for consuming alcohol is five, provided parental consent is given. It is, 

however, illegal for anyone under aged 18 to buy alcohol in a pub, off-licence, supermarket, or other 

outlet, or for anyone to buy alcohol for someone under 18 to consume in a pub or a public place. p 

Regulating access to alcohol through restrictions on the legal age of consumption and purchase is a 

particularly effective strategy for preventing alcohol-related health and social problems among young 

people. There is strong evidence from the USA that raising the legal age of consumption and 

purchase reduces consumption levels in young people (including binge drinking), and reduces the 

114, 115, 125, 150-154 

levels of alcohol-related traffic crashes, injuries and fatalities. The effect of reducing the 

legal age to purchase alcohol has been reported to increase consumption and the number of alcoholrelated 

road crashes. 155 

Hence, it is important to consider whether a review of the current legal age 

limits for consuming and purchasing alcohol is necessary. Evidence from the USA clearly demonstrates 

that raising the legal drinking age has a significant positive effect on alcohol-related problems. 

The illegal purchase of alcohol by young people is a significant problem in the UK. A nationwide 

police operation in 2004 found that 51 per cent of on-licenced premises and 32 per cent of offlicences 

had sold alcohol illegally to individuals aged under 18. 4 

The legal sale of alcohol is 

complicated by the difficulty in accurately determining the age of young people aged between 

16 and 18. There is also considerable anecdotal evidence that licensees are subjected to verbal and 

physical abuse when refusing to sell age-restricted items such as alcohol. In the UK, the Retail of 

Alcohol Standards Group (RASG) established the voluntary ‘Under 21?’ signage initiative in 

December 2005 which aims to support retailers in encouraging anyone who is over 18 but looks 

under 21 to carry acceptable identification if they wish to buy alcohol. All licensees should be 

encouraged to sign-up to this voluntary agreement. 


Numerous factors contribute to the culture of drinking to excess and the rise in underage drinking and 

alcohol-related harm in the UK. Key areas are the supply and promotion of alcohol to consumers. 

Enforcing responsible serving practices 

In addition to regulating licensing hours, legislation in the UK prohibits the sale of alcohol to 

intoxicated customers and people under the age of 18. The enforcement of licensing laws is a vital 

component of effective alcohol control that places the responsibility on licensees for the actions of 

their customers. This is an advantageous approach as it does not rely on compliance from the 

individual consumer and is likely therefore to be received as an acceptable alcohol control policy. 

Active enforcement of laws regulating licensing hours and prohibiting the sale of alcohol to 

individuals who are intoxicated or those underage have been shown to be effective at increasing 

compliance with legislation. 156 

In the USA, enforcement has also been shown to increase public 

awareness, and when coupled with measures to encourage retailers and the public to comply with 

115, 157, 158 

the law, to reduce alcohol-related problems such as road traffic fatalities and homicides. 

These benefits from increased enforcement of licensing laws have also been found to significantly 

exceed the costs. 159 

p In the UK, young people aged 16 and 17, with the licensee’s permission, can drink beer, wine or cider with a meal if it is 

bought by an adult and they are accompanied by an adult. It is illegal for this age group to drink spirits in pubs even with a 

meal. In Scotland, 16 and 17 -year -olds can buy beer, wine or cider so long as it’s served with a meal and consumed in an 

area used solely for eating meals. 



Tougher enforcement policies were introduced by the Licensing Act 2003 in England and Wales, 

including increased penalties for breach of licence conditions, additional powers for the police to 

deal with troublesome premises (eg removal or suspension of licence and limiting opening hours) 

and the use of test purchases. These are accompanied by increased powers to prohibit anti-social 

drinking in areas where there has been a history of alcohol-fuelled disorder, as well as powers 

banning individuals responsible for alcohol-related disorder from entering licensed premises or 

specific public areas. Similar provisions have also been proposed in the licensing reforms in 

Scotland and Northern Ireland. It is essential that these powers are strictly and rigorously enforced, 

and that the enforcement agencies are adequately funded and resourced. In the UK, the 

enforcement of licensing regulations is undertaken by the police in conjunction with local 

authorities and Trading Standards Officers. These authorities have numerous responsibilities and, 

consequently, the enforcement of alcohol licensing regulations is not adequately prioritised. 

International experience suggests that the use of a dedicated licensing and inspection service 

covering all licensed premises increases compliance with regulations and prohibitions on alcohol 

sales. Such a system has been introduced in the Netherlands where a dedicated alcohol control 

service consisting of approximately 70 inspectors has been found to have a significant effect on 

reducing the rate of violent crimes between 10pm and 6am. 160 

There is evidence that premises where there is little seating, loud music, crowding, large numbers 

of young customers and poorly-trained staff are particularly likely to fuel heavy drinking and 

4, 8, 114, 148 

alcohol-related crime and disorder. Other factors that have been found to be associated 

with alcohol-related violence include hidden areas, dark and noisy environments, poorly 

maintained premises, low cleanliness, and poor ventilation. 148 

The layout, design and internal 

physical characteristics of licensed premises are therefore important considerations when planning 

strategies to reduce alcohol-related crime and disorder. 

An aggressive approach by staff at closing time and the inability of staff to manage problem 

114, 148, 161, 162 

behaviour are also important factors that may increase alcohol-related problems. 

Responsible beverage service training is designed to alter attitudes, knowledge, skills and practices 

among individuals serving alcohol. Such programmes have been shown to increase the likelihood 

of servers intervening with customers who are visibly intoxicated, 163 

and to decrease bad serving 

practices such as promoting particular beverages. 114 

While server training is less likely to increase 

163, 164 

actual refusal of service to intoxicated patrons, it has been found to reduce levels of patron 

intoxification when accompanied by policing enforcement, and strong and active management 

114, 153 

support. Community-based approaches focused on licensed premises have been found to be a 

powerful mechanism for reducing problem behaviour, although the long-term efficacy of this 

approach has not been demonstrated. 114 

Voluntary codes of practice have only been shown to be 

effective when combined with community pressure from the police and public. 114 

The implementation of responsible service training when combined with rigorous enforcement can 

lead to improved management practices within drinking venues. This in turn can lead to reduced 

levels of intoxication and an associated reduction in alcohol-related problems. It is important that 

this training is compulsory and extended to staff working in off-licence premises. 


54 



Licensing legislation in the UK should be strictly and rigorously enforced. This includes the 

use of penalties for breach of licence, suspension or removal of licences, the use of test 

purchases to monitor underage sales, and restrictions on individuals with a history of 

alcohol-related crime or disorder. 

Enforcement agencies should be adequately funded and resourced so that they can 

effectively carry out their duties. Consideration should be given to the establishment of a 

dedicated alcohol licensing and inspection service. 

Marketing and advertising 

The tendency to drink quickly and to excess is frequently facilitated by heavily discounted alcohol 

prices and the use of price promotions such as two-for-one offers and happy hours. Irresponsible 

promotional activities are common in licensed premises and off-licences (including supermarkets and 

local convenience stores) throughout the UK, and are even used to target particular groups (eg 

special cheap offers for women in pubs and clubs). The heavily discounted price of alcohol in UK 

supermarkets is a particular area of concern. There is evidence that excessively cheap promotions 

are particularly likely to fuel heavy drinking and alcohol-related crime and disorder. 8 

It is essential 

that these forms of promotional activity are strictly regulated through the introduction of legislation 

prohibiting price promotions on alcoholic beverages and establishing minimum price levels. 

“” 

An incident which sticks out in my mind was having to treat multiple young adults – 

out on a one night binge – for severe smoke inhalation and lung damage. They 

began binge drinking during a “Happy Hour” in a bar and after a prolonged night 

of ingesting excessive alcohol went to the flat of one of the group to continue the 

party. One member decided to make “chips” using an unattended chip pan which 

went on fire, seriously injuring all the occupants of the flat. 

BMA member 

Alcohol marketing is a significant expenditure for the alcohol industry. The levels of alcohol 

advertising and promotion have increased substantially in recent years and this has been 

accompanied by the development of increasingly sophisticated marketing techniques such as 

internet advertising. Alcohol advertising is not necessarily an inappropriate activity per se as it is 

normal for a business to promote its products competitively. Econometric studies have generally 

found alcohol advertising to have little or no effect on total alcohol consumption. 114 

There is, 

however, significant concern regarding the impact of sophisticated marketing techniques and their 

effect on some individuals and in particular on younger people. 

Research evidence suggests that repeated exposure to high-level alcohol promotion influences 

young people’s perceptions, encourages alcohol consumption and increases the likelihood of heavy 

drinking. 114 

A 2007 review of the impact of alcohol advertising on young people found there to be 

considerable evidence that alcohol advertisements are related to positive attitudes and beliefs 

about alcohol among young people, and that young people are particularly drawn to elements of 

music, characters, story and humour. 165 

The review also found there to be seven well-designed 

longitudinal studies showing that the volume of advertisements and media exposure increase the 

likelihood of young people starting to drink, the amount they drink, and the amount they drink on 

any one occasion. 165 

These studies examined various forms of exposure including television, radio 



and printed advertisements; in-store displays; billboards; movies; and branded merchandise. No 

published longitudinal studies were found where this effect was not apparent. 165 

Specific 

advertising strategies such as sponsorship of sporting and music events, as well as advertisements 

on television and radio, in films and in other media formats all serve to reinforce the image of 

alcohol among young people and predispose them to drinking well below the legal age to 

114, 166 

purchase alcohol. Alcohol advertising using celebrity endorsements or popular images that 

symbolise good times or masculinity have also been found to appeal to younger people. 114 

Studies in the UK have found that 88 per cent of 10 to 13-year-olds and 96 per cent of 14 to 

17-year-olds were aware of alcohol advertising, while 76 per cent could identify three or more 

167, 168 

adverts even when the brand was masked. Eighty-six per cent of 10 to 17-year-olds were 

167, 168 

found to enjoy alcohol advertisements. A survey conducted by Alcohol Concern between 

December 2006 and March 2007 found that thousands of children were exposed to commercials 

for alcoholic beverage during popular children’s programmes. 169 

The marketing of alcoholic energy 

drinks and alcoholic soft drinks (commonly termed alcopops) toward younger people is another 

area of concern as they may act as a potential gateway to more traditional drinks. 

In the UK, alcohol advertising standards are controlled by a combination of non-statutory 

regulation and co-regulation that does not adequately reflect the needs of children and young 

people. A voluntary code agreed by the self-regulatory Portman Group is responsible for 

controlling the packaging and naming of alcoholic drinks. Voluntary restrictions governing 

television and radio advertising are regulated by Ofcom, while poster and magazine advertising of 

alcohol-related products are regulated by the Advertising Standards Authority (ASA). Complaints to 

the ASA, Ofcom or the Independent Complaints Panel can be made if it is considered that 

alcoholic drinks are marketed to appeal in particular to individuals aged under 18; there are no 

legislative powers to undertake enforcement. Stricter rules q 

for the content of alcohol 

advertisements were introduced in 2005; 170 

however, these changes did not address restrictions on 

the volume of advertising. 

The 2007 review of the impact of alcohol advertising on young people found that of 24 European 

countries, only the UK and the Netherlands have no statutory regulation on alcohol advertising, 

and the UK was the only country surveyed not to have at least one ban on advertising (eg bans 

covering specific timings and locations of advertising). 165 

Voluntary codes of self-regulation are not 

always adhered to and are largely ineffective. 114 

There is no available scientific evidence that nonstatutory 

regulation impacts on the content or volume of advertisements. 165 

Self-regulation has also 

not been found to prevent the kind of marketing which can have an impact on younger people. 165 

In contrast, statutory regulations are more likely to include systematic checks on violations of codes 

and are more likely to cover volume restrictions (see Box 5). 165 

q The 2005 revised rules for alcohol advertising on television and in non-broadcast media covered four main areas: links between 

alcohol and sex, appeal to under-18s, irresponsible or anti-social behaviour, and handling and serving of alcoholic drinks in 

advertisements. 


56 


Box 5 – the ‘loi Evin’: statutory legislation on alcohol advertising in France 

In France, alcohol advertising is regulated by statutory legislation passed in 1991 known as the 

‘loi Evin’. This legislation applies to beverages above 1.2 per cent alcohol by volume, and 

completely prohibits advertising on television. Advertising for alcoholic beverages is only 

permitted in certain media and the content of advertisements is strictly regulated; adverts are 

not allowed, for example, to show individuals consuming a drink or include any references 

indicating that the alcoholic beverage will improve an individual’s image, sporting ability or 

sexual attraction. 

The legislation is accompanied by strict penalties for infringement and, since 1991, many 

171, 172 

advertisements infringing the law have been condemned by the French courts of justice. 

A change in the alcohol advertising has also been observed with alcohol advertising losing 

most of its seductive character, not using images of drinkers and drinking atmospheres, and 

171, 172 

increased emphasis on the individual product. The loi Evin has been regularly criticised 

and attacked by the alcohol industry, however, only small changes have been made to the law 

since 1991 including the possibility of referring to the objective characteristics of the products 

(eg colour, smell, taste) where advertising is permitted. 171 

It is essential that there is statutory regulation of the marketing of alcoholic beverages in the UK. This 

includes prohibiting the broadcasting of alcohol advertising at any time that is likely to be viewed by 

young people, with specific provisions banning alcohol advertising prior to 9pm and in cinemas for 

films with a certificate below age 18. Consideration also needs to be given to prohibiting alcohol 

industry sponsorship of sporting and music events aimed mainly at young people. 


Legislation should be introduced throughout the UK to: 

prohibit irresponsible promotional activities in licensed premises and by off-licences 

set minimum price levels for the sale of alcoholic beverages. 

A statutory code of practice on the marketing of alcoholic beverages should be introduced 

and rigorously enforced. This should include a ban on: 

broadcasting of alcohol advertising at any time that is likely to be viewed by young 

people, including specific provisions prohibiting advertising prior to 9pm and in cinemas 

before films with a certificate below age 18 

alcohol industry sponsorship of sporting, music and other entertainment events aimed 

mainly at young people 

marketing of alcoholic soft drinks to young people. 




Considerable reductions in the incidence of drink-drive road incidents and related deaths have 

occurred in the UK since 1980. This has most likely resulted from numerous factors including 

police enforcement of drink-drive legislation, the use of portable devices to measure samples of 

drivers’ breaths, tough penalties for drink-driving (prison terms, fines and mandatory 

disqualification), high level anti-drink-drive campaigns, and improvements in automobile design. 

As noted previously, however, the number of fatalities and serious injuries resulting from drinkdrive 

road crashes remains significantly high. 

In the UK, the BAC limit is 80mg/100ml which is among the highest in Europe (see Figure 17). 

Research has found that there is a marked deterioration in driving performance between a BAC of 

50mg/100ml and 80mg/100ml. The relative crash risk of drivers with a BAC of 50mg/100ml is double 

that for a person with a zero BAC, and the risk rises to 10 times for a BAC of 80mg/100ml. 114 

Drinking 

by drivers with a BAC between 50mg/100ml and 80mg/100ml is a significant but largely hidden cause 

of road traffic crashes, and has been estimated to account for 80 road deaths a year in England. 173 

Studies in Sweden, Australia and the USA have consistently found lowering legal blood alcohol limits 

116, 145, 153, 174-178 

to produce reductions in the incidence of drink-driving and related crashes. 

Newly qualified drivers are felt to be particularly at risk of alcohol-related road crashes as a result of 

their limited driving experience. As noted previously, the highest rates of drink-drive accidents per 

100,000 licence holders occur in the 17 to 19 age group, followed by those in the 20 to 24 age 

group. 97 

Evaluation of the introduction of lower BAC limits as part of new driver licensing systems 

have shown them to be effective in reducing collisions among young drivers and novice drivers. 179-182 

In the USA and Australia, the introduction of BAC limits between 10 and 20mg/100ml for young 

116, 145, 

drivers aged under 21 have been found to reduce levels of drink-driving and fatal road crashes. 

153, 183-185 

In Spain, it is illegal for all newly qualified drivers to drive with a BAC in excess of 

15mg/100ml for the two years after they have obtained their driving licence. 

Enforcement of drink-drive legislation is essential for compliance. In the UK, this is operated 

through selective breath testing and high-profile media campaigns. Selective breath testing 

requires police to have judged that a motorist has consumed alcohol before implementing the test. 

This deterrence-based policy is insufficient as many offenders may be able to avoid detection. 

Random breath testing permits police to stop motorists who are not suspected of committing an 

offence or of being involved in an incident. This is an advantageous approach as motorists are 

unable to influence the likelihood of being tested. With the exception of Denmark and the UK, 

random breath testing is permitted throughout the EU. 186 

Research in Australia has found that 

highly visible, random testing can have a sustained and significant effect in reducing levels of 

145, 153, 176 

drink-driving, alcohol-related road traffic crashes and associated injuries and fatalities. One 

study found random testing to be twice as effective as selective testing, with a reduction in fatal 

crashes of 35 per cent and 15 per cent respectively. 176 


BAC (mg/100ml) 

58 

100 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

Croatia 

Czech Republic 

Hungary 

Romania 

Slovakia 

Estonia 

Norway 

Zero BAC limit 


It is essential that further measures are implemented to build on progress achieved over recent 

years in reducing the levels of drink-driving and associated problems in the UK. This includes a 

reduction in the legal BAC limit from 80mg/100ml to 50mg/100ml, r 

and consideration for further 

reductions for all newly qualified drivers. It is also important that a consistent approach is adopted 

across the EU where cross-border travel is commonplace. This requires standardisation of the 

maximum legal BAC while driving among the EU member states. The use of highly visible, selective 

and non-selective breath testing programmes is a key component of effective enforcement of 

drink-drive legislation. 


The legal limit for the level of alcohol permitted while driving, attempting to drive, or being in 

charge of a vehicle should be reduced from 80mg/100ml to 50mg/100ml throughout the UK. 

Legislation permitting the use of random roadside testing without the need for prior suspicion 

of intoxication should be introduced throughout the UK. This requires appropriate resourcing 

and public awareness campaigns. 

Figure 17 – the maximum BAC legal limit for selected European countries s 

Poland 

Russia 

Sweden 

Spain 

Lithuania 

Austria 

Belgium 

Bulgaria 

Denmark 

Finland 


France 

Germany 

Country 

Greece 

Iceland 

Italy 

Lativa 

Netherlands 

Portugal 

Republic of Macedonia 

Serbia 

Slovenia 

Switzerland 

Turkey 

Luxembourg 

Malta 

Republic of Ireland 

United Kingdom 

Cyprus 

r A zero limit for the level of alcohol permitted while driving is not practical as there will be cases where an individual would 

register slightly above zero even when they had not been drinking; diabetes and the use of mouthwash can both cause an 

above-zero level. The BMA doubts whether an absolute zero would be enforceable and acceptable to the public but argues 

that a 50mg level, which would bring the UK in line with most other European countries, would be effective and beneficial. 

s The maximum BAC legal limit for Croatia, Czech Republic, Hungary, Romania and Slovakia is zero. The Department of Road 

Transport in Cyprus has announced plans to reduce the BAC legal limit in Cyprus to 50mg/100ml


“” 

I dread working over weekend nights and public holiday periods. It has become 

normal to deal with major trauma casualties. In our society the message has not 

been completely received to “NEVER EVER DRINK AND DRIVE”. 

BMA member 


Education and health promotion strategies are widely used at an individual and population level. 

Providing health advice and educating the general public on the dangers of alcohol misuse, however, 

requires a clear understanding of the culture and environments associated with alcohol misuse. 

Educational programmes 

The use of public information and educational programmes is a common theme for alcohol control 

policies in the UK and internationally. Such approaches are politically attractive but have been found to 

4, 57, 114, 116, 187 

be largely ineffective at reducing heavy drinking or alcohol-related problems in a population. 

Mass media campaigns and public service messages aimed at countering the extensive promotion of 

alcoholic beverages have only been found to raise awareness and not to encourage individuals to 

114, 118 

reduce their alcohol consumption or alter their drinking behaviour. There is some evidence, 

however, that they may be effective in building or sustaining support for public health-oriented 

alcohol policies. 188 

In the UK, education on the use of alcohol is provided as a statutory requirement through 

school-based programmes (see Appendix 4). Reviews of the efficacy of school-based alcohol 

education programmes have consistently concluded that they may be effective at increasing 

knowledge and modifying attitudes, but have limited effect on drinking behaviour in the long 

4, 114, 115, 189-198 

term. Research has further found that some educational programmes have even increased 

alcohol consumption among young people. 199 

Only a very small number of credible and well-designed 

196, 200 

educational programmes have been found to reduce young people’s drinking. There is some 

evidence that comprehensive school-based programmes in the USA involving individual-level 

education and family- or community-level interventions (eg reducing alcohol sales and provision of 

alcohol to young people) have been effective in reducing drinking among young people, but these 

reductions have been difficult to sustain. 114 

The effect of alcohol educational programmes on raising awareness, increasing knowledge and 

modifying attitudes provides justification for their use; however, given their ineffectiveness at 

changing drinking behaviour, it is essential that the disproportionate focus on, and funding of, such 

measures is redressed. Educational strategies are not effective as a key stand-alone alcohol control 

policy, but can be used to supplement other policies that are effective at altering drinking behaviour, 

and to promote public support for comprehensive alcohol control measures. 


60 


Understanding recommended drinking guidelines 

Much of the strategy to reduce alcohol-related harm in the UK focuses on recommended drinking 

guidelines. While the majority of people are aware of the existence of these guidelines, there is 

evidence that few can accurately recall them. 201-203 

A 2007 ONS survey of adults in the UK found that 

69 per cent had heard of the recommended drinking daily benchmarks; however, 36 per cent of 

these people did not know what they were. 204 

It is also apparent that many people are confused by 

these guidelines, and in particular, about what a unit means, and about the relationship between 

4, 54 

units and glass sizes and drink strengths. Eighty five per cent of those surveyed in 2007 had heard 

of measuring alcohol consumption in units, and in general, the more people drank, the more likely 

they were to have heard of units. 204 

Individuals aged under 65 were more likely to have heard of units 

compared to the older age group. 204 

Those in routine and manual occupations were less likely to have 

heard of measuring alcohol in units compared to those in the managerial and professional 

occupational grouping. 204 

In relation to particular drink types, approximately one third of frequent (at 

least once a week) beer drinkers (37%) and a quarter of frequent wine drinkers (23%) and frequent 

spirits drinkers (28%) were not aware of the number of units in what they were drinking. 204 

For each 

of these drink types, awareness of the number of units they were drinking was lower among 

individuals who drank them less frequently. 204 

Just under half (45%) of all individuals who consumed 

alcopops frequently were not aware of the number of units in what they were drinking. 204 

Labelling of alcoholic beverage containers would be a useful method for providing explanatory 

guidance on recommended drinking guidelines and for supporting other alcohol control policies. 

Research following the introduction of mandatory warning labels on alcoholic beverages in the USA 

in 1989 found that, while the warning labels did not have any measurable effect on drinking 

behaviours, they did increase knowledge regarding the risks of drink-driving and drinking during 

114, 205, 206 

pregnancy among particular groups. In the UK, the Drinkaware Trust provides information on 

responsible drinking and recent voluntary agreements with the alcohol industry have led to the 

inclusion of information on unit content on some alcoholic beverages. This is an encouraging 

development; however, it is vital that there is a mandatory requirement for all alcoholic beverage 

containers to be labelled to show the following information: 

the number of units they contain 

the number of units which should not be exceeded each day 

a warning message stating that consuming more than the recommended daily guidelines is 

likely to cause the individual or others significant harm. 

This information should also be readily available from retailers at the point of sale, and in all printed 

and electronic alcohol advertisements. 

It is worth noting that the recommended guidelines may only be one of the sources that inform 

individual decision-making with respect to alcohol consumption. Other influences include 

intrapersonal factors such as prior drinking experiences and the amount of alcohol individuals 

perceive they can consume before experiencing negative consequences; interpersonal reasons such as 

peer influence. Additionally, as noted earlier, individuals vary widely in their ability to absorb and 

eliminate alcohol and its effects depend on a number of factors including age, weight, type of drink, 

level of dehydration, previous exposure to alcohol, timing and intake of food, and gender of the 

drinker. 



Health promotion and advice from healthcare professionals 

Healthcare professionals are well placed to provide advice to their patients on recommended drinking 

guidelines and the problems associated with hazardous and harmful drinking. This is in addition to 

the advice provided to patients on other lifestyle choices such as smoking habits and nutrition. As 

part of routine clinical care, general practitioners (GPs) and healthcare professionals in the secondary 

care setting have a responsibility to provide information and advice on recommended drinking 

guidelines where clinically appropriate. It is essential that the advice provided by healthcare 

professionals is up to date and consistent, and supplemented with ‘take home’ printed information. 


There should be further qualitative research examining attitudes to alcohol misuse in the UK. 

Public and school-based alcohol educational programmes should only be used as part of a 

wider alcohol-related harm reduction strategy to support policies that have been shown to be 

effective at altering drinking behaviour, to raise awareness of the adverse effects of alcohol 

misuse, and to promote public support for comprehensive alcohol control measures. 

It should be a legal requirement to: 

a) prominently display a common standard label on all alcoholic products that clearly states: 

alcohol content in units 


a warning message advising that exceeding these guidelines may cause the individual and 

others harm. 

b) include in all printed and electronic alcohol advertisements information on: 




It should be a legal requirement for retailers to prominently display at all points where 

alcoholic products are for sale: 

information on recommended daily UK guidelines for alcohol consumption 




62 



Preventing alcohol-related harm requires the accurate identification of individuals who misuse 

alcohol, and the implementation of evidence-based interventions to reduce alcohol consumption. 

These measures are primarily aimed at the individual, but can impact at a community and population 

level through raising public awareness of alcohol problems, further involving healthcare professionals 

in prevention, and providing secondary benefits to others affected by an individual’s alcohol use 

disorder. In the UK, guidance on the management and prevention of alcohol misuse is set out in 

Models of care for alcohol misusers (DH, 2006) 207 

in England and in The management of harmful 

drinking and alcohol dependence in primary care (Scottish Intercollegiate Guidelines Network (SIGN), 

2003) 208 

in Scotland. Equivalent guidance is not available in Wales or Northern Ireland. t 

Screening and brief interventions for alcohol misuse 

Identification of alcohol misuse among people not seeking treatment for alcohol problems can be 

achieved via alcohol screening questionnaires, detection of biological markers or detection of 

clinical indicators. Several alcohol screening questionnaires have been developed to provide a rapid 

method of detecting alcohol misuse including the Alcohol Use Disorders Identification Test (AUDIT), 

the Michigan Alcoholism Screening Test (MAST), The CAGE questionnaire, the 5-Shot 

questionnaire, the T-ACE questionnaire, the TWEAK questionnaire, the Fast Alcohol Screening Test 

(FAST), and the Paddington Alcohol Test (PAT). 209-216 

A 2006 review of the alcohol screening 

questionnaires found that: 

the AUDIT is a screening instrument of good sensitivity and specificity for detecting 

hazardous and harmful drinking among people not seeking treatment for alcohol problems. 

It has been validated for use in a wide range of settings, populations and cultural groups 

and should be considered as the screening instrument of first choice in community settings 

the AUDIT is superior to the MAST and CAGE for the detection of hazardous and harmful 

drinking 

shortened versions of the AUDIT (eg AUDIT-C) can be used in very busy settings without 

undue loss of efficiency compared to the full AUDIT 

the FAST offers a rapid and efficient way of screening for hazardous and harmful alcohol 

consumption that can be used in a variety of settings, and in particular, as a rapid and 

efficient screening tool for detecting alcohol misuse in the A&E setting 

the PAT is a quick and efficient screening tool in the A&E setting 

the T-ACE and TWEAK are efficient screening instruments for detecting alcohol misuse 

among pregnant women. 217 

Biological markers (eg carbohydrate deficient transferrin) may also be used as part of a 

comprehensive assessment. They have been found to be less sensitive in the detection of alcohol 

misuse in community settings compared to screening questionnaires; however, they can be useful 

for confirming self-reports, for providing motivational feedback on health status and in the 

monitoring of progress following treatment. 217 

Clinical history and physical examination can be 

used to detect harmful drinking through indicators such as hypertension, dilated facial capillaries, 

bloodshot eyes and domestic problems. Research has found, however, that the majority of 

hazardous and harmful drinkers may be missed by reliance on clinical history and indicators. 217 

t The National Institute for Health and Clinical Excellence (NICE) is in the early stages of developing guidance on the 

prevention and early identification of alcohol use disorders in adults and adolescents for England and Wales. The expected 

date of issue for this guidance is 2010. 



The use of alcohol screening questionnaires in a variety of healthcare settings is an efficient and 

cost-effective method for detecting alcohol misuse. 217 

Biological markers are less efficient primary 

screening measures but can be used as adjuncts to questionnaires for the screening process. It is 

important to note, however, that screening for alcohol use disorders is complicated by a number of 

factors including: 

under or overestimation of alcohol consumption levels in response to screening 

questionnaires, either deliberately or as a result of poor recall 

embarrassment on the part of healthcare staff who view monitoring as intrusive 

inaccurately recorded patient histories of alcohol use 

poor use of screening techniques and follow-up procedures by healthcare professionals. 

Brief interventions are intended to provide prophylactic treatment before or soon after the onset 

and identification of alcohol-related problems. Research has found that brief interventions produce 

clinically significant effects on drinking behaviour and related problems in non-alcohol dependent 

57, 114, 217-221 

individuals who consume alcohol at harmful and hazardous levels. There is however, little 

evidence that brief interventions are beneficial for alcohol dependent individuals or those with 

114, 222 

severe alcohol problems. Brief interventions are cost-effective measures that commonly consist 

of a number of stages including assessment, feedback and goal setting. They are delivered using 

behavioural modification techniques and reinforced with the provision of written material. Simple 

brief interventions involve a specific short interview conducted by a competent practitioner 

immediately following a screening assessment. Extended brief interventions incorporate a series of 

these structured interviews (between three and 12) delivered by a competent practitioner. They can 

be delivered in a variety of settings, including medical settings – such as primary care and accident 

and emergency – and in generic non-specialist services. The provision of brief interventions have 

been found to be effective at reducing alcohol consumption in non-dependent individuals in both 

218, 219 

the primary care setting, and in emergency departments. 223 

The type of advice that should be 

offered during a brief intervention includes: 

information about the nature and effects of alcohol and its potential for harm 

personalised feedback on risk and harm 

emphasis on the individual’s personal responsibility for change 

attempts to increase the patient’s confidence in being able to reduce their alcohol 

consumption (‘self-efficacy’) 

goal-setting (for example, start dates and daily or weekly targets for drinking) 

written self-help material for the individual to take away, containing more detailed 

information on consequences of excessive drinking and tips for cutting down (this can be in 

a variety of media, including electronic, such as the internet) 

signposting individuals to having a wider general health check, where indicated 

arrangements for follow-up monitoring 

information on where to get further help if necessary. 


64 


At present there is no system for routine screening and management of alcohol misuse in primary u 

or secondary care settings in the UK. Screening and management occur opportunistically and 

where clinically appropriate in both settings. This is often limited, however, due to various barriers 

including time constraints, poor availability of support services, inadequate training and guidance, 

the requirement to respond to multiple problems during patient consultations, and organisational 

221, 224-229 

barriers (eg the separation of mental health from acute trusts). Accordingly, a number of 

studies have found that the detection and management of alcohol misuse in primary and 

secondary care to be inadequate. The UK General Practice Research Database (GPRD) study found 

extremely low levels of formal identification, treatment and referral of alcohol misuse by GPs, and 

that the level of under-identification was higher in younger patients compared with older 

patients. 13 

A 2007 survey of all A&E departments in England found that only 2.1 per cent used 

formal alcohol screening tools, 12.7 per cent asked questions about consumption, 73.9 per cent 

offered advice on alcohol problems, and 44.4 per cent offered treatment for alcohol problems. 230 

A report from the Royal College of Physicians in 2001 found that many acute general hospital 

admissions are not assessed for alcohol misuse, and that there was uncertainty about what action 

to take with individuals identified as dependent drinkers. 221 

Primary care, general hospital and A&E settings provide useful opportunities for screening for 

alcohol misuse and the delivery of brief interventions. It is essential that systems are developed in 

order to encourage this activity on a regular basis. Effective operation of such systems requires 

adequate funding and resources, and comprehensive training and guidance on the use of 

validated screening questionnaires as well as the provision of brief interventions. Routine screening 

in primary care could be facilitated by the implementation of a directed enhanced service (DES). 

As these services are commissioned nationally, they have the advantage of ensuring equal service 

provision by all PCOs. Introducing a DES also makes it clear that this area of work is a national 

priority. Pilot schemes have been developed in the UK for the detection and management of 

alcohol misuse in the A&E setting and in the general hospital setting (see Box 6). 

u In the UK, GPs are not required to provide alcohol services under the essential services component of the General Medical 

Services (GMS) contract. The GMS contract does include an optional alcohol National Enhanced Service (NES) section that 

aims to create a framework that can be commissioned by primary care organisations (PCOs) for enhanced alcohol services 

including screening and more specialist interventions. Alcohol is not currently a clinical area included within the Quality and 

Outcomes Framework (QOF) of the GMS contract. The QOF is a voluntary incentive programme for all GP surgeries in the 

UK. The QOF is subject to periodic review of the evidence base for current indicators. During review any individual or 

organisation is able to submit evidence about a current or future area they feel should be included in the framework. These 

submissions are evaluated by an expert panel of senior academics and the submitting organisations or individuals are offered 

the opportunity to discuss their submissions further if they meet appropriate criteria. The evidence is then submitted to the 

QOF negotiating group for consideration. 



Box 6 – good practice in the detection and management of alcohol misuse 

In St Mary’s Hospital, London, all patients presenting to A&E with one of the targeted 

conditions (falls, collapse, head injury, assault, gastrointestinal problems, ‘unwell’, psychiatric 

problems, cardiac symptoms and accidents) are screened for alcohol misuse using the PAT. 

Individuals who score a positive result (indicating hazardous or harmful drinking) are offered 

the opportunity to have a session with the A&E’s alcohol health worker within 24 to 48 hours. 

This worker is a trained nurse who carries out a more in-depth assessment concerning the 

individual’s lifestyle and alcohol use. The worker then delivers a brief intervention of education 

and counselling concerning the patient’s use of alcohol. A review of this model found the 

introduction of this opportunistic screening and management resulted in lower levels of 

alcohol consumption over the following six months and reduced re-attendance rates at the 

A&E department. 231 

At the Royal Liverpool Hospital, an alcohol specialist nurse is employed to respond to alcoholrelated 

referrals from A&E, clinics and ward areas throughout the hospital. The main aims of 

the model are to: 

optimise medical management of alcohol-related attendance and admissions 

develop staff attitudes and knowledge about alcohol misuse 

provide patients with timely appropriate and effective clinical pathways of care 

reduce overall alcohol-related hospital admission and attendance 

reduce length of stay for alcohol-related admissions. 

An assessment of interventions by the specialist nurse found that they reduced mean daily 

alcohol consumption, reduced re-attendances, and improved staff attitudes and knowledge. 221 

Specialist alcohol treatment services 

For individuals with more severe alcohol problems and levels of dependence, specialised alcohol 

treatment services have been found to be effective and provide better outcomes for individuals 

who are alcohol dependent compared to untreated individuals, including significant reductions in 

114, 217, 232 

alcohol use and related problems. Specialised treatment services consist of both therapeutic 

approaches (eg relapse prevention) and management components (eg detoxification facilities, 

inpatient residential programmes and outpatient clinics) that can be provided within the healthcare 

system or by private providers. Evidence suggests that the most effective specific treatment 

modality is through cognitive behavioural treatments (eg behavioural self-control training), while 

pharmacotherapies (eg disulfiram) can be considered as adjuncts to cognitive behavioural 

114, 217 

treatments. 

There has been very little research into the cost-effectiveness of alcohol treatment services; 

however, cost offset studies primarily conducted in the USA have found that alcohol dependent 

individuals and their families use healthcare services more than non-alcohol dependent individuals 

of the same age and gender, and their demand for healthcare services declines following 

114, 233 

treatment. 

Not all individuals with severe alcohol problems will recognise or agree that they have an alcohol 

misuse problem, or that they require treatment. It is essential, that individuals identified as having 

severe alcohol problems or as being alcohol dependent are offered referral to specialised alcohol 


66 


treatment services. The inadequate provision of specialised alcohol treatment services in the UK is a 

significant area of concern. The 2004 ANARP found that: 

many of the patients with alcohol use disorders identified by GPs and who were felt to need 

specialist treatment, were not referred because of perceived difficulties in access (with 

waiting lists for specialist treatment being the main reason given), and patient preference 

not to engage in specialist treatment 

there was a high level of satisfaction with specialist services once access was achieved 

86 per cent of drug action team professionals indicated that their alcohol treatment budgets 

were much lower than drug budgets, and that there was a ‘very large gap’ between the 

provision of alcohol treatment and need or demand 

considerable regional variation in the number of agencies exists across England, with 

London having the largest number of agencies and the North East the fewest 

the largest proportion of referrals to alcohol agencies were self referrals (36%) followed by 

GP/primary care referrals (24%) 

the estimated annual spend on specialist alcohol treatment to be £217 million, and the 

number of whole time equivalent personnel working in specialist alcohol agencies across 

England to be approximately 4,250 

the average waiting time for assessment to be 4.6 weeks (ranging from 3.3 weeks to 

6.5 weeks) 

only 5.6 per cent (one in 18) of the alcohol dependent population were accessing 

specialised alcohol services per annum. 13 

While not all individuals who are alcohol dependent will need continuous structured treatment, 

and many may not be willing to accept treatment places, the proportion in treatment is 

disproportionately low. Similar assessments of alcohol treatment services have not been 

conducted in Wales, Scotland and Northern Ireland; however, it is generally accepted that the 

provision of specialised treatment services is deficient in most countries globally. 234 

The lack of 

necessary funding and unequal provision of specialised alcohol services is a significant concern. 

Only £15 million has been allocated to primary care trusts (PCTs) in England for alcohol 

interventions in 2007/08, 235 

and the average amount spent on alcohol treatment by a PCT in 2006 

was £273,495. 236 

The SEHD allocated £13 million over 2005/06 and 2006/07 to support local 

alcohol treatment, support and prevention activities. 237 

The absence of a ring-fenced funding 

stream for specialist services means that any funding allocated for these services may be 

withdrawn and allocated to other priorities by healthcare service commissioning bodies. It is 

essential that specialised alcohol treatment services are provided consistantly throughout the UK, 

are adequately resourced and funded, and that this funding is ring-fenced. High-level commitment 

is also required to ensure that the alcohol treatment services frameworks are prioritised when 

commissioning services. v 

The need for and provision of alcohol treatment services must also be 

continually reviewed and assessed, building on the 2004 ANARP in England, and ensuring similar 

assessments are undertaken in Scotland, Wales and Northern Ireland. 

v The alcohol treatment services framework for England is set out in Models of care for alcohol misusers (DH, 2006); for 

Scotland in Alcohol problems support and treatment services framework (Scottish Executive, 2002); for Wales in Substance 

misuse treatment framework for Wales (Welsh Assembly Government, 2003); and for Northern Ireland in New strategic 

direction for alcohol and drugs 2006–2011 (DHSSPS, 2006). 



“” 


As a GP I usually refer to the Drugs and Alcohol team, but due to the lack of 

services/resources there are long waiting times before patients are seen by the team, 

and then another wait before they get detoxification (which for my patients is only 

available outside of our local area). So even though we spend time advising 

patients and refer them for treatment, without immediate help patients tend not to 

keep appointments and continue to drink. 

BMA member 

The detection and management of alcohol misuse should be an adequately funded and 

resourced component of primary and secondary care in the UK to include: 

formal screening for alcohol misuse 

referral for brief interventions and specialist alcohol treatment services as appropriate 

follow-up care and assessment at regular intervals. 

A system for the detection and management of alcohol misuse in primary care should occur 

via the implementation of a direct enhanced service by the UK health departments. This 

must be adequately funded and resourced. 

Systems for the detection and management of alcohol misuse should be developed for A&E 

care and the general hospital setting throughout the UK. These must be adequately funded 

and resourced. 

Comprehensive training and guidance should be provided to all relevant healthcare 

professionals on the identification and management of alcohol misuse. 

Funding for specialist alcohol treatment services should be significantly increased and ringfenced 

to ensure all individuals who are identified as having severe alcohol problems or who 

are alcohol dependent are offered referral to specialised alcohol treatment services at the 

earliest possible stage. 

There should be continual assessment of the need for and provision of alcohol treatment 

services in the UK, building on the 2004 Alcohol Needs Assessment Research Project in 

England, and ensuring similar assessment is undertaken throughout the UK. 


68 



It is evident that different countries have adopted markedly varied policies for reducing the burden 

112, 234, 238-240 

of alcohol misuse. This reflects the differences in alcohol consumption and related harm 

between countries, as well as the diverse political climates and objectives. International 

cooperation on alcohol control is essential for several reasons including: the significant global 

burden of alcohol; the commonality of problems faced by different countries (eg underage 

drinking, alcohol-related road deaths); trans-border factors such as global advertising and 

production, formal and informal trading, and smuggling; and the difficulty countries have in 

dealing with alcohol problems in isolation. 

Reducing alcohol-related harm across the EU has been facilitated by the adoption in 2006 of an 

EU Alcohol Strategy with five priority themes: 

to protect young people, children and the unborn child 

to reduce injuries and death from alcohol-related road deaths 

to prevent alcohol-related harm among adults and to reduce the impact on the workplace 

to inform, educate and raise awareness on the impact of hazardous consumption 

to develop and maintain a common evidence base at EU level. 241 

In 2007, an EU Alcohol and Health Forum was set up to assist implementation of the strategy and 

to provide a common platform for relevant stakeholders who pledge to increase their actions to 

reduce alcohol-related harm. Other initiatives include the adoption of the EU Road Safety Action 

Programme 2003/08, the EU Community Public Health Programme 2003/08, and Audiovisual 

Media Services Directive (previously known as the Television Without Frontiers Directive). 241 

In 1995, 

the WHO European Charter on Alcohol – which was endorsed by all Member States of the EU – 

set out 10 key areas of health promotion that need to be addressed in reducing the burden of 

alcohol in Europe (see Appendix 5). 242 

This has since been re-enforced by the 2000 WHO European 

Alcohol Action Plan, 243 

the 2001 WHO declaration aimed at reducing alcohol misuse among young 

people, 244 

and the 2005 WHO Framework for Alcohol Policy in the European Region. 245 

While the introduction of agreements such as the WHO European Alcohol Action Plan and the 

EU Alcohol Strategy provide a useful platform for action, their effectiveness has been questioned 

because of the influence of the alcohol industry on their development. 246-248 

These questions focus 

on the omission of key policies from the 2006 strategy such as those that affect price and 

246, 247 

availability. This represents a significant shortcoming in the promotion of public health by 

EU member states. It is vital that the UK Government strongly supports EU initiatives and policies 

aimed at reducing alcohol-related harm to individual and public health. Strong support for 

WHO and World Health Assembly (WHA) initiatives on alcohol is also necessary. 

A further drawback of EU-level action and agreements is the fact that they are non-binding. 240 

Existing international agreements and treaties on trade also serve to weaken the ability of national 

and sub-national governments to restrict the alcohol market. 240 

It is therefore important that a 

legally binding international treaty on alcohol is developed and implemented to reduce the global 

burden of alcohol. There is no pre-existing international framework or convention under which 

alcohol could easily be incorporated. w 

An alternative approach would be to introduce a legally 

binding treaty similar to the WHO Framework Convention on Tobacco Control (FCTC) that came 

w The 1971 Narcotics Convention may provide a feasible international convention under which alcohol could be incorporated; 

however, resistance from the alcohol industry and from the general public is likely to make this unrealistic. 



into force in 2005 (see Appendix 6). To be effective in reducing the burden of alcohol misuse, any 

international treaty should set out legally binding provisions including regulating the availability of 

alcohol through licensing; increased taxation on alcoholic beverages; enacting comprehensive 

restrictions on alcohol advertising, promotion and sponsorship; educating the public of the harms 

associated with alcohol misuse; establishing and enforcing laws to discourage drink-driving; 

providing accessible and effective treatment services; enforcing the legal responsibility of retailers 

to sell alcoholic beverages in accordance with legislation; promoting research and the exchange of 

information among countries; establishing a priority for public health considerations in the 

regulation of international alcohol commerce; and international cooperation to combat illegal 

production and trade in alcohol. 

The introduction of a Framework Convention on Alcohol Control (FCAC) would serve to support 

governments in developing and implementing effective alcohol control policies, foster 

collaboration between countries, counter the international trade agreements that currently restrict 

governments from introducing stricter alcohol control policies, and effectively engage nongovernmental 

organisations. 


There should be strong support for European Union, World Health Organisation and World 

Health Assembly initiatives and policies aimed at reducing alcohol-related harm to individual 

and public health. 

Lobby for, and support the World Health Organisation in developing and implementing a 

legally binding international treaty on alcohol control in the form of a Framework 

Convention on Alcohol Control. This should include provisions for: 

regulation of the availability of alcohol through licensing 

increased taxation on alcoholic beverages 

statutory regulation of alcohol advertising, promotion and sponsorship 

programmes aimed at educating the public of the harms associated with alcohol misuse 

legislation to discourage drink-driving 

appropriately funded and resourced treatment services 

enforcement of the legal responsibility of retailers to sell alcoholic beverages in 

accordance with legislation 

promoting research and the exchange of information among countries 

establishing a priority for public health considerations in the regulation of international 

alcohol commerce 

international cooperation to combat illegal production and trade in alcohol. 


70 




Appendix 1 

Summary of previous BMA publications on alcohol 

Fetal alcohol spectrum disorders – a guide for healthcare professionals (BMA, 2007) 

FASD are a series of completely preventable mental and physical birth defects resulting from maternal 

alcohol consumption during pregnancy. FASD are lifelong conditions that can significantly impact on the 

life of the individual and those around them as illustrated by the case studies included within this report. 

This report focuses on the adverse health impacts of alcohol consumption during pregnancy, and in 

particular the problem of FASD. The report aims to raise awareness of FASD by examining the incidence, 

cause and outcomes of the range of disorders associated with alcohol consumption during pregnancy. 

It further outlines the responsibilities of healthcare professionals and the wider medical community in 

managing and reducing the incidence of these disorders. This report is intended for healthcare 

professionals and relevant bodies with strategic or operational responsibility for public health and 

health promotion. 

Binge drinking (2005) 

This web resource acts as a hub for information on the medical, personal and social effects of binge 

drinking. It considers the definition of binge drinking, summarises the recommended drinking guidelines 

and provides sources of further information. 

Adolescent health (2003) 

This report focuses on the problems facing adolescents and examines the evidence surrounding 

adolescent health, behaviour and interventions. It reviews four important areas in adolescent health: 

nutrition, exercise and obesity; smoking, drinking and drug use; mental health; and sexual health. 

For each area this report discusses the prevalence of the problems involved, examines which adolescents 

are affected, describes the interventions used to address the issues and evaluates the effectiveness of 

these strategies. This report is intended to raise the profile of adolescent health and to help inform 

future policy. In addition, this report acts as an information resource for healthcare professionals, 

providing an overview of adolescent health issues and the policy environment. 

Alcohol and young people (1999) 

This report examines the problem of alcohol consumption among young people. It specifically examines 

designer drinks, marketing, monitoring of the drinks industry, and education and enforcement. 

Recommendations from this report include increased regulation of the drinks industry, tougher 

advertising controls, the need for a review of the licensing laws and health education. 

Alcohol: guidelines on sensible drinking (1995) 

This report examines the existing evidence on recommended daily limits and calls for a comprehensive 

sensible drinking message to provide the public with guidelines on limits, along with concise statements 

about the evidence of benefits. It also recommends increasing the cost of drinking in light of evidence 

that education and health promotion have low efficacy in reducing the mean level of drinking. 

The BMA guide to alcohol and accidents (1989) 

This report provides information on alcohol as a cause of accidents. It also provides practical advice on 

ascertaining alcohol consumption by individuals attending casualty departments, diagnosing long-term 

alcohol abuse and managing the ‘at-risk’ drinker. 

The drinking driver (1988) 

This report examines the scientific and epidemiological evidence relating to drink-driving. It proposes a 

range of countermeasures aimed at persistent offenders who are likely to have an underlying drink 

problem and at social drinkers who offend. 


72 


Appendix 2 

UK alcohol control policies 

In the UK, separate strategies to reduce the burden of alcohol misuse have been developed in 

England, Wales, Scotland and Northern Ireland. These strategies are contained within various policy 

documents which have the common theme of encouraging the safe use of alcohol and reducing 

alcohol misuse through national, local and community-based partnership approaches. 

England and Wales 

In England, the 2004 Alcohol harm reduction strategy for England (PMSU, 2004) identified 41 action 

areas grouped in four categories: better education and communication; better health and treatment 

systems; combating alcohol crime and disorder; and working with the alcohol industry. 8 

Responsibility 

for implementation of the strategy was shared between the Home Office and the DH, and the key 

areas of the strategy were re-enforced in Choosing health: making healthier choices easier (DH, 

2004). 249 

The 2004 Alcohol harm reduction strategy for England was superseded in 2007 by Safe. 

Sensible. Social. The next steps in the National Alcohol Strategy (HM Government, 2007) which was 

jointly authored by the DH, the Home Office, the Department for Education and Skills, and the 

Department for Culture, Media and Sport (DCMS). Safe. Sensible. Social. The next steps in the 

National Alcohol Strategy (HM Government, 2007) set out eight key action areas: 

sharpened criminal justice for drunken behaviour 

a review of NHS alcohol spending 

more help for people who want to drink less 

toughened enforcement of underage sales 

trusted guidance for parents and young people 

public information campaigns to promote a new ‘sensible drinking’ culture 

public consultation on alcohol pricing and promotion 

local alcohol strategies. 54 

In Wales, the 1996 strategy document Forward together: a strategy to combat drug and alcohol 

misuse in Wales (Welsh Office, 1996) set out proposals to increase prevention activity with a view to 

reducing the acceptability of taking drugs, and excessive or inappropriate drinking. 250 

This strategy 

also focused on the national and local delivery of treatment, support and rehabilitation services. This 

strategy was superseded by Tackling substance misuse in Wales. A partnership approach (National 

Assembly for Wales, 2000) which set out four key aims: 

to help children, young people and adults resist substance misuse in order to achieve their 

full potential in society, and to promote sensible drinking in the context of a healthy lifestyle 

to protect families and communities from anti-social and criminal behaviour and health risks 

related to substance misuse 

to enable people with substance misuse problems to overcome them and live healthy and 

fulfilling lives and in the case of offenders, crime-free lives 

to stifle the availability of illegal drugs on our streets and inappropriate availability of other 

substances. 251 

While England and Wales have separate alcohol control strategies, the licensing systems in both 

regions are regulated by the Licensing Act 2003 which came into effect in November 2005. The 2003 

Act replaced the previous fragmented system with a single piece of legislation regulating all licensed 

activities involving alcohol – including off-licenses and supermarkets, entertainment and late-night 

refreshment – and incorporates a number of key measures including: 

flexible opening hours for premises, with the potential for up to 24-hour opening, seven 

days a week 

a single premises licence which can permit premises to be used to supply alcohol, to provide 

regulated entertainment and to provide refreshment late at night 



a new system of personal licences relating to the supply of alcohol which will enable holders 

to move more freely between premises where a premises licence is in force 

premises licences to be issued by licensing authorities after notification to and scrutiny of all 

applications by the police, other responsible authorities, and those living, and businesses 

operating, in the vicinity of the premises 

tougher enforcement policies including increased fines and penalties for breach of 

conditions of licence, suspension of licence, and test purchases 

personal licences to be issued by licensing authorities after scrutiny by the police where the 

applicant has been convicted of certain offences. 252 

Scotland 

In Scotland, the strategy for reducing the harm associated with alcohol use and misuse was first set 

out by the Scottish Executive Health Department (SEHD) in Plan for action on alcohol problems 

(SEHD, 2002). 253 

This aimed to reduce alcohol-related harm in Scotland by tackling the harmful effects 

of alcohol misuse with a particular focus on reducing excessive and harmful drinking by children and 

young people. In February 2007, the SEHD published Plan for action on alcohol problems: update 

which provides an update on the original 2002 strategy. 237 

This had a wider focus than just health 

concerns and outlined aims to change the culture of excessive drinking in Scotland through a 

number of key actions: 

extending the alcohol test purchasing pilot to all of Scotland in 2007 

using the Executive commissioned evaluation of effectiveness of drugs education in Scottish 

schools to develop an alcohol education programme as part of a wider, robust substance 

misuse education programme for schools 

giving Licensing Boards more power to control the spread of licensed premises, and tackling 

excessive drinking, through the implementation of the Licensing (Scotland) Act 2005 

piloting, during 2007/08, a telephone-based brief interventions service, aimed at identifying 

harmful and hazardous drinkers at an early stage and providing appropriate support 

completing, by mid 2007, a set of national publications about the short- and long-term 

effects of drinking alcohol 

supporting further development of Youth Community Alcohol Free Environments and 

working with partners to provide other diversionary activities for young people, for the 

duration of this Plan 

undertaking, by May 2007, a stocktake of Alcohol and Drug Action Teams to assess 

performance to date and capability to deliver Ministerial priorities on drugs and alcohol. This 

should establish a firm evidence base to determine the future mechanism for effective local 

action to deliver national priorities 

researching how best to improve recording and reporting information on drug and alcohol 

use during pregnancy – report anticipated in July 2007 

extending successful measures from the Alcohol Education Research Council (AERC) funded 

culture change pilot to all areas of Scotland, by December 2007 

developing a quality standards framework for drug and alcohol services 

developing a national drugs and alcohol workforce development strategy by summer 2008 

and plans for its implementation by spring 2009. 237 


74 


Licensing in Scotland is regulated by the Licensing (Scotland) Act 1976. As a result of regular extensions 

to licensing hours since 1976, Scotland has seen considerable liberalisation of opening hours to the 

extent that it is theoretically possible to purchase alcohol continuously for 24 hours. Licensing law in 

Scotland will be radically changed following the implementation of the Licensing (Scotland) Act 2005, 

which is due to come into force in August 2009 following a transition period starting in February 2008. 

The Licensing (Scotland) Act 2005 incorporates a range of new measures including: 

the introduction of two new licences (personal and premises) to replace the old system of 

seven licences and statutory opening hours 

a ‘premises by premises’ approach to opening hours authorised by local Licensing Boards 

coupled with a statutory presumption against 24-hour opening (which will only be allowed in 

exceptional circumstances) 

mandatory training of staff as a condition of licence 

the requirement for all licensees to operate on a no-proof no-sale basis and the overhaul of 

under-age drinking offences 

prohibition of irresponsible promotional activities that encourage speed and binge drinking 

including two-for-one offers and happy hours 

the introduction of tougher enforcement with a wider range of sanctions and new Licensing 

Standards Officers. 254 

Northern Ireland 

The Department of Health, Social Services and Public Safety (DHSSPS) sets out the alcohol control 

policies for Northern Ireland in Strategy for reducing alcohol related harm (DHSSPS, 2000). 255 

This strategy set out five key action areas: 

to encourage the responsible use of alcohol through health promotion and education 

programmes, which will have particular emphasis for those groups identified as being 

most at risk 

to promote and improve treatment and support services, ensuring that they are effective, 

adequate to the real level of need in the community, and fairly available 

to protect individuals, families and communities from the anti-social and often criminal 

consequences of alcohol misuse 

to develop a research and information programme that provides detailed and up-to-date 

knowledge of local drinking patterns and behaviours 

to implement and manage the strategy effectively through a regular and systematic review 

process involving local implementation groups. 255 

Licensing in Northern Ireland is regulated by the Licensing (Northern Ireland) Order 1996. The Order 

includes restricted opening hours although it is possible for a court to grant additional opening hours to 

public houses, hotels, restaurants, conference centres and higher education establishments under 

certain conditions. In October 2005, the Department for Social Development (DSD) published draft 

proposals for reform of the licensing laws in Northern Ireland. 256 

The provisional implementation date for 

these proposals is 2009 and they incorporate a number of measures including: 

a move from a court-based system to a licensing authority under the aegis of district councils 

a modest extension of current opening hours, creating scope for opening to 2am Monday to 

Saturday and midnight on Sunday, with some extra flexibility for special, major events 

the introduction of a range of measures for the protection of children (eg new test purchasing 

powers and a voluntary proof of age scheme) 

the introduction of new and more effective enforcement measures to enforce licensing laws 

(eg immediate temporary closure powers for the police, a penalty points system for breaches 

of the legislation and the creation of new liquor licensing officers); and replacement of the 

current licences categories with a dual system of personal and premises licences. 256 



Appendix 3 

Excise duty rates in the European Union 

Country Excise duty (pence) per unit of alcohol VAT (%) 

Beer Wine Spirits 

Austria 3.27 0 6.79 20.0 

Belgium 2.78 2.91 11.93 21.0 

Bulgaria 1.27 0 3.82 20.0 

Cyprus 3.27 0 4.11 15.0 

Czech Rep 1.41 0 6.43 19.0 

Denmark 4.65 5.09 13.68 25.0 

Estonia 2.54 4.11 6.61 18.0 

Finland 13.24 13.10 19.21 22.0 

France 1.76 0.21 9.86 19.6 

Germany 1.30 0 8.86 19.0 

Greece 1.83 0 7.43 19.0 

Hungary 3.52 0 6.43 20.0 

Ireland 13.52 16.88 26.68 21.0 

Italy 3.84 0 5.42 20.0 

Latvia 1.23 2.62 6.03 18.0 

Lithuania 1.37 2.69 6.29 18.0 

Luxembourg 1.30 0 7.07 15.0 * 

Malta 1.23 0 15.86 18.0 

Netherlands 3.42 3.65 10.21 19.0 

Poland 2.89 2.17 7.96 22.0 

Portugal 2.25 0 6.36 21.0 * 

Romania 1.27 0 5.36 19.0 

Slovakia 2.43 0 5.71 19.0 

Slovenia 4.68 0 4.71 20.0 

Spain 1.34 0 5.64 16.0 

Sweden 10.77 14.68 36.68 25.0 

UK 13.73 16.2 19.57 17.5 

* VAT rates lower for wine (12%) 

These data were calculated using excise duty rates from the Statistical handbook 2007 (British Beer 

and Pub Association, 2007). The price per unit of alcohol was calculated based on: 

Beer pence per pint at 5 per cent ABV 

Wine pence per 75cl bottle at 11 per cent ABV 

Spirits £ per 70cl bottle at 40 per cent ABV 

Number of units = Amount of drink (ml) x ABV (%) 

1000 


76 


Appendix 4 

School-based alcohol education in the UK 

In England and Wales, alcohol education is a statutory requirement of the National Curriculum 

Science Order 1991, and schools are expected to use the non-statutory framework for personal, 

social and health education (PSHE) as the basis for extending their provision in this area. Alcohol 

education also features as one of the 10 themes of the National Healthy School Standard (NHSS). 

In Scotland, alcohol education is included in the ages five to 14 Health Education National 

Guidelines and NHS Health Scotland distributes teaching resources to schools, Drink talking and 

Alcohol: what every parent should know, that contain information on the effects of alcohol on the 

body and the health of unborn children. The current statutory curricular arrangements in Northern 

Ireland include a cross-curricular health education programme for young people aged between 

four and 16 years. Specifically, alcohol education is included within the Programmes of Study for 

Science and Technology (Key Stages 2-4). 



Appendix 5 

World Health Organisation European Charter on Alcohol 

The 1995 WHO European Charter on Alcohol sets out 10 key strategy areas for implementation by 

each Member State: 

1. Inform people of the consequences of alcohol consumption on health, family and society 

and of the effective measures that can be taken to prevent or minimise harm, building 

broad educational programmes beginning in early childhood. 

2. Promote public, private and working environments protected from accidents and violence 

and other negative consequences of alcohol consumption. 

3. Establish and enforce laws that effectively discourage drink-driving. 

4. Promote health by controlling the availability, for example for young people, and 

influencing the price of alcoholic beverages, for instance by taxation. 

5. Implement strict controls, recognising existing limitations or bans in some countries, on 

direct and indirect advertising of alcoholic beverages and ensure that no form of 

advertising is specifically addressed to young people, for instance, through the linking of 

alcohol to sports. 

6. Ensure the accessibility of effective treatment and rehabilitation services, with trained 

personnel, for people with hazardous or harmful alcohol consumption and members of 

their families. 

7. Foster awareness of ethical and legal responsibility among those involved in the marketing 

or serving of alcoholic beverages, ensure strict control of product safety and implement 

appropriate measures against illicit production and sale. 

8. Enhance the capacity of society to deal with alcohol through the training of professionals 

in different sectors, such as health, social welfare, education and the judiciary, along with 

the strengthening of community development and leadership. 

9. Support nongovernmental organisations and self-help movements that promote healthy 

lifestyles, specifically those aiming to prevent or reduce alcohol-related harm. 

10. Formulate broad-based programmes in Member States, taking account of the present 

European Charter on Alcohol; specify clear targets for and indicators of outcome; monitor 

progress; and ensure periodic updating of programmes based on evaluation. 

Source: European Charter on Alcohol (WHO, 1995). 


78 


Appendix 6 

Framework Convention on Tobacco Control 

The Framework Convention on Tobacco Control (FCTC) was adopted by the WHO in 2003 and 

came into force on 27 February 2005. 257 

The FCTC is a legally binding treaty which was negotiated 

by the 192 Member States of the WHO. It commits governments to reducing the burden of 

tobacco-related morbidity and mortality. The treaty incorporates a range of measures designed to 

reduce the devastating health and economic impacts of tobacco and provides the basic tools for 

countries to enact comprehensive tobacco control legislation. The key provisions set out by the 

treaty are aimed at encouraging countries to: 

enact comprehensive bans on tobacco advertising, promotion and sponsorship 

obligate the placement of rotating health warnings on tobacco packaging that cover at 

least 30 per cent (but ideally 50% or more) of the principal display areas and can include 

pictures or pictograms 

ban the use of misleading and deceptive terms such as ‘light’ and ‘mild’ 

protect citizens from exposure to tobacco smoke in workplaces, public transport and 

indoor public places 

combat smuggling, including the placing of final destination markings on packs 

increase tobacco taxes. 257 

The FCTC encompasses additional measures such as mandating the disclosure of ingredients in 

tobacco products, providing smoking cessation services, encouraging legal action against the 

tobacco industry, and promoting research and the exchange of information among countries. The 

treaty is an important first step to effective international tobacco control as it coordinates 

international, national and regional efforts; facilitates the sharing of research and expertise; 

prioritises tobacco control within governments; and raises public awareness. 



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92 



Adolescent health 

British Medical Association 

Board of Science and Education 

www.bma.org.uk



Adolescent health 

December 2003

ii 

Editorial board 

A resource from the BMA science and education department and the Board of Science and Education 

Chairman, Board of Science and Education Professor Sir David Carter 

Director of professional activities Dr Vivienne Nathanson 

Head of science and education Dr Caroline Seddon 

Project manager Nicky Jayesinghe 

Research and writing Fleur Conn 

Editorial secretariat Dalia Ben-Galim 

Hilary Forrester 

Elaine Martyn 

British Library Cataloguing-in-Publication Data. 

A catalogue record for this book is available from the British Library. 

ISBN: 0 7279 1846 X 

Cover photograph: Getty Images 

Printed by the BMA publications unit 

© British Medical Association 2003 – all rights reserved. No part of this publication may be reproduced, 

stored in a retrievable system or transmitted in any form or by any other means that be electrical, 

mechanical, photocopying, recording or otherwise, without the prior permission in writing of the 

British Medical Association. 

British Medical Association Adolescent health


This resource was prepared under the auspices of the Board of Science and Education of the 

British Medical Association, whose membership for 2003/2004 was as follows: 

Professor Sir Brian Jarman President, BMA 

Dr George Rae Chairman, BMA representative body 

Dr James Johnson Chairman, BMA council 

Dr David Pickersgill Treasurer, BMA 

Professor Sir David Carter Chairman, Board of Science and Education 

Dr P H Dangerfield 

Dr A Elsharkawy 

Dr G D Lewis 

Professor S Lingam 

Dr P Maguire 

Dr S J Nelson 

Dr S J Richards 

Dr D M B Ward 

Dr C Smith 

Dr L Smith 

Dr N D L Olsen Deputy member 

Approval for publication as a BMA report was recommended by BMA Board of Professional Activities 

Directorate on 24 September 2003. 

Acknowledgements 

The association is very grateful for the help provided by the BMA committees and outside experts and 

would particularly like to thank Dr Helen Sweeting (MRC Social and Public Health Sciences Unit, 

University of Glasgow) and Dr Russell Viner (Senior Lecturer, Great Ormond Street Hospital for Children 

and Institute of Child Health, London). 

British Medical Association Adolescent health iii

Foreword 

The Board of Science and Education, a standing committee of the British Medical Association (BMA), 

provides an interface between the medical profession, the government and the public. One major aim of 

the board is to contribute to the improvement of public health. It has developed policies on a wide range 

of issues such as alcohol, smoking and eating disorders, and specific groups such as children and the 

elderly. The board’s work on public health has resulted in a number of publications including School sex 

education: good practice and policy (1997), The misuse of drugs (1997), Alcohol and young people (1999), Growing 

up in Britain: ensuring a healthy future for our children (1999), Eating disorders, body image and the media (2000) 

and Sexually transmitted infections (2002). 

This report focuses on the problems facing adolescents and examines the evidence surrounding 

adolescent health, behaviour and interventions. It reviews four important areas in adolescent health: 

nutrition, exercise and obesity; smoking, drinking and drug use; mental health; and sexual health. For 

each area this report discusses the prevalence of the problems involved, examines which adolescents are 

affected, describes the interventions used to address the issues and evaluates the effectiveness of these 

strategies. 

This report is intended to raise the profile of adolescent health and to help inform future policy. In 

addition, this report acts as an information resource for healthcare professionals, providing an overview 

of adolescent health issues and the policy environment. 

Professor Sir David Carter 

Chairman, Board of Science and Education 

December 2003 

Editorial note 

There are many definitions of the age range covered by the term adolescence. This report does not 

define adolescence by age and the age groups chosen by the sources used in this report vary. Most 

cover young people aged between 11 and 19 years old. 

The BMA has a number of policies relevant to the topics addressed in this report. These are listed 

separately in annex 1. 

British Medical Association Adolescent health v

vi 

Contents 

Introduction..........................................................................................................................................1 

Adolescent health and its implications....................................................................................................1 

Influences on adolescent health .............................................................................................................1 

Socio-economic background.......................................................................................................1 

Gender .......................................................................................................................................2 

Age .............................................................................................................................................2 

Family and peer influences .........................................................................................................2 

Environment...............................................................................................................................2 

Co-morbidity...............................................................................................................................2 

Interventions in adolescent health ..........................................................................................................3 

Nutrition, exercise and obesity .............................................................................................................4 

Nutrition, exercise and obesity in adolescents .......................................................................................4 

The nutritional status of adolescents..........................................................................................4 

Adolescents and exercise............................................................................................................5 

Adolescents and obesity..............................................................................................................5 

Which adolescents have poor nutrition, are inactive or obese?...................................................7 

Interventions in adolescent nutrition, exercise and obesity..................................................................8 

Interventions in adolescent nutrition..........................................................................................8 

Interventions in adolescent exercise and obesity........................................................................8 

Evaluating the effectiveness of interventions in adolescent nutrition, exercise and obesity..............9 

The importance of early intervention.........................................................................................9 

The effectiveness of education...................................................................................................9 

The importance of structural and environmental change.........................................................10 

Clinical interventions................................................................................................................11 

Summary ..................................................................................................................................................13 

Smoking, drinking and drug use .........................................................................................................14 

Adolescents and smoking, drinking and drug use..............................................................................14 

Smoking....................................................................................................................................14 

Drinking....................................................................................................................................14 

Drug use ...................................................................................................................................15 

Which adolescents drink, smoke and use drugs? ......................................................................17 

Interventions in adolescent smoking, drinking and drug use ............................................................19 

Interventions in adolescent smoking ........................................................................................19 

Interventions in adolescent drinking ........................................................................................19 

Interventions in adolescent drug use........................................................................................20 

Evaluating the effectiveness of interventions in adolescent smoking, drinking and drug use.........21 

Limiting the availability of cigarettes, alcohol and drugs..........................................................21 

Regulating the advertising and marketing of cigarettes and alcohol.........................................22 

Educating adolescents about the dangers of tobacco, alcohol and drugs misuse......................22 

Education promoting the development of social skills .............................................................23 

The use of mass media .............................................................................................................23 

Targeting interventions in adolescent smoking, drinking and drug use....................................24 

Multifaceted interventions........................................................................................................24 

Harm minimisation approaches................................................................................................24 

Treatment .................................................................................................................................25 

Summary........................................................................................................................................................26 


Mental health ......................................................................................................................................27 

The mental health of adolescents..........................................................................................................27 

Defining and measuring mental health .....................................................................................27 

Mental health problems in adolescence ...................................................................................28 

Which adolescents have mental health problems? ....................................................................28 

Interventions in adolescent mental health ...........................................................................................31 

Promoting ‘emotional wellbeing’ ..............................................................................................31 

Interventions in mental health disorders ..................................................................................31 

The importance of intervention in adolescent mental health ...................................................33 

Summary ..................................................................................................................................................33 

Sexual health.......................................................................................................................................34 

Adolescents and sexual health ...............................................................................................................34 

Sexual health and sexual activity in adolescence ......................................................................34 

Adolescents and STIs................................................................................................................35 

Adolescents and ‘teenage pregnancy’........................................................................................35 

Which adolescents experience teenage pregnancy and STIs? ...................................................36 

Interventions in adolescent sexual health.............................................................................................38 

Evaluating the effectiveness of interventions in adolescent sexual health.........................................39 

Education .................................................................................................................................39 

Public health campaigns ...........................................................................................................40 

Improving access to services.....................................................................................................40 

Screening ..................................................................................................................................41 

Targeted interventions..............................................................................................................41 

Helping adolescent parents ......................................................................................................42 

Summary ..................................................................................................................................................42 

Interventions in adolescent health ......................................................................................................43 

Early intervention .....................................................................................................................43 

Targeted intervention ..............................................................................................................43 

Education .................................................................................................................................43 

Improving access to health services..........................................................................................43 

Clinical interventions................................................................................................................44 

Multifacted interventions .........................................................................................................44 

Multiprofessional interventions................................................................................................45 

Structural and environmental change .......................................................................................45 

The way forward .................................................................................................................................46 

Annex 1...............................................................................................................................................48 

BMA policy on adolescent health ..........................................................................................................48 

References ..........................................................................................................................................50 

British Medical Association Adolescent health vii

viii

Introduction 

It is clear that many aspects of adolescent health and health behaviour could be improved. In light of the 

available evidence, the future health of the population and pressure on the health service are legitimate 

causes of concern. 

This report reviews four areas of adolescent health: nutrition, exercise and obesity; smoking, drinking and 

drug use; mental health; and sexual health. It also provides an overview of adolescent health and outlines 

some of the influences that determine health behaviour and outcomes. The BMA outlines possible 

approaches for improving adolescent health through publicly lead initiatives. 

Adolescent health and its implications 

In general, adolescents are not eating optimal diets, and many do not meet recommendations for exercise. 

As a result of these factors, in common with the general population, overweight and obesity are 

increasingly prevalent: in 1998, over one fifth of 13 to 16 year olds in England were overweight or obese. 1 

Poor nutrition, obesity and low levels of exercise not only have an immediate impact on the health of 

adolescents but also contribute to adult susceptibility to diseases, such as diabetes and coronary 

heart disease. 

Almost a quarter of 15 and 16 year olds in the United Kingdom (UK) smoke at least once a week and over 

a fifth of this age group report having used drugs in the last month. UK adolescents have begun to drink 

greater quantities of alcohol and now have one of the highest levels of alcohol use and binge drinking in 

Europe. Smoking increases the risk of morbidity and mortality while heavy drinking and drug use can lead 

to physical, emotional, mental and social problems, many of which are not yet fully elucidated. All three 

types of substance abuse pose risks of dependence. 

Up to one in five adolescents may experience some form of psychological problem. 2 

These range from 

behavioural disorders to depression, eating disorders, self-harm and neurosis. Mental health problems 

which develop in adolescence often persist into adulthood and can deteriorate over time. They are often 

associated with other problems including risk taking behaviour. 

The prevalence of sexually transmitted infections (STIs) among adolescents is high and increasing. As 

many as one in 10 females aged 16 to 19 may be infected with chlamydia. 3 

STIs can result in preventable 

infertility, ectopic pregnancy, pelvic inflammatory disease and psychological stress. Rates of ‘teenage 

pregnancy’ (where the woman is under 20 years old) have remained high and fairly stable in the UK for 

the past 10 years; around 3 per cent of women conceive under the age of 20. 4 

Adolescent maternity can 

lead to physical and social disadvantages for the offspring. Like mental health problems, it can have an 

adverse impact on adolescents’ education and social development. 

Influences on adolescent health 

Socio-economic background 

It is well known that socio-economic factors are related to rates of morbidity and mortality in both 

childhood and adulthood. 5 

One of the surprising findings from reviewing adolescent health is that overall, 

by comparison with both earlier and later stages in the life-course, adolescence is characterised by relative 

health equality. 6 

Most of the problems and behaviours reviewed in this report are shared by adolescents 

from different social backgrounds. 

Despite this relative equality, socio-economic background is related to certain areas of adolescent health: 

• the eating habits of younger adolescents are related to social class and income 

• although recreational drug use, smoking and drinking are not confined to any particular groups, 

British Medical Association Adolescent health 1

2 

heavier smoking, drinking and more problematic drug use are all more pronounced among lower 

social groups 

• in early adolescence, behavioural, emotional and relationship difficulties are more common among 

those from lower social groups and lower income households 

• socio-economic deprivation is associated with a greater risk of teenage pregnancy. 

Gender 

There are important gender differences in adolescent health: 

• boys are more physically active from an early age and are significantly more likely to engage in 

vigorous activity during adolescence. Girls are more likely than boys to be dissatisfied with their 

body size and shape 

• adolescent girls are more likely to be regular smokers than boys. The prevalence of drinking, the 

amount drunk and the use of drugs is, however, slightly higher among boys. Gender differences in 

lifestyle now appear to be diminishing, meaning that girls are increasingly at risk of substance use 

and misuse 7 

• there are pronounced differences in mental health by gender, although effects differ by type of 

disorder 

• girls are more vulnerable to STIs and are normally more affected by young parenthood. 

Age 

Physical activity declines with age. Throughout adolescence there is an increase with age in smoking, 

drinking, drug use and mental and sexual health problems. Age also affects the drugs and alcohol which 

adolescents are exposed to and the type of mental health problems experienced. 

Family and peer influences 

There is considerable evidence that both family and peer factors influence adolescent health. For 

example, nutrition and exercise are related to family and peer modelling and support. The behaviour of 

family and peers has also been found to influence adolescent smoking. Coming from a non-intact family, 

and favouring peer opinion over that of the family, are risk factors for smoking, drinking and drug use. 

Reliance on the peer group rather than the family for support may also increase adolescent vulnerability 

to peer pressure to engage in substance abuse and risky sexual behaviour. 6 

Mental health difficulties are more common in lone parent households than in two parent families. The 

quality of family relationships, levels of parental stress and family type have all been linked to adolescent 

mental health. A history of child abuse, parental substance misuse, mental illness, personality disorder and 

marital disharmony can all influence the mental health of adolescents. 

Environment 

Individuals bear some responsibility for their own health, even during early adolescence. It is clear, 

however, that health is subject to social and economic circumstances that are often beyond individual 

control. 8 

The social environment plays an especially important role in nutrition through social norms and 

the availability of healthy food. Access to appropriate recreational facilities also influences adolescents’ 

physical activities. 

Social and psychological circumstances can cause long-term stress. Continuing anxiety, insecurity, low 

self-esteem and social isolation can have powerful adverse effects on health, and are associated with 

emotional disorders such as depression and anxiety. 8 

Co-morbidity 

There is evidence that many of the health problems and risk taking behaviours of adolescents examined 

in this report can influence and exacerbate one another. The likelihood of smoking, drinking or using 

drugs is higher among adolescents who use another substance. Adolescents report having more risky sex 


when they are under the influence of alcohol. There is a strong link between alcohol and substance misuse 

and mental health problems. Overall there is a strong correlation between psychiatric disorders, substance 

misuse and risky sexual behaviour. Health problems in adolescence can compound one another. For 

example, mental health problems may act as a potent risk factor for substance misuse and such substance 

misuse can contribute to existing mental health disorders. 9 

Although many health behaviours are common to adolescents, risk factors for more acute problems are 

identifiable. Socio-economic group, family and peer influences, and an adolescent’s environment all 

influence health behaviours and mental and sexual health. Additional influences include youth offending, 

truancy, school exclusion, family problems, homelessness and deprived communities. 

Social disadvantage plays an important role in adolescent health. Smoking, drinking and drug use are all 

more likely among adolescents who have been in trouble with the police, suspended from school or who 

have poor academic performance and low future expectations. Low educational attainment is also 

associated with early motherhood. 

It becomes clear that, while many health concerns are common to all adolescents, it is possible to identify 

several especially vulnerable groups who are more likely to experience health problems. 

Interventions in adolescent health 

Governments throughout the UK use health education to improve adolescents’ nutrition and sexual 

health, and to discourage the use of alcohol, tobacco and drugs. In addition, they are seeking to improve 

adolescent health through increasing access to healthy food and decreasing access to alcohol, tobacco and 

drugs. UK governments are also working on improving addiction and sexual health services for 

adolescents. Current strategies involve targeting drug and sexual health services to groups of adolescents 

most at risk. 

Evidence for the effectiveness of many interventions in adolescent health is equivocal. However, it is 

possible broadly to evaluate intervention strategies in adolescent health. A number of approaches emerge 

which could be adopted to improve adolescent health: a full list is included at the end of this report. 

Early intervention and targeted intervention are valuable approaches in all aspects of adolescent health. 

Health education offers some potential benefits but needs to be approached in the right way. School-based 

education will not reach all adolescents and does nothing to tackle environmental influences on 

adolescent health. Across all areas of adolescent health, more could be done to make structural and 

environmental influences more positive. Improving access to services is vital if adolescent health is to be 

improved: this involves ensuring not only adequate resources but also age appropriate, welcoming 

environments and the provision of information and support to service users. Multifaceted interventions in 

adolescent health (those using several different types of approach) are a useful way of countering the 

many different influences on adolescents. Similarly, multiprofessional approaches (those involving several 

services) are useful because of the interrelation between different areas of adolescent health and between 

health and other aspects of adolescents’ lives. 


4 

Nutrition, exercise and obesity 

Nutrition, exercise and obesity in adolescents 

Adolescents in the UK are not eating optimal diets, often exercise too little and are increasingly likely to 

be overweight or obese. This section discusses the current nutritional status of adolescents, their activity 

patterns and the prevalence of obesity amongst this group. It outlines the policy approaches that have 

been adopted to improve the situation in these areas and reviews the effectiveness of various interventions. 

The nutritional status of adolescents 

The diet of adolescents is important. Nutritional status can have an immediate impact on the health of 

adolescents, contributing to obesity, susceptibility to illness and general health. Also, there is increasing 

evidence that adult susceptibility to disease is associated with nutrition in childhood and adolescence. 10 

The National Diet and Nutrition Survey (2000) examined the diets of British school children aged four to 

18 years. It found that adolescents ate more than the recommended level of sugar, salt and saturated fat. 

The most frequently consumed foods were white bread, savoury snacks, biscuits, potatoes and chocolate 

confectionery. Although in general, average vitamin intakes exceeded recommendations, there was 

evidence of low intake of some minerals in adolescents, especially in girls. 11 

On average, adolescents fail to 

eat the recommended amount of fruit and vegetables. The Health Survey for England 2001 found that less 

than 20 per cent of boys and less than 15 per cent of girls aged 13 to 15 managed to eat five or more 

portions of fruit and vegetables per day. 12 

In 2000 less than half of 15 to 16 year olds in Wales reported eating 

fresh fruit on a daily basis. 13 

Much attention has recently focused on adolescents’ high consumption of fast food and confectionery. 

Fast food typically incorporates all of the potentially harmful dietary factors including saturated and trans 

fat (fat from partially hydrogenated vegetable oils), a high glycaemic index, high energy density and, 

increasingly, large portion size. These foods also tend to be low in fibre, micronutrients and antioxidants; 

dietary components that affect risk of cardiovascular disease and diabetes. 14 

High salt consumption (over 6 grams per day, or over 5 grams per day for children aged seven to 14) may 

also pose a health risk to adolescents. Eating too much salt, especially during childhood, has been 

associated with the development of hypertension 15 

and may even contribute to hypertension in the 

young. 16 

Adolescents’ diets are typically high in salt. Some pre-prepared meals, including many of those 

marketed as healthy, have been found to contain more than the recommended daily intake of dietary salt 

for an adult. 

Adolescent consumption of soft drinks is also a cause of concern. The physiological effects of energy intake 

on satiation appear to be different for energy in fluids as opposed to solid food. 17 

This means that 

consumption of energy at meal times may not be adjusted to take into account the energy consumed in 

the form of soft drinks, thus contributing to obesity. 18 

The Food Standards Agency and the Department for Education and Skills have recently undertaken 

qualitative research into 14 to 16 year olds’ dietary knowledge and choices. Preliminary analysis suggests 

that adolescents have a broad sense of the key constituents of a healthy diet but do not critically assess their 

own diet in the context of recommendations. Respondents did not tend to check nutritional labelling and 

generally did not weigh up the nutritional content of the foods that they chose for themselves. 19 


Adolescents and exercise 

Physical activity is an increasingly important focus for health promotion. In 1997 the Health Education 

Authority (HEA) recommended that all young people should participate in one hour of moderate 

physical activity per day and that young people who currently do little activity should participate in physical 

activity of at least moderate intensity for at least half an hour per day. 20 

As a key determinant of energy expenditure, physical activity is fundamental to energy balance and weight 

control. 17 

It can help to prevent and reduce the risk of coronary heart disease, stroke, high blood pressure, 

non-insulin-dependent diabetes mellitus, osteoporosis and cancer of the colon. 21 

It can also improve 

psychological wellbeing by reducing symptoms of depression and anxiety and enhancing self-esteem. 22 

The rationale for adolescents to take part in physical activity includes: 

• optimising fitness, current health and wellbeing, and growth and development 

• developing an active lifestyle that can be maintained throughout adult life 

• increasing bone mineral density and thereby reducing the risk of osteoporosis 

• reducing the incidence of overweight and obesity and the risk of chronic 

diseases of adulthood. 22 

Measuring physical activity is notoriously difficult since, in addition to organised sport, it involves activities 

such as walking and physical effort expended at work, at home or in other settings. It also involves 

consideration of the frequency, duration and intensity with which an activity is undertaken. 6 

The National Diet and Nutrition Survey (2000) estimated that 40 per cent of boys and 60 per cent of girls 

surveyed in Britain were failing to meet the HEA recommendations. Boys are more active than girls from 

an early age and, during adolescence, are significantly more likely to engage in vigorous activity. 11 

The 

Health Survey for England 1997 found that, overall, participation rates in four categories of activity 

declined with age after the age of about eight to 10. The decline was steeper among girls, so that, from 

the age of 12, fewer than half of girls participated in physical activities for at least 30 minutes on most 

days. By the age of 15, only 36 per cent of girls undertook 30 minutes physical activity on most days, 

compared with 71 per cent of boys. 23 

Rates of adolescent participation in physical activity are similar 

for Scotland. 24 

The 1997 survey showed that inactivity (‘sitting’) increases with age among both boys 

and girls. 23 

Several determinants of adolescent participation in physical activity have been identified. These include 

psychological determinants such as enjoyment, feelings of competence, control and autonomy, 

confidence, positive attitudes, definition of personal goals; and perceptions of benefits. Social and 

environmental determinants that also play a role include family and peer modelling and support, access 

to appropriate environments, the influence of mass media; and cultural factors. 22 

Adolescents and obesity 

Obesity has come to be considered a global epidemic and excess body weight is now the most common 

childhood disorder in Europe. 25 

Measuring and monitoring childhood obesity has recently been made 

easier by the development of centile curves for children, based on internationally acceptable cut 

off points. 26 

There has been an increase in the prevalence of overweight and obesity in British children over recent 

years. An analysis of data collected in the Health Survey for England in 1998, shows that there has been 

a sharp increase in the prevalence of overweight among seven to 11 year olds, rising by 60 per cent 

between 1994 and 1998 and by 150 per cent between 1980 and 1994. 1 

Moreover, trends in waist 

circumference of 11 to 16 year olds have greatly exceeded those in body mass index. 27 


6 

The data for 1998 shows a 21 per cent prevalence of overweight and obesity for adolescents aged 13 to 

16. 1 

The Health Survey for England 1997 found that, in the 16 to 24 year old age range, 23 per cent of 

men and 19 per cent of women were overweight, and a further 6 per cent of men and 8 per cent of 

women were obese. 23 

The prevalence of obesity in adolescents does not differ markedly between England 

and Scotland. 24 

In childhood, excess weight can cause dyslipidaemia, hyperinsulinaemia and hypertension. Recently, the first 

obesity-related cases of type 2 diabetes in white adolescents have been reported in the UK. 28 

In children, 

as in adults, centralised or upper body fat carries an increased risk for metabolic complications. 27 

Overweight 

children are more likely to become overweight adults. Adult obesity increases the risk of suffering 

significant health consequences. These include hypertension, type 2 diabetes, cardiovascular and 

gallbladder disease, dyslipidaemia, insulin resistance, breathlessness, sleep apnoea, asthma, osteoarthritis, 

hyperuricaemia and gout, reproductive hormone abnormalities, polycystic ovarian syndrome, 

impaired fertility and lower back pain. 25 

Obesity has also been linked to the development of certain 

cancers. 29 

Obesity and overweight can have a significant impact on psychological wellbeing, with many adolescents 

developing a negative self image and experiencing low self-esteem. 30 

Psychological ill health related to 

obesity may be expressed in eating disorders, poor social relations and educational disadvantage. 25 

Obese 

adolescents show declining degrees of self-esteem associated with sadness, loneliness, nervousness and 

high-risk behaviours. 31 

Obesity, and the significant health problems associated with it, have serious social, as well as individual, 

implications. A report by the UK National Audit Office 32 

predicted that social and health sector costs of 

adult obesity in England would rise to £3.6 billion annually by 2010. 1 

The aetiology of overweight and obesity is complex. Predisposition alone seems to be related to at least 

250 obesity-associated genes and perhaps perinatal factors. 14 

Twin studies suggest a heritability of fat mass, 

and disorders of energy balance that arise from genetic defects. For example, serum leptin 

concentrations have been found, in general, to correlate positively with indices of obesity. 33 

Unhealthy diets and sedentary lifestyles, as outlined above, both contribute to obesity but expert opinion 

is divided on the primary causal factor. While much emphasis is placed on dietary content, there is 

evidence, based on the National Food Survey’s annual measures of household food consumption, that 

the British are becoming more overweight in spite of consuming less energy than in the 1970s. In recent 

decades children and adolescents have engaged in less exercise. Importantly, this decline in exercise has 

coincided with an increase in sedentary activities: proxy measures of physical inactivity such as car 

ownership, computer use and television viewing seem more closely related to changes in obesity than 

household food consumption. 34 

Weight gain and obesity is caused by an excess of calories consumed over energy expended. The growing 

prevalence of adolescent obesity can therefore probably be attributed to a combination of physical 

inactivity and high energy in the diet. 17 

The ‘obesogenic’ environment 

The term ‘obesogenic’ has been used to describe modern environments which encourage and 

promote high energy intake and inactivity. This environmental factor is distinguishable from 

genetic causes of obesity. 35 

A recent World Health Organisation report concluded that the 

obesogenic environment appears to be largely directed at the adolescent market, making healthy 

choices more difficult. 17 


Changes in family eating patterns and the consumption of fast foods, pre-prepared meals and carbonated 

drinks, have taken place over the past 30 years while the amount of physical activity has been greatly 

reduced both at home and in school. 17 

Eating behaviours that have been linked to overweight and obesity 

include snacking/eating frequently, binge-eating patterns, and eating out; in contrast, exclusive 

breastfeeding of infants has a protective effect. 17 

Though the increase in obesity among adolescents is a worrying trend, it is important not to contribute to 

unnecessary anxiety among adolescents about their weight. Various studies of children and adolescents 

have shown that a sizeable proportion are dissatisfied with their body size and shape. 23 

This concern 

increases with body mass index (BMI) and is more prevalent in females than in males. Research also 

suggests a rise over time in dieting among adolescent females. 36 

The Health Survey for England 1997 

found that 20 per cent of 16 to 24 year old females who had a desirable body mass index (a BMI of between 

20 and 25) thought they were too heavy. A significant proportion who were not overweight were trying to 

lose weight (10% of the underweight and 45% of those with desirable weight). 23 

Which adolescents have poor nutrition, are inactive or obese? 

The Health Survey for England 1997 found that the eating habits of two to 15 year olds, though not those 

of ‘young adults’, were related to social class and income. There was a decrease from social classes I and 

II (combined) to IV and V (combined), and also from the highest to the lowest income quintile, in the 

proportion consuming fruit and vegetables more than once every day. There was a corresponding increase 

in the proportions consuming sweet foods, soft drinks and crisps more than once every day, or consuming 

chips at least five days a week. 23 

More recently, foods consumed by 14 to 16 year olds have been found to 

be similar across socio-economic groups. Despite this similarity, those in higher social groups report wider 

exposure to different foods while adolescents in lower social groups report greater independence in 

food choices and more responsibility for organising these choices. 19 

The Health Survey for England 23 

and the Scottish Health Survey 24 

both found some socio-economic 

gradient in physical activity. The Health Survey for England found no consistent relationship between 

overall activity (sports and exercise, active play, walking and housework/gardening) and social class or 

household income. However, there were differences in participation in the different activity types 

according to social class and equivalised household income. In particular, there was a marked social class 

gradient in participation in sports and exercise among younger boys and all girls, with participation being 

lower among social classes IV and V. Participation rates in sport among 11 to 15 year old girls of social class 

I and II was 63 per cent in 1997; by contrast the participation rate among girls in social class IV and V was 

47 per cent. 23 

The Scottish Health Survey found subtle differences in the relationship between 

participation in physical activity and social class. Girls in manual social class households were slightly 

less likely to have a low level of activity but those in social class I/II were more likely than girls in 

other groups to have participated in sports and exercise activities in the week before the interview. 24 

Children and adolescents are at greater risk of gaining excess weight if one or both of their parents are 

overweight. They may also be at greater risk in households with low incomes. 25 

Children who suffer from 

neglect, depression, or other related problems are at substantially increased risk of obesity during 

childhood and in later life. 14 


8 

Interventions in adolescent nutrition, exercise and obesity 

As concern about nutrition, exercise and obesity among adolescents, children and the population as a 

whole has grown, interventions have been introduced to improve nutritional status, increase physical 

activity and prevent and manage obesity. With regard to obesity in particular, many non-governmental 

organisations do not view current interventions as radical enough to prevent the growing crisis which some 

predict will end in epidemic rates of serious adult diseases such as diabetes and chronic heart disease. 

Interventions in adolescent nutrition 

Intervention in nutrition in early life has the potential to bring about major reductions in the incidence 

of several adult diseases. 10 

Unfortunately there is little agreement on the best way to improve the diets of 

adolescents. Two main strands of current policy can be identified; first, educating adolescents about the 

importance of making better nutritional choices and second, limiting the availability of unhealthy food 

and providing healthy alternatives. 

To date, most health policy has focused on educational interventions in schools. This approach has 

recently been expanded; a new Healthy Schools Programme has been developed to promote health 

education through local education and health partnerships. The government is encouraging schools to 

adopt a whole school approach to food and nutrition. This involves integrating knowledge about nutrition 

into all areas of the curriculum. The Food Standards Agency is currently involved in several initiatives to 

raise the knowledge and skills of young people as they relate to food and nutrition. These initiatives 

include travelling classrooms for cookery lessons and resources for schools and youth organisations. The 

Food Standards Agency is also investigating peer education approaches. 19 

Educational interventions in adolescent nutrition need not be limited to diet and health awareness. The 

Food Standards Agency and Department for Education and Skills have identified several ‘competencies’ 

for health education including consumer awareness, food handling and preparation and food hygiene. 19 

In addition to health education initiatives, the government has introduced several programmes to improve 

the nutritional content of adolescents’ diets through the provision of healthy food. For example, in 2001, 

minimum nutritional standards for school lunches were re-introduced in England. In Scotland nutrient 

standards for school lunches in secondary schools will be introduced by 2006. 37 

The government has also 

recently introduced a National School Fruit Scheme, which will be fully operational by 2004, entitling 

school children in England aged four to six to a free piece of fruit each school day. A similar scheme is 

being introduced in Scotland 37 

while Wales has launched a national strategy to improve physical and 

economic access to healthy food. This is aimed at priority groups, including infants, children and young 

people. 38 

Although not targeted at today’s adolescents, the fruit schemes may help to encourage habits of 

healthy eating among young children which will last until adulthood. Initial evaluation of the scheme in 

England has been encouraging 39 

and ongoing monitoring may provide a basis for adopting similar 

schemes for older children and adolescents. If these current healthy eating initiatives are evaluated 

positively, they could be sustained and built upon in the future. 

Interventions in adolescent exercise and obesity 

There are currently no overweight and obesity targets for England, Wales, Scotland or Northern Ireland. 

However, the NHS Plan stated an intention to tackle obesity and the government currently has a number 

of school-based initiatives to improve dietary habits (see above). Wales is working to develop and manage 

initiatives to prevent and manage overweight and obesity among the population. 38 

The Children’s National 

Service Framework, due to be launched at the end of 2003, will address childhood obesity as part of the 

broader issues around promoting a healthy diet and physical activity. 40 


In 2002 the English government published Game plan: a strategy for delivering government’s sport & physical 

activity objectives. 41 

This set an extremely challenging target that by 2020, 70 per cent of the English 

population will be reasonably active * 

. Young people (aged both under 11 and 11 to 16) were identified as 

a target group for intervention. The government is currently involved in several schemes to increase 

physical activity in these age groups. For example it is investing in school sport coordinators to increase 

sports opportunities for young people. The Department for Education and Skills, and the Department for 

Culture, Media and Sport are implementing a joint public service agreement target to provide two hours 

of physical education and school sport to 70 per cent of pupils by 2006. A cross departmental Sport and 

Physical Activity Board (SPAB) has been established: it is hoped that this will raise the levels of mass 

participation in sport for young people and adults. 

Evaluating the effectiveness of interventions in adolescent nutrition, 

exercise and obesity 

Numerous systematic reviews have recently been undertaken to evaluate the effectiveness of interventions 

in adolescent nutrition, exercise and obesity. 42 

This section provides a brief overview of the main types of 

intervention. 

The importance of early intervention 

There is growing consensus that good nutritional practices and physical activity should be encouraged as 

early as possible in children’s lives before unhealthy habits become established. It appears, for example, 

that access and exposure to a range of fruit and vegetables in the home is important for the development 

of preferences for those foods. Furthermore, parental knowledge, attitudes and behaviours related to 

healthy diet and physical activity are important in creating role models. 17 

The social gradient in nutritional status makes it especially important that parents, including adolescent 

mothers and fathers, are provided with good, simple information on feeding their children. This should 

include information on the benefits of breastfeeding. The weaning period is important for introducing 

nutritional variety and there is evidence that food preferences developed during these years may affect 

food preference behaviour throughout life. 43 

Inappropriate weaning foods including those with excess 

sugar and salt, can set harmful dietary patterns for life. 44 

Since an excess of overweight and obesity in 

children in the UK has been found before the age of school entry, 45 

efforts to prevent obesity should also 

ideally begin in early childhood. 

The effectiveness of education 

There is some evidence that multifaceted school-based programmes that promote physical activity, the 

modification of dietary intake and the targeting of sedentary behaviours may help to reduce obesity in school 

children, particularly girls. 46 

The government hopes that its Healthy Schools Programme will have an impact 

on nutrition, physical activity and obesity. Within the sphere of health education, peer education has become 

a popular strategy. Peer-led nutrition approaches in schools designed to increase fruit and vegetable intakes 

and lower the intake of fatty foods have been found to be feasible and have high acceptability. 47 

Adolescents may be confused as to where to go for advice about their diet. The Trust for the Study of Adolescence 

found that 30 per cent of adolescents would seek dietary advice from their GP, 9 per cent would go to the school 

nurse and 50 per cent would not go to anybody for advice. 48 

Within the sphere of health education it would seem 

important that adolescents know where to turn for advice about nutrition, exercise and weight management. 

This may also help to counter widespread, unnecessary worry among adolescents about their size. 

* Sport policy is a devolved matter. In Let’s make Scotland more active: a stategy for physical activity (2003), Scotland set a target to get 

50 per cent of adults, and 80 per cent of those under 16, active by 2022. Both Wales and Ireland have committed to increasing 

activity among their populations. 


10 

The efficacy of traditional educational interventions in preventing obesity, increasing physical activity and 

improving nutritional status among adolescents has been questioned. A recent American attitude study 49 

found that healthy eating messages are reaching adolescents but interventions are needed to assist them to 

translate this knowledge into healthy behaviours. Following the perceived failure of traditional educational 

approaches, structural and environmental factors are increasingly considered important. 

The importance of structural and environmental change 

The World Health Organisation recently concluded that, for adolescents, prevention of obesity 

implies the need to: 

• promote an active lifestyle 

• limit television viewing 

• promote the intake of fruit and vegetables 

• restrict the intake of energy-dense, micronutrient-poor foods (eg packaged snacks) 

• restrict the intake of sugar-sweetened soft drinks. 

Additional measures identified included modifying the environment to: 

• enhance physical activity in schools and communities, and family interactions 

• limit the exposure of young children to heavy marketing practices in respect of energy-dense, 

micronutrient-poor foods 

• provide the necessary information and skills to allow healthy food choices. 17 

It is important that health policy programmes recognise the wide range of structural and environmental 

factors, principally inadequate income and inadequate access to healthy food, which can make it much 

more difficult for low income families to improve their diets and thus their health. 

The modern economy provides a perverse incentive to eat the ‘wrong’ foods because, in general, the 

cheapest calories come from fatty, oily foods which are often high in salt and sugar. 44 

Research in 1997 

found that households in the bottom tenth of the income distribution spend on average 29 per cent of 

their disposable income on food (after allowance for housing costs); those in the top tenth spend 18 per 

cent. Low income families with children spend a relatively small amount of money per person on food. 

This leads to the purchase of foods richer in energy (high in fat and sugar) to satisfy hunger. These are 

much cheaper per unit of energy than foods rich in protective nutrients (like fruit and vegetables). 50 

The 

Joseph Rowntree Foundation 51 

found that among low income families the cost of food and the money 

available were the most important factors when deciding which foods to eat. The Poverty and Social 

Exclusion Survey reported that around one in 10 ‘poor children’ did not eat fresh fruit or vegetables 

daily. 52 

Several studies have suggested that low income not only restricts the ability to buy foods rich in protective 

53, 54 

nutrients, but also limits access to the food retailers where healthy food can be purchased more cheaply. 

Food deserts 

Since the mid 1990s the term ‘food desert’ has been used to describe areas (usually densely 

populated and urban) where residents do not have access to an affordable and healthy diet. The 

fact that few poor families have access to a private car to transport them to out of town retailers, is 

often given as a reason for poor health. 55 

The evidence supporting this theory has recently been 

questioned. 55 

However, it has already begun to inform government policy in the UK. 56 


The inability to afford, or have reasonable access to, food which provides a healthy diet is known as ‘food 

poverty’. Those experiencing food poverty may have limited money for food after paying for other household 

expenses or live in areas where food choice is restricted by local availability and transport to supermarkets. 

They may also be lacking in the knowledge, skills or cooking equipment necessary to prepare healthy meals. 38 

The International Obesity Task Force has attributed the rise in obesity to societal factors and has called 

on the government to move away from approaches based on health education – which rely on an 

unrealistic expectation of sustained behavioural change – to a more structured approach which targets 

the ‘toxic environment’. 25 

These approaches focus on increasing the opportunities for participation in 

physical activity, increasing the availability of healthy food, and sometimes, in addition, legislating to 

reduce the availability of unhealthy food. For example, it has been suggested that curriculum standards 

may need to be developed to ensure adequate attention is given to children’s physical activity needs – 

especially for girls, people of low socio-economic status and older adolescents. 22 

This may include capital 

projects or the extension of the school day. 25 

In the light of several studies which suggest an association 

between fast-food consumption and total energy intake or bodyweight in adolescents and adults, 14 

several 

organisations and health experts are calling for tighter regulation of the food industry, pricing and 

advertising. These interventions may prove more effective in improving nutrition and stemming the rise 

in obesity among adolescents. They are, however, unlikely to be politically feasible in the short term. 

Clinical interventions 

Pilot schemes involving systematic and comprehensive approaches to childhood and adolescent 

overweight and obesity are currently under way. To date, however, evidence about what can be done for 

obese and overweight adolescents is limited. Many of the studies undertaken have methodological 

problems such as small sample size and high levels of attrition. 30 

As a consequence, guidance on the 

clinical treatment of adolescent obesity often has to be extrapolated from research studies in adults or in 

children receiving specialist services. 57 

Few paediatric studies have sought to ascertain the effect of dietary composition on bodyweight 

controlling for treatment intensity, physical activity, and behavioural modification techniques. 14 

There is 

little evidence about how qualitative aspects of physical activity, such as frequency and intensity, affect 

body composition and health risk. 14 

Most drugs used in the treatment of obesity over the past century have had serious side effects. When 

there is no inherent biological cause, it has therefore been suggested that pharmacological treatment 

should only be prescribed for children with obesity-related complications. Even in these cases 

prescription should follow careful consideration of immediate and long-term risks and benefits in the 

context of a comprehensive weight-management programme. 14 

Similarly, the potentially serious 

consequences of bariatic surgery make it, at best, a last resort for severely obese adolescents. 14 

Studies of the effectiveness of obesity management in adolescents have covered behaviour modification 

programmes and pharmacological interventions. 30 

Behaviour modification programmes involving 

parents have been shown to help children and adolescents lose weight. 58 

For older children and 

adolescents there is some evidence that cognitive-behavioural modification programmes with no parental 

involvement may reduce weight over time. 59 

Providing ‘exercise on prescription’, where patients are referred to a programme of exercise, usually 

delivered via a local leisure facility, has become increasingly common practice in the treatment of 

overweight and obese adults. Published reviews of these programmes demonstrate small but possibly 

meaningful improvements in physical activity patterns and other related measures. Many studies of the 

treatment of adolescent obesity have also used conventional exercise prescriptions. In both cases, 

strategies focused on increasing lifestyle activity, which carry fewer sport and fitness connotations, may 

prove to be more conducive for long-term weight control. 14,21 


12 

The treatment of individuals within the health service may not be a sufficient means of tackling the rising 

epidemic of childhood and adolescent obesity. 25 

Excess weight is difficult to treat and there is a high failure 

rate. 25 

Reviews of recent studies have suggested that most paediatric obesity interventions are marked by 

small changes in relative weight or adiposity and by substantial relapse. 60 

The relative intellectual and 

psychological immaturity of some adolescents compared with adults, and their susceptibility to peer 

pressure, present practical obstacles to successful treatment. 14 

Screening has been suggested as a means of identifying overweight at an early stage. However, in the 

absence of effective treatment, this approach has not been recommended in the general population. 61 

Despite the well documented difficulties in weight management, health professionals (including GPs, 

school and practice nurses, nutritionists and clinical psychologists) may be able play an important role in 

the recognition and management of adolescent obesity. 30 

More research should be undertaken on the 

value of a multiprofessional team in the treatment of overweight and obesity. 25 

The Royal College of Paediatrics and Child Health, in conjunction with the National Obesity Forum, have 

published guidelines on the weight management of children and adolescents. These emphasise the 

importance of providing ongoing support to make incremental changes in the behaviour of an individual 

or family willing to make lifestyle changes. The Health Education Board for Scotland (HEBS) has 

developed a comprehensive guide for primary healthcare professionals for the identification, 

understanding and treatment of obesity, including a thorough guide to childhood weight management. 62 

In order to establish good practice in the clinical management of adolescent obesity, future research must 

be sound methodologically, involve appropriately large numbers of participants in appropriate settings 

and be of longer duration and intensity. A priority for future research at this stage must be to identify the 

efficacy of the methods and treatments available to overweight and obese adolescents. 30 


Summary 

Nutrition, exercise and obesity can all have an impact on the health of adolescents and contribute 

to adult susceptibility to disease. These factors, particularly obesity, can also influence psychological 

wellbeing. 

Adolescents in the UK are not eating optimal diets. Girls in particular fail to meet recommendations 

for exercise. As a result, in common with the rest of the population, overweight and obesity is 

increasingly prevalent among adolescents. There are socio-economic gradients in adolescent 

dietary habits and physical activity. 

The government is increasingly concerned with interventions in adolescent nutrition, exercise and 

obesity. Across the UK, measures are being introduced to educate young people about nutrition and 

increase access to healthy food. The forthcoming National Service Framework for Children will 

address the issues of obesity and exercise. 

Obesity is difficult to treat. Multidisciplinary teams may be able to help reduce weight and promote 

healthy habits among adolescents. Early intervention in children’s lives is however, crucial for the 

promotion of good nutrition and exercise. Teaching parents, including adolescents, the importance 

of good early nutrition may be an effective way of promoting the health of future generations. 

Despite some evidence that school-based education can be effective in promoting better nutrition 

and exercise, there have been calls for an approach which addresses the structural and 

environmental causes of poor nutrition, inactivity and obesity. These include enhancing the 

opportunities for physical activity, increasing access to healthy foods and even limiting exposure to 

unhealthy food. 


14 

Smoking, drinking and drug use 

Adolescents and smoking, drinking and drug use 

The use of addictive substances by adolescents is an issue of great concern. This section reviews the 

prevalence of smoking, drinking and drug use and examines which adolescents are most likely to be 

involved with these behaviours. Interventions are examined and their effectiveness is assessed. 

Smoking 

A succession of studies affirm the causal connection between smoking and increased morbidity and 

mortality, the diseases concerned including many cancers, chronic obstructive airways disease, coronary 

heart disease and stroke. 6 

Although the major impact of smoking occurs later in life, even after a relatively 

short smoking career young smokers have poorer respiratory health. 63 

Most smokers begin in adolescence 

and the younger someone starts, the less likely they are to give up. Early initial use of tobacco also greatly 

increases the risk of lung cancer. 64 

A recent report by the Schools Health Education Unit, examining trends between 1983 and 2001 in young 

people’s attitudes to smoking, found that in 2001 adolescents were more likely than in previous years to 

‘experiment’ with smoking. Around 40 per cent of 12 to 13 year olds and around 60 per cent of 14 to 15 

year olds had tried a cigarette. 65 

Adolescent girls are more likely to be regular smokers than boys. The national survey of 11 to 15 year olds 

Smoking, drinking and drug use among young people in England 2002, found that 11 per cent of girls smoked 

regularly (usually at least one cigarette a week) compared with 9 per cent of boys. 66 

There is a sharp increase in smoking prevalence as adolescence unfolds. One per cent of 11 year olds in 

England smoke regularly compared with 23 per cent of 15 year olds. 66 

Among 16 to 24 year olds prevalence 

rises to 30 per cent among men and 26 per cent among women. 67 

The figure is higher still in Scotland 

where self-reported cigarette smoking among 16 to 24 year old men is 37 per cent. 24 

Statistics for the prevalence of adolescent smoking across the various parts of the UK are not strictly 

comparable but prevalence figures are very similar. For example, the survey Smoking, drinking and drug use 

among young people in Scotland in 2000 shows that 10 per cent of 12 to 15 year olds smoked at least one 

cigarette a week. As with England, there was a gender difference (13% of girls and 8% of boys smoking 

every week) and an age difference (2% of 12 year olds and 19% of 15 year olds being regular smokers). 68 

The prevalence figures for smoking among 15 to 16 year olds are the easiest to compare across the UK. In 

England 23 per cent of 15 year olds smoked at least one cigarette a week (2002) 66 

while in Scotland this 

figure is 19 per cent (2000) 68 

and in Wales 25 per cent (2000). 13 

In Northern Ireland 20 per cent of 15 to 

16 year olds reported smoking daily and 32 per cent reported smoking in the last 30 days (1999). 69 

Drinking 

The drinking habits of adolescents arouse considerable concern due to both the prevalence of alcohol 

consumption and the amount drunk. Adolescents in the UK have one of the highest European levels of 

alcohol use, binge-drinking (consuming more than five drinks in a row) and getting drunk. 70 

The survey Smoking, drinking and drug use among young people in England 2002 found that 24 per cent of 11 

to 15 year olds had had an alcoholic drink in the last week: 66 

in Scotland the figure for 12 to 15 year olds 

was 21 per cent in 2000. 68 

In 2000, 55 per cent of Welsh 15 to 16 year olds reported drinking at least once 

a week. 13 

In 1999, in Northern Ireland, 66 per cent of girls and 70 per cent of boys reported drinking in 

the past 30 days. 69 


As with cigarette smoking, there is a sharp increase in prevalence of drinking with age: only 5 per cent of 

all pupils aged 11 had had an alcoholic drink in the last week, but 47 per cent of 15 year olds had done 

so. 66 

In Scotland in 2000 the figures stood at 6 per cent for 12 year olds and 39 per cent for 15 year olds. 68 

In 2002, the average weekly consumption among English 11 to 15 year old pupils who drank alcohol in 

the last seven days was 10.5 units, a significant increase from the 5.3 units drunk in 1990. Both the 

prevalence of drinking, and the amount drunk, was slightly higher among boys than girls. 66 

In Scotland in 

2000 12 to 15 year olds who drank reported drinking an average of 11.1 units a week. The amount drunk, 

but not the prevalence of drinking, was higher for boys than girls. 68 

The medically recommended alcohol 

limit for adults is 14 units per week for women and 21 units for men. Among 16 to 24 year olds, in 1997, 

33 per cent of young men were estimated to be drinking more than 21 units of alcohol a week, and 9 per 

cent more than 50 units a week. Twenty-two per cent of women were estimated to be drinking more than 

14 units of alcohol a week, and 5 per cent more than 35 units a week. 23 

The Centre for Social Marketing carried out qualitative research on behalf of the Health Education Board 

for Scotland in 2000 exploring alcohol use and misuse among 15 to 24 year olds in Scotland. 71 

The 

attitudes which emerged from this study are likely to be representative of attitudes throughout the UK 

since England, Wales, Scotland and Northern Ireland have similar cultures and patterns of adolescent 

drinking. 72 

The study found drinking and intoxication to be pervasive behaviours and perceived as the 

norm in the context of leisure activities. Drinking experience is seen by adolescents to follow a ‘natural’ 

progression which starts in the early teens, increases over the following few years and is reduced as 

adolescents emerge unscathed into a life of increased responsibilities. These perceived patterns of 

drinking are substantiated by the Health Survey for England 1997. This showed that alcohol consumption 

increases during adolescence with age to a peak at about age 19 to 23 for men and 19 to 21 for women 

before it started to decrease by the age of 24. 23 

Attitudes and behaviour towards drinking were found to 

reflect few social limitations and considerable disposable income and time. However, they were bound by 

certain limitations such as work and study and therefore tended to be confined to one or two days a week 

where intoxication (rather than intense drunkenness) and value for money were the key aims. 

Regular heavy alcohol consumption and binge drinking are associated with physical problems, antisocial 

behaviour, violence, accidents, suicide, injuries and road traffic accidents. They can also affect school 

performance and crime. Alcohol misuse is associated with a range of mental disorders and can exacerbate 

existing mental health problems. Adolescents report having more risky sex when they are under the 

influence of alcohol; they may be less likely to use contraception and more likely to have sex early or have 

sex they later regret. 70 

Drinking too much on a regular basis increases the risk of damaging one’s health, 

including liver damage, mouth and throat cancers and raised blood pressure. 73 

Unhealthy patterns of 

drinking by adolescents may lead to an increased level of addiction and dependence on alcohol in 

adulthood. However, alcohol dependence is not confined to adulthood. In 2000, nearly 14 per cent of 

16 to 19 year olds in Great Britain were found to experience dependence on alcohol. 74 

Although alcohol 

misuse is an issue relevant to the UK as a whole, adolescents and young adults are of particular concern 

because of the high prevalence of binge drinking and heavy alcohol consumption among this age group. 

Drug use 

Among the key findings of the survey Smoking, drinking and drug use among young people in England in 2002 

was the fact that 11 per cent of 11 to 15 year olds had used drugs in the last month and 18 per cent had 

used drugs in the last year; the proportion of boys was slightly higher than that of girls. Thirty-eight per 

cent of pupils had been offered drugs at some time; cannabis was the most common but 21 per cent 

reported that they had been offered stimulants and 17 per cent volatile substances to sniff. 66 

In Scotland 

in 2000, 14 per cent of 12 to 15 year olds reported using drugs in the past year (again a higher proportion 

of boys than girls) and 47 per cent reported that they had ever been offered drugs. 68 


16 

The use of illicit substances, and the likelihood of having been offered drugs, is significantly related to 

age. 75 

Drug taking is considerably less common during the years of compulsory schooling than in the 

young adult years and rates of experimentation with drugs peak at the end of adolescence. In 2002 only 6 

per cent of 11 year olds in England had used drugs in the last year, while 36 per cent of 15 year olds had 

done so. 66 

The British Crime Survey of 2001/2 found that 30 per cent of 16 to 24 year olds in England and 

Wales had used drugs in the last year and 19 per cent had done so in the last month. 76 

The figure for 

Scotland in 2000 was 19 per cent for use over the last year. 77 

The pattern for volatile substance use differs 

from that of other drugs, peaking in the mid-teens. 78 

Cannabis is by far the most likely drug to have been used by adolescents in England, Scotland and Wales. 

The 2002 survey found that 13 per cent of 11 to 15 year olds in England had used it in the past year. 66 

In 

2002 cannabis was used by 27 per cent of English and Welsh 16 to 24 year olds; 76 

the figure for this age 

group in Scotland was 15 per cent in 2000. 77 

Among 11 and 12 year olds however, use of volatile substances 

is more common than the use of cannabis. 66 

Volatile substance abuse is more common in Northern Ireland 

than in the rest of the UK. Though cannabis is the drug most widely used by adolescents in Northern 

Ireland, in 1999, 28 per cent of boys and 23 per cent of girls in the 15 to 16 year old age group reported 

ever having used volatile substances. 69 

Recreational drug use among adolescents – defined as the use of psychoactive substances to ‘have fun’ in 

nightlife settings – is increasingly common. 79 

In dance settings, stimulant drugs such as MDMA (ecstasy), 

cocaine, and amphetamines are frequently used. Hallucinogenic drugs and plants and amyl nitrate 

(‘poppers’) are also taken. Cannabis, sedatives, hypnotic drugs and tranquillisers are sometimes used in 

conjunction with recreational drugs. 79 

In 2002, 4 per cent of 11 to 15 year olds reported using Class A drugs in the last year. 66 

The British Crime 

Survey of 2001/2 found that, among 16 to 24 year olds in England and Wales, Class A drug use had not 

changed significantly since 1994. However, the use of cocaine, crack and ecstasy had increased and, 

overall, 9 per cent reported using Class A drugs in the last year. 76 

The risks associated with acute and chronic drug misuse are well documented; a comprehensive summary 

can be found in the joint Department of Health and National Addiction Centre publication Dangerousness 

of drugs. 80 

Many associated risks are indirect but nevertheless important, such as the increasing number of 

fatalities caused by drug driving and the viral infections which can be transmitted by injecting users. 81 

The greatest public health issue regarding the use of recreational drugs by adolescents is the possibility of 

long-term impairment caused by regular or ‘binge’ use of amphetamine-type stimulants such as ecstasy. 79 

There is also growing interest in the possible links between drug use and psychosis. Recent research has 

highlighted links between ecstasy use and long-term mental health problems including memory loss, lack 

of concentration and clinical depression. A recent study suggests that frequent cannabis use in teenage 

girls predicts later depression and anxiety, with daily users carrying the highest risk. 82 

There is also evidence 

that about one-fifth of adolescents who smoke cannabis become dependent on the drug by early 

adulthood. The risk of young adult cannabis dependence is most likely for regular adolescent users; weekly 

cannabis use seems to mark a threshold for increased risk of later dependence, with selection of cannabis 

in preference to alcohol possibly indicating an early addiction process. 83 

More immediate risks of 

recreational drug use include dehydration due to prolonged dancing in poorly ventilated rooms, traffic 

and other accidents, and the health risks of tablets taken and sold as ecstasy but containing other 

psychoactive substances. 79 


Which adolescents smoke, drink and use drugs? 

Several investigations have been made into the correlation between personality type, social circumstance 

and adolescent smoking, drinking and drug use. 

It is clear from the rates of drug use, smoking and, especially, drinking among adolescents that these 

activities are not confined to the margins of adolescent life. Of the three activities, drug use is most 

commonly associated with social disadvantage. From reviewing recent studies however it is evident that no 

specific personality type, family background, socio-economic grouping or environmental situation 

categorically predicts drug use. 81 

The Joseph Rowntree Foundation published research in 1997, based on 

quantitative re-analysis of a survey and qualitative interviews, which showed that adolescents who had tried 

an illicit drug tended to be similar to those who had not in terms of sociability, self-esteem, ‘puritanical’ 

outlook and levels of trust and respect for their families. 84 

The findings of the Joseph Rowntree Foundation 

have more recently been repeated by the European Monitoring Centre for Drugs and Drug Addiction 

which stated that, contrary to common stereotypes, adolescents using recreational drugs are found 

predominantly among the young, studious, employed and relatively affluent. 79 

Although smoking, drinking and drug use are widespread among adolescents, ‘risk’ and ‘protective’ 

factors have been identified which help to predict these activities. A survey of 11 to 16 year old pupils in 

five English schools identified several social factors influencing these activities. These ‘risk factors’ were 

ranked in the following order of importance: 

• concurrent use of second and third substances 

• having been in trouble with the police 

• perceived poor academic performance and low academic expectations 

• a lack of religious belief 

• coming from a non-intact family 

• favouring peer over family opinion 

• having been suspended from school. 

Many of these relationships were age-sensitive. Substance use peaked at age 15. 85 

A number of risk factors have been associated specifically with the uptake of smoking. These include the 

smoking behaviour and attitudes of parents, siblings and peers, family structure, school factors, risk 

behaviours, self-esteem and health concerns. 86 

Across Europe smoking prevalence among 15 year olds is 

lowest among those in intact families and highest among adolescents in stepfamilies. 87 

Young people are more likely to smoke if family and friends are smokers. 65 

The Health Survey for England 

1997 found that levels of smoking among 13 to 15 year olds were higher in households where at least one 

adult smoked (24%) than in households where no adults smoked (7%). 23 

However, parents who smoke 

influence young people’s smoking habits less than same sex siblings who smoke. A ‘smoking’ close friend 

consistently appears to be an important influence. 65 

Studies have also found that peer group structure, 

consistently described by young people as hierarchical, is closely related to smoking behaviour. In one 

study, girls at the top of the social pecking order who projected an image of high self-esteem were 

identified as the most likely to smoke. 88 

The Teenage Smoking Attitudes Survey of 1998 found that 11 to 

15 year olds with higher educational expectations were less likely to take up smoking. 89 

The prevalence of ‘regular’ or ‘current’ smoking among adolescents does not normally appear to be 

significantly differentiated by social class. ‘Regular’ smoking can, however, be defined by surveys as having 

smoked at least one cigarette a week. A study in the west of Scotland, which examined the association 

between social class and adolescent smoking, found that the ratio of smokers from unskilled compared 

with professional backgrounds rose with increasingly stringent definitions of smoking. 90 

The Health Survey 

for England 1997 also found that both self-reported cigarette smoking and cotinine (a metabolite of 

nicotine) tests showed relatively low levels of cigarette smoking among adolescents in households in social 

class I and high levels among those in households in social class V. In analysis by accommodation type, 


18 

smoking prevalence was highest among young people in social housing and lowest among those in owneroccupied 

accommodation. 23 

Lists of ‘risk’ and ‘protective’ factors associated with drug misuse have also been published. 81 

In contrast to the term ‘drug use’, ‘drug misuse’ is often defined as drug taking which harms health 

or social functioning. Drug misuse may entail dependency (physiological or psychological) or drug 

taking that is part of a wider spectrum of problematic or harmful behaviour. 91 

The factors associated with drug misuse include environmental influences such as availability, family 

influences including whether or not there is appropriate supervision, individual and personality factors 

including links with poor mental and emotional health 91 

and educational factors. 78,92 

In 1996 the Health Advisory Service (HAS) detailed the factors associated with adolescent or adult 

drug misuse: 93 

• physiological factors: 

physical disabilities 

• family factors: 

belonging to families who condone substance misuse, where there is parental substance use, 

where there is poor and inconsistent family management, where there is family conflict 

• psychological and behavioural factors: 

mental health problems, alienation, early peer rejection, early persistent behavioural problems, 

academic problems, low commitment to school, association with drug-using peers, attitudes 

favourable to drug use, early onset of drug or alcohol abuse 

• economic factors: 

neighbourhood deprivation and disintegration. 

Many of these risk factors also predict other adolescent problem behaviours such as alcohol problems, 

smoking, crime and sex-risk behaviour. 81 

Although experimentation with drugs cuts across the social spectrum during adolescence, problematic 

patterns of use are concentrated among those who are worst-off. 91 

The risk factors which have been 

associated with problematic drug use in adolescence include youth offending, truancy, school exclusion, 

family problems and deprived communities. These are likely to be more prevalent among particular 

groups including those who are in the care of social services, those with parents who misuse drugs, young 

offenders, the homeless, school excludees and truants and those involved in prostitution: a combination 

of these experiences seems to increase adolescents’ vulnerability to substance misuse. 93 

Vulnerable adolescents have higher lifetime prevalence rates for the whole range of substances than their 

non-vulnerable peers. Those that use drugs generally start at an earlier age than do young people generally 

and commonly try an illegal drug by the age of 13 (they also initiate alcohol and tobacco use between one 

to two years earlier than their peers). 93 

The period following the transition to secondary school can be a 

particularly vulnerable time during which ‘at risk’ adolescents may become progressively disengaged from 


school while experiencing poor levels of supervision in the home. 93 

Comorbidities are vital to understanding smoking, drinking and drug use among adolescents. Concurrent 

use of the second and third substance is the highest risk factor for involvement in any one of these three 

activities. The Health Survey for England 1997 found that among 16 to 24 year olds, there was an 

association between alcohol and cigarette smoking: smokers were considerably more likely than nonsmokers 

to drink more than 21 units a week (males) or 14 units (females). 23 

Moreover, many of the risk 

factors associated with these activities are common to all three. 

It has been estimated that at least two-thirds of young people with substance misuse disorders are likely to 

have co-existing (usually pre-existing) psychosocial problems. 94 

Positive correlations have been found 

between substance misuse and suicide, depression, conduct disorder, school dropout and poor 

achievement. Traumatic events such as family conflict, bereavement and sexual abuse seem to initiate or 

increase drug use. 93 

It is likely that there is reciprocity between mental health disorders and substance 

misuse: the former acts as a potent risk factor for the latter, and substance use can contribute to the 

existing disorder. .9 

Interventions in adolescent smoking, drinking and drug use 

Interventions in adolescent smoking 

The white paper Smoking kills set targets to reduce the prevalence of regular smoking among adolescents 

from a baseline of 13 per cent in 1996 to 11 per cent by 2005 and 13 per cent or less by 2010. 95 

The 

Government’s tactics include making clear the risks of smoking and enforcing the law on under age sales. 

Scotland has also set targets to reduce adults’ and children’s smoking behaviour. It hopes to reduce the 

prevalence of smoking for 12 to 15 year olds from 14 per cent in 1995 to 12 per cent in 2005 and 11 per 

cent by 2010. It also aims to reduce the social class gradients in the prevalence of smoking. 96 

Interventions in adolescent drinking 

The government has made a commitment to implement a National Alcohol Harm Reduction Strategy 

by 2004. 

The Home Office has an interest in adolescent alcohol consumption because of the crime and disorderly 

behaviour that can result from irresponsible use. Its current strategy includes the enforcement of licensing 

regulations and consideration of education policy. The Department for Culture, Media and Sport, which is 

responsible for licensing laws, will introduce new measures to back-up restrictions on underage drinking. 

These are set out in the Time for reform proposals for the modernisation of our licensing laws white paper. 97 

During the nineties, new ranges of alcohol drinks such as alcopops were introduced onto the market. 

There has been significant debate on the appeal and marketing of these drinks to adolescents. 73 

Since 1990 

there has been a substantial increase in the popularity of spirits and alcopops among 11 to 15 year olds, 

and especially among girls. 98 

Currently there is a voluntary code of practice governing the marketing of 

alcoholic drinks. Complaints can be made if it is considered that alcoholic drinks are marketed to appeal 

in particular to under-18s. However, there are no legislative powers to undertake enforcement. 73 

The UK 

government considers that non-statutory controls are effective in subjective areas of advertising and 

promotion content where they believe formal regulation is apt to be contentious. 99 

In 2002 the Scottish Executive launched a plan for action on alcohol problems. Two key priorities of the 

plan are to reduce binge and harmful drinking by children and adolescents. Methods include a national 

communication strategy, prevention and education including school-based education and a framework 

leading to the improvement of and support for treatment services. 99 


20 

Interventions in adolescent drug use 

Prevention of drug misuse is one of the Secretary of State for Health’s 13 priorities and is subsumed within 

the NHS Plan. 100 

The government’s 1998 10-year strategy for tackling drug misuse Tackling drugs to build a better Britain 

announced significant new investment in drugs education and prevention. The strategy had four 

main aims: 

• helping adolescents to resist drugs misuse 

• protecting communities 

• improving treatment 

• stifling the availability of drugs. 101 

When launched in 1998, the 10-year drugs strategy aimed to reduce ‘last year’ and ‘last month’ use of 

cocaine and heroin among adolescents under 25 by 25 per cent by 2005 and 50 per cent by 2008. 101 

All local public agencies including the NHS, social services, police, probation, youth offending teams and 

education, are required to work together in planning drug misuse services. Each area has a Drug Action 

Team (DAT) coordinator to facilitate this work and provide substance misuse education for all adolescents 

and their families, advice and support for vulnerable groups, early identification of need and tailored 

support to those that need it. 102 

In 2001 The young person’s substance misuse plan set out to ensure that drug 

interventions for adolescents are part of the provision of mainstream children’s services. 81 

In 2002 the government launched the Updated drug strategy 2002. 103 

This modifies the targets established by 

the 1998 drugs strategy to reduce Class A drug use to a set of vaguer promises. In addition, the Updated 

drug strategy 2002 will: 

• aim to increase participation of problem drug users in treatment programmes by 55 per cent by 

2004 and 100 per cent by 2008 

• launch a new communications campaign 

• expand drug education and prevention programmes 

• improve services for parents and carers 

• expand substance misuse treatment within the youth justice system. 

The Updated drug strategy 2002 also aims to improve treatment and support. This involves, among other 

measures, increasing the involvement of GPs and other primary health care professionals working with 

drug users. Drug prevention takes place in the context of the Health Advisory Service four-tiered model 

of service interventions for adolescents where Tier 1 targets the general population, Tier 2 identifies the 

vulnerable, Tier 3 responds to those in need and Tier 4 provides specialised and intensive forms of therapy 

and other interventions for young drug misusers with complex needs. 81 

The government’s current strategy focuses early interventions on people in vulnerable groups including 

the homeless, children in care, truants and children excluded from school, young offenders and children 

of drug users. Non-school services such as ConneXions and Positive Futures are intended to play an 

important role in ensuring vulnerable adolescents have access to education, diversions and support. 102 

NHS funding has been allocated for primary healthcare professionals to offer support to teachers in 

delivering drugs education as part of Personal Social and Health Education. These schemes have been 

piloted and interesting case studies and guidance are available. 102 

During these pilot interventions GPs 

have worked in primary school lessons to assist with drugs education. Under similar future schemes, 

schools will be encouraged to work in partnership with other primary healthcare professionals, police, 

drugs agencies and the youth service. 102 


Although the UK government is responsible for setting the overall drug strategy, each devolved 

administration exercises its delegated powers to shape the strategy to address local circumstances. The 

Scottish Executive set out its drugs strategy in Tackling drugs in Scotland: action in partnership and in 2000 

Wales launched Tackling substance misuse in Wales: a partnership approach. 

Evaluating the effectiveness of interventions in adolescent smoking, 

drinking and drug use 

Many risk taking behaviours such as binge drinking and drug use, peak during adolescence and early 

adulthood. Most adolescent use of recreational drugs is limited to a particular phase in a young person’s 

life before work and family responsibilities take over. Evidence suggests that the main limiting factor of 

these behaviours is change in circumstance. 79 

Nevertheless, the risk taking behaviours of adolescents are 

of concern to the government. Effective intervention would improve adolescents’ current and future 

health and may prevent the development of addiction. This section reviews some of the most common 

types of intervention in adolescent smoking, drinking and drug use. 

Limiting the availability of cigarettes, alcohol and drugs 

Controlling access to cigarettes is a well established strategy in attempts to prevent adolescents from 

becoming addicted to tobacco. This forms part of the government’s strategy set out in the white paper 

Smoking kills to reduce the prevalence of smoking among young people. The government is also hoping to 

reduce drinking among adolescents by enforcing the law on under age drinking. In drugs policy too, 

limiting the supply of illegal substances has consistently represented an important strand of the 

government’s tactics. 78 

There are two main strategies for limiting the access of adolescents to cigarettes and alcohol. Firstly, the 

government can enforce existing age restrictions on the purchase of these commodities in the hope that this 

will decrease their physical availability, secondly, it can choose to increase the price of tobacco and alcohol 

products thereby reducing their economic availability. In the case of drugs, the government can attempt to 

reduce both the physical and economic availability to adolescents by decreasing supply in the UK. 

A reduction in the availability of illegal substances in the UK as a whole would reduce their use among 

adolescents. However, the efficacy of efforts to reduce the availability of cigarettes and alcohol for a specific 

age group is debatable. There is ample evidence that the great majority of young smokers have little or no 

difficulty purchasing cigarettes from a variety of retail outlets. 68 

Enforcement of licensing laws can have an 

effect on retailer behaviour but it is less clear whether these measures are likely to have much impact on 

adolescent behaviour. 104 

The Schools Health Education Unit found that, in 2001, 14 and 15 year olds were 

less likely to buy cigarettes from a shop than in previous years. As this activity is illegal for the under-16s, 

the downward trend suggests that attempts to dissuade young people from buying cigarettes from shops 

may be working. 65 

However, there are many potential sources of cigarettes for adolescent smokers 

including parents, friends and vending machines. 105 

A survey of drinking behaviour among 11 to 15 year 

olds in 2000 found that 49 per cent of pupils who have ever had a drink never buy alcohol. Purchasing 

from off-licenses (17% in 2000) or shops/supermarkets (9%) has become markedly less common since 

1996, whereas increasing numbers have been purchasing from friends or relatives (17%). 98 

Increasing the cost of cigarettes and alcohol may be a more effective method of reducing their use by 

adolescents. The evidence that tax and price increases reduce alcohol-related harm is stronger than that 

for the efficacy of educational measures. 106 

Increasing the price of cigarettes quickly and sharply has also 

been suggested as a potentially effective area for policy change to impact upon adolescent tobacco use. 107 

Smoking habits among adolescents have been found to be driven by the availability of both cigarettes and 

money. One study found youth, minorities and low-income smokers to be two to three times more likely 

to stop smoking than other smokers in response to price increases. 108 

However, while a packet of cigarettes 

can be perceived as expensive, adolescents do not necessarily consider individual cigarettes themselves to 


22 

be expensive given the amount consumed, the availability of single cigarettes from friends or unscrupulous 

retailers, and the relative availability of cheap cigarettes on the black market. 105 

For this reason there can 

be no guarantee that increasing the cost of cigarettes will reduce adolescent smoking. Unless tobacco tax 

closes the price gap between products, an increase in the price of premium brands can only lead to an 

increase in consumption of cheaper brands, including hand-rolling tobacco. 

Managing the availability of cigarettes, alcohol and drugs does not directly tackle the attitudes of 

adolescents to these substances. This makes it unlikely that adolescents will modify their behaviour where 

these substances are still available. Attempts to limit the availability of cigarettes and alcohol also fail to 

take into account the maturity and autonomy that adolescents often feel lies behind their decision to 

smoke or drink. It has been found that adolescent smokers believe that they are old enough to make up 

their own minds about smoking and, as a result, tend to hold negative opinions about the importance and 

effectiveness of tobacco control. 105 

Regulating the advertising and marketing of cigarettes and alcohol 

Advertising and marketing are likely to be relevant in adolescents’ decisions to start smoking or 

drinking. 104,105 

The Teenage Smoking Attitudes Survey of 1998 found adolescents’ awareness of cigarette 

advertising and sponsorship of sport to be well established. 89 

The Centre for Social Marketing study found 

not only that peer activity and social norms support drinking and intoxication, but that active marketing 

and retailing strategies positively encourage and enable the process. In the wider environment perceived 

general population norms and marketing activity generate a sense of acceptability and encouragement of 

drinking among adolescents. 71 

Calls for tighter regulation of advertising, broadcasting, sponsorship and packaging of both alcohol and 

cigarettes have wide support. Alcohol Concern has recently made detailed recommendations for 

controlling the promotion of alcohol and for promoting responsible drinking. 109 

Appropriate, clear 

labelling may also help promote healthy behaviour among adolescents. Health warnings against excessive 

alcohol consumption could be incorporated into alcohol advertisements while lower cost, low alcohol and 

non-alcoholic drinks are promoted. 110 

Educating adolescents about the dangers of tobacco, alcohol and drugs misuse 

School-based education, has been the most common method used to prevent the uptake of adolescent 

smoking, drinking and drug use. For example, educating adolescents about the risks of smoking is one of 

the key tactics currently used by the government to reduce the prevalence of regular smoking. Similarly, 

the Scottish plan for action on alcohol gives priority to public information and education, with less 

emphasis on control policies and treatment. 72 

This approach can have several drawbacks, the most obvious being that school-based programmes often 

fail to reach the most vulnerable adolescents who may be excluded from, or non-attenders at, school. 

Education programmes for adolescents may also be provided too late since attitudes towards smoking may 

already be established. Where education is provided, it has therefore been suggested that policy makers 

should consider targeting children as young as four to eight years of age. 104 

The approaches traditionally used in school-based education have also been questioned. A review of 

recent studies, mostly from the US and Canada, found that evidence for the effectiveness of school-based 

programmes in preventing the uptake of smoking is limited. 104 

The Schools Health Education Unit found 

that the proportion of adolescent smokers wanting to give up had not risen between 1983 and 2001, 

despite anti-smoking campaigns and health education programmes. This suggests that anti-smoking 

information is not effective for these adolescents or that the other ‘smoking’ influences are too great for 

anti-smoking campaigns and health education programmes to overcome. 65 


In the past, education strategies have often included scare or shock tactics, based on the assumption that 

adolescents started to smoke because they lacked knowledge about the adverse effects associated with 

smoking. 104 

However, a study of adults in Britain found no evidence to suggest that smokers deny the health 

risks of smoking: 111 

a study of adolescent smokers in the UK and US found that most respondents perceived 

themselves as mature, informed, autonomous and knowledgeable adults at low risk from the long-term 

consequences of smoking. 105 

Health promotion messages and advice on smoking cessation generally focus upon the negative aspects of 

continuing to smoke and contrast these with the benefits of giving up; yet many smokers perceive a 

number of benefits from smoking, and health and social problems with the process of cessation. 112 

The 

1998 Teenage Smoking Attitudes Survey found that smokers were more likely than non-smokers to 

perceive benefits from smoking – such as its perceived calming effects and role in image and slimming. 89 

Another study of adolescent smokers’ perceptions found that they identified many benefits of smoking, 

enjoyed the physiological effects and social benefits and perceived it to relieve stress, reduce boredom and 

boost self-image and identity. 105 

It has been suggested that perceived benefits of alcohol consumption, based on personal positive 

experiences, also play an important role in the drinking behaviour of adolescents. Therefore, like smoking 

policy, alcohol education may need an increased focus on positive outcomes. 113 

Though acknowledgement of the attractive, pleasurable aspects of smoking and drinking and even drug 

use may be seen as unacceptable and irresponsible, it could provide an opportunity to relate better to 

adolescents. 112 

Understanding adolescents’ attitudes and behaviours before implementing education 

policies is likely to increase the effectiveness of interventions. It is the perception that adults do not 

understand adolescent choices that may sometimes limit the impact of health education. Where education 

is used to encourage prevention there is evidence that peer-led programmes are more effective than 

teacher-led programmes. 114 

More methodologically sound evaluations of interventions undertaken in schools are needed to judge the 

efficacy of health education programmes and promote good practice. 

Education promoting the development of social skills 

Health education policy in schools has recently begun to move away from the traditional emphasis on risk, 

towards an emphasis on social and environmental factors which influence smoking, drinking and drug 

use. The government’s present drug strategy for example seeks to teach people from the age of five 

upwards ‘the skills needed to resist pressure to misuse drugs’. 102 

Evidence for the effectiveness of these 

strategies is scarce. Adolescents may reject such approaches if they feel that their behaviour is determined 

by personal choice. 105 

Moreover, these programmes are unlikely to reduce initial experimentation if, as 

some evidence suggests, 84 

people who try drugs possess similar or greater levels of attributes such as selfesteem 

as the general population. 

Nevertheless, reviews of the existing evidence suggest that programmes which combine components on 

short-term health, information on social influences and training on how to resist pressure, seem to be 

more effective than traditional knowledge-based interventions. 104 

The Health Development Agency has 

found that interactive programmes, which foster the development of interpersonal skills, may reduce 

alcohol use. 114 

While life skills programmes may not prevent initial experimentation, they may help to 

prevent misuse and could be targeted at those most likely to develop problems. 84 

The use of mass media 

Mass media campaigns have become increasingly popular and are seen as a particularly appropriate 

method for delivering health messages to adolescents. There are methodological problems with many of 

the studies of media interventions but some support seems to be provided for their effectiveness. 104 

There 


24 

is potential to use the media, not only to publicise the risks of smoking, drinking and drug use, but also to 

disseminate information on substance abuse and how specifically to access medical services to help. 110 

The intensity and duration over which health education messages are delivered appear to be important 

factors. Research suggests that health education messages also need to come from a credible source; a 

government or even NHS provenance may be rejected. 115 

Campaigns should be adequately funded and 

their messages must be kept simple and relevant. Consideration needs to be given to the information 

presented in media campaigns, especially since, by its nature, it is not targeted at key populations. 

Targeting interventions in adolescent smoking, drinking and drug use 

As discussed earlier, some adolescents are more vulnerable than others to smoking, hazardous drinking 

and the misuse of drugs. It is important that health policy recognises this fact and, especially where 

resources are scarce, targets interventions to ‘at risk’ populations. Responses to widespread recreational 

drug use and drinking should focus specifically on those who are most at risk of developing problematic 

habits and long-term health problems, even though general use is widespread. 79 

Because the most 

vulnerable adolescents are often disengaged from the education system, targeted intervention must be 

integrated into the wide range of other services provided for vulnerable young people. 93 

This suggests that 

successful intervention strategies will be multiprofessional in nature and necessitate a good awareness of 

drugs issues among staff in all adolescent services. 

Targeting interventions at the most vulnerable adolescents is often associated with early, pre-emptive, 

interventions. In the context of substance misuse for example, it has been suggested that interventions 

should focus on children who, in primary school, begin to display educational or behavioural problems, 

or appear to be disengaging from education. Early, targeted intervention in these cases could consist of 

extra support in the last few years of primary school to ease the transition to secondary schools. 93 

The 

government’s current drugs strategy is commendable in that it aims to target resources on the most 

vulnerable adolescents. 

Multifaceted interventions 

There is evidence that community approaches involving multiple coordinated intervention components 

can influence adolescent behaviour, particularly when multiple sites within a community are targeted. 104 

For example, age restrictions for tobacco purchase, smoke-free public places, media campaigns and school 

programmes can be combined in an integrated approach. Multifaceted approaches to smoking prevention 

recognise the complex range of individual, social and environmental factors influencing decisions to 

smoke, drink and use drugs. 104 

There is evidence to suggest that restrictions on smoking at home, even when parents smoke, more 

extensive bans on smoking in public places, and enforced bans on smoking at school may reduce 

adolescent smoking. Such measures give an unequivocal message to adolescents about the unacceptability 

of smoking. 116 

The government’s Healthy Schools Programme recognises the influence of the school 

environment. Although school smoking bans are common, they are often poorly complied with. Both the 

absence of smoking policies in schools, or lapses in enforcement, may be instrumental in shaping 

adolescents’ views about the acceptability of smoking. 105 

Schools should aim to create supportive 

environments by consistently enforcing bans on pupil smoking. 104,116,117 

Harm minimisation approaches 

Harm minimisation approaches to mainstream recreational drug use are common throughout the EU. 79 

For example, simple, basic rules in the organisation of dance events can effectively prevent some 

immediate harm caused by drugs such as ecstasy. Dissemination of information on long-term risks to 

recreational drug users at nightlife venues may also be useful. 79 

For injecting drug users, harm 

minimisation interventions such as needle exchange schemes have been in operation for many years in an 

attempt to prevent the transmission of blood borne diseases such as hepatitis C and HIV. 


Treatment 

The treatment of adolescents involved in substance misuse has not traditionally been high on the 

government’s agenda. While there is a growing body of evidence on the effectiveness of treatments in the 

adult addiction literature, there is a dearth of literature regarding the treatment of adolescents. 9 

Services 

and programmes for the treatment of smoking, drinking and drug use have been fragmented and are 

often ill-equipped for dealing with adolescents. Many treatment programmes are biased towards adults 

and involve adopting adult treatment models. 9 

However, given the already high prevalence of regular 

smoking and drug use in this age group, and the worrying levels of alcohol dependence, helping 

adolescents to change their habits may be as important as prevention. In contrast to alcohol or drug use, 

misuse is likely to necessitate clinical intervention. 93 

Brief interventions in hospital emergency departments or in primary care settings have been shown to 

reduce hazardous and risky drinking. 118,119 

There is also strong evidence for the effectiveness of brief 

interventions in the treatment of adolescents with early signs of drug misuse. A brief intervention typically 

consists of two or three sessions in which education on substance use is combined with attempts to increase 

the participant’s motivation to think about and address their substance using behaviour. 81 

Cessation counselling and substitute prescribing can help modify smoking and drug taking behaviour. 

Many adolescent smokers may have tried to quit at least once. 120 

The Schools Health Education Unit found 

that, in 2001, 75 per cent of adolescent smokers wanted to give up. 65 

The three most common reasons 

regular smokers of 11 to 15 try to give up is worry about health, cost and fitness. 89 

Knowing this may help 

to inform education and treatment policy. One study in 1991 found that 60 per cent of teenage smokers 

who received smoking cessation counselling agreed a contract with the GP to give up. 121 

Trials are currently 

under way to assess the effectiveness of nicotine replacement therapy for people under 16. In the case of 

drug use, substitute prescribing can prevent or reduce harm to the individual or the public. 81 

Many of the problems facing dependent drug users are far beyond the remit of medical interventions and 

working in multiprofessional teams is becoming an increasingly popular approach in treating and 

intervening in adolescent smoking, drinking and drug use. This may involve collaboration between 

doctors, school health services, young offenders teams, social workers and specialist treatment centres. 

This is a particularly valuable approach in drug prevention, where adolescent use is frequently related to 

other complex, non-medical social problems. 81 

The answers to adolescent smoking, drinking and drug use are unlikely to be simple and will probably 

require multiprofessional and multi-tiered service provision. Alcohol Concern, and similar organisations, 

are calling for coordinated core services for those in need of support and treatment. This would include 

outreach work, screening in primary healthcare and hospital settings, minimal interventions and brief 

treatments within primary healthcare, hospital and alcohol services settings, longer term specialist 

remedial treatment and self-help support groups. 109 


26 

Summary 

Adolescents in the UK are increasingly likely to experiment with smoking and use recreational 

drugs. Over time they have begun to drink greater quantities of alcohol and now have one of the 

highest levels of alcohol use and binge drinking in Europe. Smoking, drinking and drug use are all 

significantly related to age and their use increases throughout adolescence. There are slight gender 

differences; girls are more likely than boys to smoke, but drinking and drug use are slightly more 

common among boys. The use of addictive substances is spread across all sections of the adolescent 

population. However, certain social, educational, family and peer factors are associated with the use 

of alcohol, tobacco and drugs and problematic use is concentrated among the worst off. Many 

young people who misuse substances are likely to have co-existing mental health problems. 

The risks of using addictive substances are well documented. Adolescents who smoke suffer 

increased mortality and morbidity including poorer respiratory health, lung cancer, heart disease 

and stroke. Heavy drinking and drug use can lead to physical, emotional, mental and social 

problems. All three types of substance abuse pose risks of dependence. 

The government has set targets to reduce the prevalence of smoking and drug use among 

adolescents and is working on interventions to tackle alcohol misuse. It is also working to provide 

targeted education and coordinated services for adolescents and drug users. 

Changes in circumstance and the acquirement of responsibilities are often the most effective factors 

in stopping the abuse of alcohol and drugs. However, in view of the damage that these substances 

can inflict and their addictive nature, policy makers are bound to continue to seek effective 

interventions. Reducing the availability of drugs, cigarettes and alcohol may have an impact on 

adolescent use. In particular, there is evidence that increasing the price of cigarettes and alcohol 

may be an effective intervention. However, these policies can prove impractical and do nothing to 

tackle adolescents’ attitudes. Stronger regulations of the marketing of cigarettes and alcohol may 

help to change attitudes and reduce abuse. Education, though an important strategy, may fail to 

reach the most vulnerable adolescents. If it is used, incorporating an understanding of adolescents’ 

attitudes and an element of social skills development is likely to be important. Media strategies and 

multifaceted community interventions can help to reduce smoking, drinking and drug use among 

this age group. Harm minimisation and treatment, though not historically a focus of intervention, 

may become more important, particular in helping to reduce the prevalence of smoking. Since 

misuse of alcohol and drugs is concentrated among the disadvantaged, targeting successful 

intervention is likely to be both efficient and effective. 


Mental health 

The mental health of adolescents 

The mental health of adolescents is extremely important, not only in itself, but also because of the strong 

links that it has with adolescent health risk behaviours, violence and delinquency. In many senses, mental 

health is at the centre of adolescent health frameworks. Poor mental health can influence exercise 

patterns, obesity and body image, substance abuse and sexual behaviour. 

A recent Office for National Statistics (ONS) survey reported that one in 10 children and young people 

suffer from a mental disorder. 122 

However, many commentators suggest that, at any one time, up to one in 

five children and young people experience some form of psychological problem. 123 

Young Minds, a child 

mental health charity, has calculated that in any secondary school of 1,000 pupils there are likely to be 50 

pupils who are seriously depressed, 100 suffering serious distress, between 10 and 20 pupils with obsessive 

compulsive disorder and between five and 10 girls with an eating disorder. 124 

This chapter reviews the mental health of adolescents in the UK. It begins by outlining common 

definitions of mental health and explaining some of the methods used to measure it. It then explores the 

prevalence of mental health disorders among different groups of adolescents. Finally, current 

interventions in the mental health of adolescents are outlined and assessed. 

Defining and measuring mental health 

As a recent review of mental health data 125 

notes, inconsistency arises because there is no agreed definition 

of what constitutes mental health. The clinical model tends to focus on ‘mental disorders’, or illnesses 

usually associated with considerable distress and interference with an adolescent’s everyday life. 122 

‘Mental disorders’ can include: 

• emotional disorders such as phobias, anxiety and depression 

• conduct disorders 

• hyperkinetic disorders such as attention deficit disorder 

• developmental disorders 

• habit disorders 

• eating disorders 

• post-traumatic syndromes 

• somatic disorders such as chronic fatigue syndrome 

• psychotic disorders such as schizophrenia and drug-induced psychosis. 126 

An alternative definition of mental health includes general happiness and overall satisfaction with life, 

rather than just the absence of clinical disorders. Some commentators refer to this as ‘emotional 

wellbeing’. 125 

Measuring the mental health of adolescents is difficult. Medical records focus on narrow clinical 

definitions and record only those people who use services. For this reason, most data sources rely on 

questionnaires administered to the general population to gain information on adolescents’ mental health. 

For example, the ONS uses a combination of clinical measures and the General Health Questionnaire 

(GHQ12) for 13 to 24 year olds, or the Strengths and Difficulties Questionnaire (SDQ) for four to 15 year 

olds. The self-administered GHQ12 asks about general levels of happiness, depressive feelings, anxiety and 

sleep disturbance while the SDQ is filled out by parents and focuses on emotional and behavioural 

problems. 


28 

Mental health problems in adolescence 

Adolescence is an important phase for mental health. Early adolescence (11 to 14 years) is characterised 

by high rates of conduct and emotional disorders, with adult-type depressive disorders beginning to make 

an appearance. Mid and late adolescence are peak ages for the onset of depressive disorder, 

schizophrenia 124 

and other mental health disorders. While statistics are available on the general mental 

health of adolescents, certain disorders are commonly isolated by researchers due to their relatively high 

prevalence among adolescents or their high rates of related mortality. 

Conduct disorders, the most frequently diagnosed disorders for children and young adolescents, are 

characterised by a repetitive and persistent pattern of dissocial, aggressive or defiant conduct. Conduct 

disorders in childhood predict many adverse developmental outcomes, including educational 

underachievement, juvenile offending, substance misuse and dependence, anxiety, depression and suicide 

attempts. 94 

Depressive symptoms are very common in adolescence. There is now good evidence for a modest genetic 

component of these symptoms. 94 

The ONS survey of 2000 estimated that depression occurs in 1.7 per cent 

of boys and 1.9 per cent of girls between the ages of 11 and 15. 122 

Most depressive disorders at this age are 

comorbid with anxiety states or, slightly less commonly, with conduct disorder. 127 

One of the most widely discussed mental health disorders is self-injury or self-harm. Deliberate self-harm 

involves intentional self-poisoning or injury. 128 

Common examples include; hitting, cutting or burning 

oneself, pulling hair or picking skin, and self-strangulation. 129 

As with other mental health issues, the 

prevalence of self-harm can be hard to gauge. A recent National Statistics survey found that about one in 

17 people from 11 to 15 years old had tried to harm, hurt or kill themselves. 130 

However, this figure could 

be as high one in 10. 129 

Deliberate self-harm is especially common in adolescent girls 131 

but rates are 

increasing among males. 132 

Although the mean age of the self-harm population is in the early 30s for both 

sexes, the peak age for presentation is 15 to 24 years for women and 25 to 34 years for men. 130 

Risk factors 

for female self-harm include self-harm by friends or family members, drug misuse, depression, anxiety, 

impulsivity and low self-esteem. In males, risk factors include suicidal behaviour in friends and family 

members, drug abuse and low self-esteem. 131 

Eating disorders such as bulimia and anorexia nervosa tend disproportionately to affect young females. 

They have one of the highest death rates of all psychiatric illnesses and, even when not fatal, can lead to 

serious chronic medical complications. 133 

The mental health issues affecting adolescents, unlike those affecting younger children, extend to suicide. 

Although the rate of suicide is very low under 14 years old, attempted suicide begins to occur around 11 

to 12 years old and rapidly increases in frequency in the early and mid-teens. 127 

There are 13 suicides per 

100,000 15 to 19 year olds each year; young men in this age group are particularly at risk and are less likely 

than girls to show their distress beforehand. 134 

Which adolescents have mental health problems? 

Evidence suggests that age, gender and family-related factors are extremely important in explaining the 

mental health of adolescents. 

Adolescents are more likely to experience mental health problems than younger children, and the 

likelihood of having a mental disorder increases throughout adolescence. These age differences are 

particularly pronounced for emotional disorders. 125 

The Health Survey for England of 1997 reported that 

while only 6 per cent of boys aged 13 to 15 had a score of over 4 on the GHQ12 (the threshold used to 

identify possible psychological illness), 10 per cent of young men aged 16 to 19 did. This compared to 14 

per cent of girls aged 13 to 15 and 21 per cent of young women aged 16 to 19. 23 


Most studies have found pronounced differences in mental health by gender, although effects differ by 

type of disorder. The Health Survey for England’s study of four to 15 year olds found that boys were more 

likely than girls to have conduct and hyperkinetic disorders and peer problems; girls were more likely to 

experience emotional symptoms. 23 

A Scottish study of 11, 13 and 15 year old pupils found that, by the age 

of 15, a clear excess in female general ill-health and depressive mood had emerged. 135 

The Health Survey for England 1997 found GHQ12 scores of 13 to 24 year olds did not vary significantly 

by social class or household income. The prevalence of high GHQ12 scores was greater among lone parent 

families than among two parent families. Females’ scores were significantly associated with those of their 

mother, but not their father, while scores of males were not associated with those of either parent. 23 

For children and younger adolescents, the SDQ revealed that behavioural, emotional and relationship 

difficulties increased from social class I to social class V and from higher to lower income households; 

there was a significant inverse relationship between the SDQ score and the mother’s educational 

attainment. These difficulties were more common in lone parent households than in two parent families. 23 

Using different instruments for measuring mental health, the 2000 report The mental health of children and 

adolescents in Great Britain also found that the quality of family relationships, levels of parental stress and 

family type were linked to adolescents’ mental health. 125 

The study found that mental disorders were more 

common among five to 15 year olds who 

• were children of lone parents (16% were defined as having a mental disorder, compared to 

8% of children of couples) 

• came from reconstituted families or larger households 

• came from families where parents stated that there was poor communication and low levels of 

support (18% were defined as having a mental disorder compared to 7% in other families) 

• had parents who were assessed as having a neurotic disorder (18% compared to 8% respectively) 

• had experienced three or more stressful life events (31% of children with mental disorders). 122 

In this survey of children and younger adolescents, a clear relationship was found between social class and 

mental health, with nearly three times as many children in social class V families having a mental disorder 

compared to children in social class I families. In particular, 10 per cent of children in social class V families 

suffered a conduct disorder, compared to only 2 per cent of children from social class I. The ONS study also 

found that the probability of a child having a mental disorder in a family where both parents were 

unemployed was nearly twice that of a child in a family where both adults in the family were employed. 125 


30 

Risk factors for conduct, depressive and anxiety disorders include: 

• adverse temperamental characteristics in the child 

• parental mental illness, substance misuse, marital disharmony or personality disorder 

• chronic or acute stress at school, at home or in the neighbourhood 

• use of tobacco, alcohol and illicit drugs. 

Specific risk factors for conduct disorder include: 

• inadequate parental supervision 

• use of physical methods of punishment 

• violence in the home 

• a family history of criminal behaviour 

• a history of attention-deficit/hyperactivity disorder (ADHD) in the child 

• a delinquent peer group 

• academic underachievement 

• attendance at a ‘failing’ school. 

Specific risk factors for anxiety and depressive disorders include a family history of these conditions, and 

earlier experience of child abuse. 127 

A longitudinal study of over 4,000 families found that maternal anxiety and depression, poverty, parent 

relationship conflict and marital break-up during early childhood are associated with a small, but 

significantly increased risk, of anxiety-depression symptoms in adolescence. 136 

Childhood and adolescent abuse can have a significant impact on mental health. Adolescents who 

experienced physical and sexual abuse as children are significantly more likely to experience moderate to 

severe depressive symptoms and moderate to high levels of life stress as well as regular smoking, alcohol 

consumption and illicit drug use. 137 

Evidence suggests that adolescent and persistent maltreatment have 

stronger and more consistent negative consequences during adolescence than does maltreatment 

experienced only in childhood. 138 

A recent study of the psychological effects of stress in childhood and adolescence found a significant 

association between stress and psychological symptoms. In adolescence high levels of stress, whether 

assessed in terms of negative life events or negative circumstances, were found to be associated with 

emotional disorders like depression and anxiety. The study suggested that, since there is an association 

between the total number of stressors and the probability of having mental health problems, societal-level 

factors place certain populations of children at risk. 139 

Some groups of adolescents are known to be at high risk of mental disorders. These include 

adolescents who: 

• have physical or learning disabilities 

• are in care or are care leavers 

• are excluded from school 

• are in the criminal justice system 

• are homeless 

• are young carers, especially of a parent with mental illness. 94 


Interventions in adolescent mental health 

When assessing interventions in adolescent mental health, it is important to stress the difference between 

promoting ‘emotional wellbeing’ among adolescents and the treatment of mental health disorders. The 

arenas and approaches to interventions in these two areas are markedly different. 

Promoting ‘emotional wellbeing’ 

It has been suggested that school-based mental health initiatives are appropriate interventions in 

adolescent mental health. These could include educating school pupils about mental health problems 

and screening for those most at risk. 131 

Mental health promotion focuses on public awareness and understanding of mental health to encourage 

the earlier recognition of the signs of emotional and psychological distress and add to knowledge about 

the help available. 94 

A recent study of secondary school students revealed that adolescents use an extensive vocabulary of 

270 different words and phrases to describe people with mental health problems; most of these were 

derogatory. The same research showed that short education workshops can produce positive changes in 

participants’ reported attitudes towards people with mental health problems. 140 

In 2001 the government issued guidance on promoting children’s mental health within early years and 

school settings. 141 

School nurses and other school professionals may be in a key position to help 

adolescents handle stressful events in their life before a crisis develops. 142 

For example, the identification 

by teachers of children showing sudden or gradual onset of withdrawn and depressive behaviour, 

followed by the offer of counselling, may have positive effects in the prevention of depressive disorders 

in early adolescence. In some areas, school nursing services, linked to primary care, have set up drop-in 

clinics in or close to secondary schools to provide a first-line service for less severe problems to prevent 

the development of more serious mental disorders. 127 

Schools signing up to the Healthy Schools Initiative are expected to monitor progress to achieve 

emotional health and well-being. Social skills training in schools and life skills training for at risk groups 

may help to improve the mental health of adolescents. 143 

An anti-bullying programme is now mandatory 

in all schools. These offer the possibility of reducing rates of depression and suicidal behaviour which 

may be associated with victimisation and bullying. However, few studies have examined the mental health 

problems of adolescents who are being bullied. One study found that bullied adolescents are more 

anxious. It also found that there is a relation between having a high depression score and being a bully. 144 

Sport and physical activity is generally believed to be beneficial to young people’s psychosocial health. 145 

Physical activity is associated with lower levels of mental health problems, and seems to promote selfesteem. 

One study concluded that emotional wellbeing is positively associated with extent of 

participation in sport and vigorous recreational activity among adolescents. 146 

Interventions in mental health disorders 

The present government has shown some initiative in interventions in mental health. It has for example 

launched a national suicide prevention strategy for England. 147 

Most importantly for adolescent mental 

health, a children’s national service framework, including standards for mental health services, is due to 

be published in 2004. 

Of all the issues discussed in this review of adolescent health, mental health services for adolescents are 

perhaps the least targeted. Although the government has promised to turn its attention to adolescent 

mental health strategies, the current English national service framework for mental health focuses almost 

exclusively on services for adults. 


32 

Currently, specialist mental health services for adolescents are provided by either Child and Adolescent 

Mental Health Services (CAMHS) or by adult mental health services. 124 

A recent review by the organisation 

for children’s mental health, Young Minds, 124 

found that many CAMHS and other professionals report a 

dangerous lack of service cover for adolescents with mental health problems. In reality neither CAMHS 

nor adult mental health services can always provide the services that adolescents need. Many paediatric 

wards and adult psychiatric wards are unsuitable for young people with mental health problems. Moreover, 

the transition from CAMHS to adult mental health services can prove difficult for some adolescents who 

may drop out at this point. At present CAMHS frequently does not address drug and alcohol problems 

directly, despite evidence of the strong links between alcohol and drug misuse and mental health 

problems. 

Young Minds has recommended that a mental health service for adolescents must have user sympathetic 

access and facilities which are appropriate and acceptable to young people. Staff should be interested in 

working with adolescents and have specialist knowledge of typical adolescent mental health issues such as 

self-harm, eating disorders, early psychosis and complex behavioural problems. A flexible and seamless 

service must be created to carry adolescents through to adult mental health services. Young Minds believes 

that this can be best achieved through the creation of local, virtual, multiprofessional teams for 

adolescents. 124 

The mental health of adolescents is closely related both to other health problems and behaviours. For 

example, young people who are misusing drugs or alcohol have the highest risk of death by suicide. 134 

Also, 

research indicates a link between cannabis and psychosis as well as between marijuana and depression. 148 

The National Statistics study of self-harm found that 11 to 15 year olds who had tried to harm, hurt or kill 

themselves were much more likely to have a physical complaint such as difficulties with coordination or 

epilepsy. 130 

These statistics are important to bear in mind when designing interventions in adolescent 

mental health. Understanding the prevalence of problems across different groups can help target 

interventions. It is also vital to recognise the part played by substance abuse in mental health so services 

can be delivered effectively. The Royal College of Psychiatrists has recommended that preventative 

measures should be targeted at those young people at high risk of suicide, especially those suffering from 

conduct disorder, schizophrenia, major affective disorder, drug and alcohol misuse and anorexia 

nervosa. 127 

There is an ongoing debate about who should be responsible for child mental health services. 149 

Health 

professionals including health visitors, GPs, paediatricians, clinical psychologists and psychiatrists have a 

part to play in prevention, early detection and management of mental health problems. However, mental 

health problems are often a result of a combination of biological and environmental forces. For example, 

self-harm is associated with problems with employment, education and finance. 5 

Healthcare practitioners 

may therefore be involved in the identification and treatment of adolescent mental health in partnership 

with social services and education. 150 

The Acheson Report recommended that primary healthcare should 

play an important role in identifying and coordinating the management of people at high risk. 

Community mental health teams can ensure effective working between different disciplines and agencies 

which should address all the needs of the patient, including employment, housing and social support. 5 

There are many forms of treatment for mental disorders. Psychotherapeutic approaches, for example, can 

take the form of cognitive-behavioural therapy, family or group therapy or psychodynamic therapy. Until 

recently, pharmacological treatments were considered inappropriate for the majority of adolescents 

suffering from psychiatric disorders. However, over the past decade, drug treatments have increasingly 

come to be recognised as appropriate for adolescents, albeit with caution and often in conjunction with 

psychological treatments. 94 

Since mental health problems are often the result of a combination of biological and societal factors, 

changes at a societal level may help to reduce mental illness among adolescents. For example, it has been 

suggested that reducing exposure to media images of thin women, and increasing awareness of issues 


elating to body image, self-esteem and pressure to diet in the school curriculum, may reduce the risk 

factors for eating disorders and increase young people’s resistance to them. 151 

The importance of intervention in adolescent mental health 

A recent follow up study of children and adolescents with mental health problems suggests that 

psychopathology often persists into adulthood, particularly among those with conduct disorders and 

hyperkinesis. 152 

Analysis of this persistence led the researchers to suggest that everyone in contact with 

adolescents should take the symptoms of emotional distress, behavioural difficulty and hyperactivity 

seriously, as they impair function and development and are unlikely to be transient. Evidence based 

interventions may help alleviate distress and minimise the secondary handicap that results from disrupted 

education and impaired social development caused by mental health problems in adolescence. Ongoing 

research shows that early assessment and treatment of even the more serious and enduring mental health 

disorders can reduce problems later on. 153 

For example, robust evidence exists for the efficacy of 

behavioural parenting training programmes for children with conduct disorder. 154 

School-based 

behavioural interventions can also be effective. 94 

Summary 

Up to one in five adolescents may experience some form of psychological problem. Adolescence is 

an important time in the development of mental health disorders and the likelihood of having one 

increases with age. There are gender differences in the mental health problems experienced by 

adolescents, and some evidence that socio-economic variables are related to mental health 

disorders in early adolescence. 

Family type, educational level of the mother, individual characteristics, substance misuse and 

educational factors are associated with the likelihood of developing a mental health problem. Some 

adolescents including those with disabilities, those in care, school excludees, the homeless, those in 

the criminal justice system and young carers are at a greater risk of developing mental health 

disorders. 

Interventions to promote emotional wellbeing among adolescents can include education about 

mental health problems and the identification of those in need of help. The provision of school 

nurses or some sort of first line service may help to promote emotional wellbeing. Social skills 

training and anti-bullying policies within schools may also help to promote mental health. 

There have been some recent interventions by government in adolescents’ mental health disorders 

and the National Service Framework for children is expected to introduce new interventions. To 

date however, the provision of mental health services has been inadequate and poorly targeted. 

Provision should be integrated with other services, especially those for substance abuse which is 

often linked with mental health problems. Early intervention in adolescent mental health problems 

is essential to try to stop the deterioration of mental health, alleviate distress and minimise the 

impact of mental health disorders on education and social development. 


34 

Sexual health 

Adolescents and sexual health 

This section discusses the current status of adolescent sexual health in the UK, looking specifically at the 

issues surrounding sexually transmitted infections(STIs) and teenage pregnancies. It begins by defining 

sexual health and outlining sexual activity in adolescence. It then explores the prevalence of STIs and 

teenage pregnancies. Finally, interventions in the sexual health of adolescents are outlined and assessed. 

Sexual health and sexual activity in adolescence 

As a recent review of sexual health in adolescence has noted, 6 

it is important to be clear about the scope 

of the relevant health issues in order to make a sensible assessment of the sexual health of adolescents. 

Sexual health 

At its simplest, sexual health is compromised when sex is forced or unwanted and/or it has 

undesirable health or reproductive consequences such as the transmission of an STI or the 

conception of an unwanted pregnancy. 6 

The World Health Organisation’s definition of sexual 

health goes further to include a state of physical, emotional, mental and social wellbeing related to 

sexuality. 155 

Sexual competence is an important concept for understanding adolescent sexual health. The National 

Survey of Sexual Attitudes and Lifestyles (NATSAL) 2000 used four variables relating to circumstance: 

regret, willingness, autonomy and contraception at first intercourse to construct a measure of sexual 

competence. 156 

Sexual competence may protect adolescents’ sexual health by ensuring that sexual 

intercourse is not coerced and that contraception is used to help prevent unwanted pregnancy or the 

transmission of STIs. 

Although sexual competence, particularly the use of contraception, can help to protect the sexual health 

of adolescents, no sexual intercourse is risk free. Condoms provide the best protection against STIs but 

can be an unreliable method of protection, especially among people who lack experience. At least one 

survey of pregnant teenagers has found a large proportion (in one survey, 80%) of 13 to 19 year olds 

claimed to be using contraception at the time of conception. Many of the condom users knew why the 

contraception had failed, attributing conception to the condom splitting, coming off or leaking. 157 

In England, Scotland and Wales it is illegal to have sex under the age of 16. In Northern Ireland the age 

of consent is 17. This law exists to help protect adolescents from engaging in an activity that they are not 

ready for. It is assumed that even if adolescents under the age of consent think that they want to have sex, 

they may not be mature enough to understand the consequences of their actions. A cohort study of New 

Zealanders in 1993-4 investigated how age at first sexual intercourse is related to the reported 

circumstances. It found that, among women, there were increasing rates of coercion with younger age at 

first intercourse. Most women (70%) regretted having sexual intercourse before the age of 16. 158 

NATSAL provides valuable information about early sexual behaviour in Britain. Over 11,000 participants 

aged between 16 and 44 were interviewed about first heterosexual intercourse, communication about sex, 

pregnancy and STIs. 156 

NATSAL found, among those aged 16 to 19 at interview, the proportion reporting 

first intercourse at younger than 16 years was 30 per cent for men and 26 per cent for women. 

Among adolescents as a whole there is considerable diversity in sexual experience. Evidence suggests that 

for most of those who have had sexual intercourse it has involved enjoyable, protected sex with one 

person, often as part of a steady relationship. 6 

Peer pressure to have sex has been found to be much more 

important among younger adolescents and significantly more important to adolescent boys. 159 


It is important to exercise caution about the relationship between age and sexual experience. There is 

evidence to suggest that age at first intercourse may not take into account variations in individual 

development and social norms. NATSAL found that more than a third of young women for whom first 

intercourse occurred at age 15 years were sexually competent, and more than a third of those aged 18 to 

24 were not. 156 

Among adolescents there has been a sustained increase in condom use over time; only a small minority of 

the 16 to 19 year olds interviewed (7.4% of men and 9.8% of women) reported having had unprotected 

first intercourse. 156 

A quarter of young women were already using oral contraception at first intercourse. 156 

Among 16 to 24 year olds, non-use of contraception increased with declining age at first intercourse; 

reported by 18 per cent of men and 22 per cent of women aged 13 to 14 at occurrence. 156 

Adolescents and STIs 

STIs have increased in the UK in recent years. The Health Protection Agency (formerly the Public Health 

Laboratory Service or PHLS) collates comprehensive data on communicable diseases seen in 

genitourinary medicine (GUM) clinics – these do not include cases treated in primary care. Data show 

that, between 1995 and 2000, diagnoses of gonorrhoea, syphilis and chlamydia all more than doubled in 

England, Wales and Northern Ireland. 160 

In England, the latest figures indicate an increase of 78 per cent 

in cases of gonorrhoea since 1997. Chlamydial infection has increased by 73 per cent and syphilis by 374 

per cent. 3 

Large and increasing numbers of diagnoses of STIs among adolescents, especially females, are of 

particular concern. 160 

Chlamydia is most commonly seen in young people; the peak age is between 

20 and 24 in men and between 16 and 19 in women. Two pilot studies of chlamydia screening carried out 

in the Wirral and Portsmouth reported that 10 per cent of women under 25 years of age attending health 

services and being screened were infected with chlamydia. 3 

Young women have been found to be at greater 

risk of chlamydial reinfection than those over the age of 25. 161 

One of the reasons for the currently high prevalence rates of STIs is that most, such as chlamydia and 

gonorrhoea, may go undiagnosed because the infection is asymptomatic and screening is not widely 

available. This enables STIs to spread rapidly and sometimes reach epidemic proportions. 160 

In a single act 

of unprotected sex with an infected partner, adolescent girls have a 1 per cent chance of acquiring HIV, a 

30 per cent risk of getting genital herpes and a 50 per cent chance of contracting gonorrhoea. 162 

Costs of 

STIs to the individual, society and the NHS include preventable infertility, ectopic pregnancy, hospital 

admissions for pelvic inflammatory disease, and psychological stress. 160 

Adolescents and ‘teenage pregnancy’ 

There is no biological reason to suggest that having a baby before the age of 20 is associated with ill health. 

In fact it is older women who face increased risk of chromosomal abnormalities and complications of 

pregnancy. 163 

The children of adolescent mothers can fare as well in physical and social terms as those born 

to older women. Early childbearing can protect women from breast cancer, and their children from 

diabetes. 164 

Many teenage pregnancies are, however, unplanned. Being an adolescent parent can lead to 

an increase in relative poverty, unemployment, poorer educational achievements and poor health of the 

child born. 165 

Evidence suggests that teenage pregnancy can increase the likelihood of having a low birth 

weight baby 166 

and the risk of sudden infant death syndrome. 167 

Children of teenage mothers are also more 

likely to be admitted to hospital as a result of an accident than the children of older mothers. 168 

Forty-one 

per cent of teenage mothers have an episode of depression within one year of childbirth. 169 

Some people argue that the so called public health problem of teenage pregnancy is really a reflection of 

what is considered to be socially, culturally and economically acceptable in the UK. 163 

However, although 

teenage pregnancy is not necessarily a public health problem, the cumulative effect of social and economic 

exclusion on the health of mothers and their babies, whatever their age, is. 163 

Teenage motherhood often 


36 

interferes with the adolescent’s education. High teenage pregnancy rates are linked to high levels of social 

exclusion and poor knowledge of contraception; they partly reflect poor sexual health practice. 165 

Rates of teenage pregnancy are higher in the UK than in other western European countries. 170 

The UK has 

a teenage pregnancy rate almost five times higher than in the Netherlands and over three times higher 

than Denmark. In the developed world only the United States has a higher rate of teenage pregnancy. 171 

Teenage (under 20) conception rates for England and Scotland are broadly similar at 

29 per 1,000, but higher in Wales at 35 and lower in Northern Ireland at 26. The teenage conception rate 

is in decline in England and Wales and Scotland but on the increase in Northern Ireland. 4 

In England and Wales in 2000, 61 per cent of conceptions to women aged under 20 led to a delivery. 172 

Being an adolescent parent can lead to the health and social problems outlined above. Terminations of 

pregnancy can also have an adverse effect on the health of adolescents, and adolescents who have a 

miscarriage may suffer due to inadequate support. 173 

Which adolescents experience teenage pregnancy and STIs? 

Data comparing teenage pregnancy across ethnic minority groups is sparse. However, analysis of the 

Labour Force Survey in 2001 indicated that teenage motherhood is more common among Caribbean, 

Pakistani and especially Bangladeshi women, than among white women. However, young Indian women 

are less likely than white women to have a baby before they are 20. Rates of teenage births among white 

and Caribbean women are stable but there has been a marked decline in early parenthood in South Asian 

communities in Britain. 174 

During the 1990s there were marked regional variations in conceptions to adolescents. There was a northsouth 

divide in England with higher under-18 conception rates and lower percentages leading to abortion 

in the northern regions. London had both high conception rates and high percentages leading to 

abortion. In the UK, rates of teenage pregnancy are considerably higher in areas of greater socioeconomic 

deprivation. 170 

The highest levels of teenage pregnancy in Great Britain tend to be in urban and 

industrial areas; the lowest rates tend to be in rural and prosperous areas. The association between teenage 

childbearing and residence in more deprived areas seems to be largely due to personal disadvantage 

rather than to area characteristics. 175 

Research in Scotland revealed that the variations in teenage 

pregnancy rates between more affluent and more deprived areas widened between the 1980s and 1990s. 170 

In general, higher percentages of adolescent conceptions lead to abortion in more prosperous areas, and 

to maternity in less prosperous ones. 176 

Research using the ONS longitudinal study shows that the risk of unintentionally becoming a teenage 

mother is 10 times higher among girls from manual unskilled social backgrounds than among those from 

professional backgrounds. 4 

Early sexual initiation is an important factor in teenage pregnancy and STIs. NATSAL found that early age 

at first intercourse was significantly associated with pregnancy, motherhood and abortion under 

18 years. The prevalence of reported STIs is also higher among men and women for whom first 

intercourse occurred before age 16. 156 

A number of factors are associated with early sexual initiation including social influences (such as 

family structure and main source of information about sex), 159 

available health services, 173 

socioeconomic 

factors and individual characteristics (including educational level and age at 

menarche). 159 


The association between early sexual initiation, pregnancy and STIs may be explained partly by sexual 

incompetence. Among adolescents there are wide variations by age in sexual competence (defined by 

measurements of regret, willingness, autonomy and contraception). However, there is an association 

between age at intercourse and competence. According to analysis of NATSAL, 91 per cent of girls and 67 

per cent of boys aged 13 to 14 at first intercourse were not sexually competent. 156 

Sexual incompetence at 

first intercourse is associated with reported STIs. 156 

Educational level is significantly associated with sexual competence and use of contraception for both men 

and women; low attainment is also associated with early motherhood. The data collected by NATSAL 

clearly identifies a group of women vulnerable to teenage pregnancy; 29 per cent of sexually active young 

women in this study who left school at 16 with no qualifications had a child at age 17 or younger. 156 

Source of information about sex is also significantly associated with sexual competence and use of 

contraception. Among men, discussion with parents about sexual matters is associated with use of 

contraception. 156 

NATSAL found that the prevalence of reporting STIs was higher among those whose 

main source of information about sex was friends and others. 156 

In 1999 a survey of adolescents’ attitudes 

towards sexual activity found that adolescents who were well informed on sexual health matters were 

significantly less likely to be influenced by peer pressure or to be sexually active. 159 

The Social Exclusion Unit’s report of teenage pregnancy attributed the UK’s high rates to three factors: 

low expectations, ignorance and mixed messages. 162 

Research in the UK has associated teenage pregnancy with certain groups thought to be most likely 

to become pregnant. These have included young people: 

• living in deprived areas 

• who do not attend school 

• who are looked after by a local authority 

• who are homeless 

• who are themselves the children of young parents, particularly teenage mothers. 4 

A recent cross-sectional study in a birth cohort of 21-year-old New Zealanders has highlighted a strong 

correlation between psychiatric disorders, substance misuse, and risky sexual behaviour. There is an 

increased probability of risky sex across a range of mental health diagnoses; even the most prevalent, 

clinical depression, was associated with increased rates of risky sex, STIs and early sexual experience. 177 

Many researchers have documented a high prevalence of risky behaviour in association with substance 

misuse. 178 

Increased use of alcohol and marijuana at younger ages is related to subsequent riskier sexual 

activity. 179 

It has been suggested that alcohol and drug consumption may increase the likelihood that 

adolescents will engage in high risk sexual behaviour, as a result of impaired decision making, mood 

elevation, and the reduction of inhibitions. Similar mechanisms may apply in the context of psychiatric 

impairment. Engaging in risky sex may represent an indirect expression of anger or a mechanism to exert 

some control over one’s life. Sexual activity might also be used as a diversion, to relieve tension or as a 

strategy for affection seeking. 180 


38 

Interventions in adolescent sexual health 

The health of the nation: a strategy for health in England, published in 1992, identified HIV/AIDS and sexual 

health as one of five priority areas, with specific objectives and targets being set. Objectives included 

reducing the incidence of HIV infection and gonorrhoea and halving the rate of conception among girls 

under 16 by 2000. Five years after the strategy was published, the gonorrhoea target had been achieved 

but most other sexually transmitted infections had increased and pregnancy rates had not decreased. 3 

In June 1999 the Social Exclusion Unit published a report Teenage pregnancy examining teenage pregnancy 

and assessing interventions. The report’s 10-year action plan for England included a national campaign, 

‘joined up action’, better prevention and better support for pregnant teenagers and teenage parents. The 

prevention element includes better education in and out of school, access to contraception and targeting 

of at-risk groups, with a new focus on reaching young men. 162 

Following the report, a Teenage Pregnancy 

Unit was established at the Department of Heath to coordinate action across government to reduce 

teenage pregnancy in England. 162 

Also in 1999, The National Assembly for Wales published A strategic framework for promoting sexual health in 

Wales. 181 

In Scotland the white paper Towards a healthier Scotland identified sexual health and the 

development of a sexual health strategy as a public health priority. 96 

The English government published its sexual health and HIV strategy for consultation in July 2001. This 

set out plans to: 

• reduce the transmission of HIV and STIs 

• reduce the prevalence of undiagnosed HIV and STIs 

• reduce unintended pregnancy rates 

• improve health and social care for people living with HIV 

• reduce the stigma associated with HIV and STIs. 

In response to the consultation a 27 point action plan was published in June 2002. 182 

This strategy is now 

being implemented. Key elements include a model for sexual health services that can be delivered by every 

primary care trust and the evaluation of new one-stop sexual health services. A national information 

campaign has been launched, more money has been allocated to GUM and abortion services, and a 

chlamydia screening programme is under way. Despite these commitments, concern has already been 

expressed that the allocated resources are insufficient. 183 

Current policy in the UK aims to halve the conception rate of under 18s and set a downward trend in the 

rate for under 16s by 2010. It also aims, in the light of evidence of poor social, economic and health 

outcomes for mother and child, to achieve a reduction in the risk of long term social exclusion of teenage 

parents and their children. 163 

This involves a multifaceted approach which includes helping young people 

resist pressure to have early sex through improved sex and relationship education, increasing uptake of 

contraceptive advice through the development of easily accessible youth friendly advice services and 

support for parents in talking to their children about sex and relationship issues. 

A similar approach has been adopted in Wales through its Sexual Health Strategy. In Northern Ireland 

Myths and reality: teenage pregnancy and parenthood was published in 2000. The only country in the UK which 

has so far not set out its plans to reduce teenage pregnancy in a strategic document is Scotland, although 

this is currently under consideration. Scotland did set a target in 1994, reaffirmed in 1999, to reduce the 

pregnancy rate among 13 to 15 year olds by 20 per cent between 1995 and 2010. 4 

The Sex and relationship education guidance for the national teaching curriculum in schools, states that sex 

and relationship education (SRE) should be firmly rooted within the framework for Personal, Social and 

Health Education (PSHE) and Citizenship. During key stages 3 and 4 (from 11 to 16 years), pupils should 

be given knowledge, understanding and the ability to recognise the physical and emotional changes that 


take place at puberty. They should be taught how to manage these in a positive way, in a context of the 

importance of relationships, human reproduction, contraception, STIs, HIV and high-risk behaviours 

including early sexual activity. 184 

Evaluating the effectiveness of interventions in adolescent sexual health 

This section attempts to evaluate the effectiveness of several interventions in adolescent sexual health. To 

date, most sexual health interventions for adolescents have not been evaluated; consequently there is not 

a great deal of reliable evidence regarding the effectiveness of different approaches. 185 

A recent review of international variations in teenage pregnancies shows that even those adolescents in the 

most affluent areas of the UK have a higher birth rate than the average for the Netherlands or France. 

This, the authors suggest, leads to the possibility that teenage pregnancy is susceptible to policy 

interventions. 4 

Over the past four decades, fluctuations in the adolescent fertility rate seem to track 

intervention-related factors such as access to, and use of, contraceptive services, and the general climate 

surrounding the sexual health of young people. 156 

This also seems to demonstrate the potential of 

interventions in improving, or harming, adolescent sexual health. 

Education 

The UK has a poor record of sex education in comparison to some other European countries. 186 

However, 

school-based lessons are now, according to respondents in NATSAL, the main source of information about 

sexual matters for adolescents. 156 

School-based physical, health and social education can encourage 

behaviour modification in adolescents to help prevent unwanted pregnancy and the transmission of STIs. 

Education can focus on increasing awareness of STIs and birth control. It can also develop social skills, 

such as negotiating in relationships and accessing and using sexual health services. 160 

Some people recommend that sex education for adolescents should focus on abstinence. In the US, 

medical journals regularly publish articles encouraging healthcare professionals to recommend 

abstinence and giving detailed advice on how to do so most effectively. 187 

Abstinence-based educational 

approaches generally develop decision-making and refusal skills and rarely provide information on 

contraceptive methods or services. 173 

Reservations about abstinence-based education have been expressed 

by those who believe adolescents want practical information and help with sexual health rather than 

didactive approaches emphasising anatomical or moral aspects of sexual behaviour. 185 

One review of 

educational approaches to the prevention of teenage pregnancy found that, in comparison to usual sex 

education, abstinence programmes had no additional effect on either delaying sexual activity or reducing 


Evaluative studies of educational strategies show that school-based sex education can be effective in 

reducing teenage pregnancy, especially when linked to access to contraceptive services. School-based skills 

building, combined with factual information and programmes encouraging vocational development, may 

also help to reduce rates of unwanted teenage pregnancy. The most reliable evidence shows that sex 

education does not increase sexual activity or pregnancy rates. 173 

Early intercourse and non-use of contraception is more common among adolescents whose main source 

of information about sex is not lessons at school. 156 

One analysis of NATSAL concluded that the association 

between school sex education and risk reduction provides grounds for optimism regarding the role of 

education in improving adolescents’ sexual health. 156 

Interviews with pregnant adolescents in inner London found that the major causes of unintended teenage 

pregnancy are failures to anticipate personal risk and error in the use of contraception. 188 

Successful school 

sex education needs to combine clear advice about contraceptive methods and how and when to access 

services, with educational techniques designed to help teenagers assess personal risk. 189 


40 

The timing of educational interventions appears to be important: young people who are already sexually 

active at the commencement of interventions are less likely to change their contraceptive behaviour. 173 

Although school education reaches a large proportion of the adolescent population, its impact as an agent 

of change is affected by variable political and social constraints. It is important to remember that schoolbased 

programmes for sexual health promotion are not uniformly administered. They may also lack 

components shown to enhance the learning of sexual health information and skills. 190 

Peer education has proved popular among adolescents. This can ensure that sex education is delivered in 

a language and style that adolescents can related to. The House of Commons Health Committee has 

recommended that the Department for Education and Skills and the Department of Health should work 

together to promote peer education in all schools, as a supplement to formal schools-based relationships 

and sex education. 4 

Sexpression, a national organisation based in UK medical schools, run mostly by 

medical students, provides good quality, peer-led sex education in local schools. 

Public health campaigns 

The decline in the number of STIs in the late 1980s and early 1990s in response to government publicity 

about the HIV epidemic illustrates the importance of continually conveying the ‘safer sex’ message to 

maintain the public’s awareness of STIs. Popular television programmes aimed at adolescents may be able 

to raise the issues of STIs and family planning. 160 

Community-level programmes using social networks and institutions (such as the media) and providing a 

supportive environment have led to reductions in sexual risk behaviour as well as to the maintenance of 

low-risk behaviours over time. 190 

Improving access to services 

Check-ups for STIs should be encouraged among all those who are sexually active, including adolescents. 

The BMA publication Consent, rights and choices in health care for children and young people 191 

offers 

comprehensive practical guidance on the ethical and legal issues which arise in the healthcare of patients 

under 16 years of age. In the UK, adolescents under the age of 16 can, with some exceptions, be provided 

with contraceptive care even if unwilling to inform their parents. Nonetheless, many adolescents express 

doubts about confidentiality in these circumstances as well as fear of being judged. 192 

It is important that 

adolescents understand professional confidentiality and are reassured that their consultations will remain 

private. 

Immediate treatment of STIs can help to identify and treat sexual partners, avoid complications, and 

prevent potential onward transmission. 3 

Offering sexual health promotion counselling to individuals 

newly diagnosed with an STI is also important because of the association between a history of STI and the 

likelihood of re-infection. Theoretically-based, individual counselling programmes in clinical settings have 

been shown to reduce sexual risk behaviours and STI re-infection. 190 

Studies show an association between conception rates and the level and type of contraceptive services 

available locally. Recent evidence suggests that variations in teenage pregnancy rates may be associated 

with local general practice characteristics. A survey of pregnancies of 13 to 19 year olds in Trent between 

1994 and 1997 found that general practices with female doctors, young doctors or more nurse time had 

lower teenage pregnancy rates. 193 

Services appear to have a more positive effect on adolescent sexual 

health when they are provided by (youth-oriented) clinics. 173 

One study found that most adolescents who 

became pregnant attended general practice in the year before pregnancy; many had sought contraceptive 

advice. There was an association between the provision of emergency contraception and pregnancy 

ending in termination, suggesting the need for continuing follow up of teenagers consulting for this form 

of contraception. 194 


Given the private nature and social stigma associated with sexual health, it is vital to improve service 

structure to facilitate simple and unrestricted access to treatment and diagnoses. For adolescents, this may 

necessitate more young people’s clinics and referral to GUM clinics by school-based professionals 

(including school nurses). Community family planning clinics have a key role to play in the prevention of 

STIs and are able to target their services directly at adolescents via accessible, drop-in services. 160 

Young 

people’s perceived barriers to using services might be overcome through clinic or GP visits to schools and 

youth settings, or through school visits to the contraceptive service. 173 

Increasing the availability of 

contraceptive clinic services for young people is associated with reduced pregnancy rates. 173 

Services 

should be based on an assessment of local needs and ensure accessibility and confidentiality. 173 

The increase in infections, pregnancies and high risk sexual behaviour puts considerable demands on the 

existing services for STIs and HIV, contraception, abortion and health promotion. In England, clinics for 

STIs and GUM departments have seen a substantial rise in attendance over the past 10 years. The length 

of waiting times has consequently increased and immediate access is increasingly difficult to deliver. 3 

In 

1988 the Monks Report set a target for patients with a new problem to be seen in GUM clinics within 48 

hours. 195 

However, evidence now indicates that waiting times for appointments are on average 12 days for 

males and 14 days for females. In large urban areas patients may have to wait for over a month until the 

next available appointment. 3 

These waiting times pose a considerable threat to public health. 

Screening 

The government’s sexual health and HIV strategy specifies chlamydia as an area needing development. 

Screening may be vital for preventing the transmission of asymptomatic infections. Evidence shows that a 

significant reduction in pelvic inflammatory disease can be achieved through screening and management 

of chlamydial infection among women. 196 

There have been two pilot studies of opportunistic chlamydia 

screening of sexually active young women in the UK. These have shown that screening is feasible and 

acceptable, achieving high levels of population coverage. The high prevalence of infection found in these 

pilot screening programme has lead to the conclusion that screening is likely to be cost effective. Since the 

prevalence of infection in partners of positive women is high, effective partner notification is an important 

part of screening programmes. 197 

Targeted interventions 

It has been suggested that, as adolescents are not homogenous, programmes should be tailored to the 

group they serve. 173 

The frequent clustering of risk among adolescents makes the identification of high risk 

groups a sensible strategy in intervention. For example, adolescents who drop out of school will have 

special and often complex needs; they may have high rates of risky sexual behaviour, mental health 

problems and drug misuse. In light of an association between mental health problems and sexual risk 

taking, there may also be potential for exploring the sexual behaviour of young people with depression, 

anxiety and other mental health disorders. 180 

There is a great need for providing adolescent boys with sound and accessible services. Service provision 

has tended to centre on girls with little encouragement or emphasis being made towards boys. One study 

of adolescents’ attitudes to sexual activity concluded that the provision of some single-sex sex education, 

and a determined effort by community family planning services and primary care to inform teenage boys 

of the services available to them, may help to address the imbalances found in attitudes and behaviour 

between girls and boys. 159 

The strong association between low educational attainment and early motherhood supports the 

government’s current strategy to involve education and social services in a bid to reduce teenage 


General anti-poverty strategies are likely to influence rates of teenage pregnancy and help 

reduce adverse outcomes. 173 


42 

Helping adolescent parents 

The health and development of teenage mothers and their children has been shown to benefit from 

programmes promoting access to antenatal care, targeted support by health visitors, social workers or ‘lay 

mothers’ and provision of social support, educational opportunities and pre-school education. 173 

Specific 

interventions including the provision of supplementary nutrition, social support, education opportunities 

and pre-school education, are likely to be effective in reducing the adverse outcomes of teenage 

pregnancies. Improving the housing conditions of some teenage parents and their children may also be 

important. 173 

Summary 

There is considerable diversity in sexual experience among adolescents. Many enjoy safe, 

consenting, sex, often as part of a steady relationship. However, there is a great deal of concern 

about the growing prevalence of STIs among this age group. These can cause preventable infertility, 

ectopic pregnancy, hospital admissions for pelvic inflammatory disease and psychological stress. 

Policy makers also wish to lower the rates of unwanted adolescent pregnancy, which is often 

associated with social disadvantage and poor mental and physical health of mother and child. 

Rates of teenage pregnancy are higher in areas of socio-economic deprivation. Both STIs and 

teenage pregnancy are associated with early sexual initiation, sexual incompetence, lower education 

level and informal sources of information about sex. Certain groups of adolescents are more likely 

than others to experience teenage pregnancy and STIs. 

Governments across the UK have developed targets and strategies for reducing STIs and unwanted 

pregnancies. These strategies involve multifaceted approaches including improving adolescents’ 

social skills, providing better sex education and increasing the uptake of contraceptive services. The 

sexual health of adolescents does seem to be amenable to intervention. School based education can 

be effective, especially when linked to access to contraceptive services. Public health campaigns and 

community-level programmes have also proved successful in the past. Prompt diagnosis and 

treatment of STIs is crucial and good contraceptive services can result in lower conception rates. 

The services available to adolescents are therefore important for their sexual health. It is often 

suggested that services for adolescents are most effective when youth-oriented and geared to local 

needs. Adequate follow up after service use is vital to avoid unwanted pregnancy and the recurrence 

of STIs. Education and services for adolescents should be targeted towards those at greatest risk. In 

light of the social disadvantage that can follow adolescent parenthood, it is vital that young parents 

are well supported to avoid unnecessary psychological strain and ensure the best possible start to 

the lives of their children. 


Interventions in adolescent health 

Evidence for the effectiveness of health promotion interventions aimed at adolescents is often 

inadequate. Some interventions are not evaluated at all and many of the studies that have been 

undertaken involved small samples. Evaluations of many interventions, such as some clinical 

interventions, are therefore based on studies of adults. In other cases, the effectiveness of interventions 

can be evaluated against knowledge of adolescent behaviour and motivations. 

Early intervention 

In all the areas discussed in this report, early intervention emerges as an important factor in improving 

adolescent health. Early intervention is crucial for the promotion of good nutrition and exercise and 

there is growing consensus that these should be taught as early as possible before unhealthy or addictive 

habits become established. This might entail providing parents with information on breastfeeding and 

weaning as well as teaching young children the importance of good nutrition. Early assessment and 

treatment of mental health problems can reduce problems later on. It can also help to minimise the 

secondary handicap that results from disrupted education and impaired social development. Early 

intervention is also crucial for the promotion of sexual health, since young people who are already 

sexually active at the commencement of intervention are less likely to change their contraceptive 

behaviour. 

Targeted intervention 

The government has acknowledged that certain groups of adolescents are particularly vulnerable to risky 

behaviour and health problems. The governments’ Updated drugs strategy 2002 103 

deliberately targets the 

most vulnerable groups. There is also scope for targeting mental and sexual health interventions to those 

groups who are most likely to experience problems. Once adolescents are pregnant, targeted advice and 

support can help to improve the life prospects for both parent and child. 

Education 

School-based programmes may help to promote physical activity, improve nutrition and help to prevent 

obesity. However, school-based education measures may fail to reach the most vulnerable adolescents. 

When education is used to address smoking, drinking and drug use, it is important to understand 

adolescents’ attitudes and behaviours and to acknowledge the perceived benefits of these behaviours. 

Recent education interventions have begun to include the development of life skills. Evidence for the 

effectiveness of these strategies is scarce but information on social influences and resisting pressure may 

be a useful addition to traditional knowledge-based education. 

Education may be effective in promoting emotional wellbeing among adolescents and has potential for 

raising awareness about mental health problems. Education also has a role in improving adolescent 

sexual health. Those who are well informed on sexual health matters are significantly less likely to be 

influenced by peer pressure or to be sexually active at an early age. Education may also have a less direct 

role to play in reducing teenage pregnancy by raising educational aspirations and promoting 

expectations. School-based sex education is most likely to be effective when it is linked to access to 

contraceptive services and when it helps adolescents to assess risk. 

Improving access to health services 

Improving access to appropriate services is an important intervention in all areas of adolescent health. 

As a recent report concluded, there is a relative dearth of specific or discrete services for adolescents 

within health provision. 198 

This applies particularly to addiction and mental health services which have 

often been fragmented and ill-equipped for dealing with adolescents. 

There is a need for improved adolescent health services including outreach work, screening and 

treatment, coordinated with education and social services and the youth justice system. Some adolescents 


44 

are more difficult to reach than others, so services must be capable of providing advice and help through 

diverse environments. 

Often neither children’s nor adults’ services are appropriate for adolescents. There may be difficult 

transition issues, especially in mental health care provision, where adolescents can fall between CAMHS 

and adult mental health services. Mental health services in particular should be capable of treating the 

conditions common among adolescents in an appropriate age environment. Recently there have been 

calls for every healthcare organisation to have a policy and identified lead professional for the provision 

of services for young people. 198 

Professionals dealing with adolescents may sometimes benefit from 

specialised training. 

Improving adolescents’ access to services must involve adolescents’ perceptions of the services provided. 

Adolescence is often a time when individuals use health services independently for the first time. In this 

sense, adolescents can be considered ‘new’ users of healthcare services and should be provided with the 

necessary information, support and encouragement. 198 

Adolescents should also perceive services to be 

user friendly. For example, sexual health services appear to have a more positive effect on adolescents 

when they are provided by youth-oriented clinics. Resources have been developed to help professionals 

provide appropriate services for adolescents. 199 

Taking into account the views and self-defined needs of adolescents may be one way to improve their use 

of health services. Article 12 of the United Nations (UN) Convention of the Rights of the Child states that 

children should have the right to express their views freely in all matters affecting them and that these 

views should be given weight in accordance with the age and maturity of the child. 

A key concern for adolescents, which may affect their use of services, is confidentiality. Young people over 

16 are considered competent and should be assured of confidentiality in consultations. However, even 

under this age, adolescents are assumed to be competent for confidentiality purposes if the clinician is 

confident that they understand the consequences of their decisions. Adolescents presenting for 

contraception services are generally given complete confidentiality. 198 

Health services may need to 

explain patient confidentiality to adolescents in order to encourage them to use the services provided. 

Consent, rights and choices in health care for children and young people (2001) contains a full discussion of 

adolescents’ confidentiality issues. 191 

Clinical interventions 

Although many interventions in adolescent health focus on prevention, clinical treatment is also 

important. Treatment of adolescent addiction has not traditionally been high on the government’s 

agenda. However, in the context of smoking, drinking and drug use, helping adolescents to change their 

behaviour may prove to be as important as prevention. There is evidence that brief interventions, 

cessation counselling and substitute prescribing may help to modify behaviour. Appropriate and effective 

clinical interventions are vital for treating mental and sexual health problems. Adolescent obesity may 

also be tackled in a clinical environment, though success is typically limited. 

Multifaceted interventions 

Multifaceted interventions involving, for example, education, the media and community, may be 

successful in improving adolescent health. Multifaceted approaches have the advantage of recognising 

the individual, social and environmental influences on behaviour. The most important criteria for 

multifacted interventions is that the messages delivered are consistent and straightforward. For example, 

the most effective way to prevent adolescents from smoking may be to use a combination of school-based 

education, media campaigns, price increases, cessation support and smoking bans in public places. 


Multiprofessional interventions 

Health problems can impact on many other areas of adolescent life. Problems facing dependent drug 

users are, for example, often far beyond the remit of medical interventions. For this reason, many 

commentators advocate a multiprofessional approach to intervention. 124,200 

This may involve collaboration 

between doctors, school health service professionals, young offenders teams, social workers and specialist 

treatment centres. This can be a particularly valuable approach in drug prevention where adolescent use 

is frequently related to other complex, non-medical social problems. Liaison between health and 

education services is also valuable to adolescent sexual health. Local multiprofessional forums can inform 

strategy, monitor performance and develop joint commissioning. 200 

Multiprofessional collaboration may 

help to ensure that adolescent health services are provided seamlessly and that adolescents do not suffer 

harm during the transition between children’s and adult services. 

Structural and environmental change 

Structural and environmental factors are increasingly recognised as playing an important role in 

adolescent health. Ensuring adequate access to good, affordable food and recreational activity may make 

more difference to adolescents’ diets and activity than health education. 8 

Reducing the availability of 

cigarettes and alcohol by enforcing age restrictions or increasing their price may help to reduce tobacco 

and alcohol use. Regulating the advertising and marketing of cigarettes and alcohol may be able to 

change adolescents’ attitudes to substance use. Since mental health problems are often the result of a 

combination of biological and societal factors, changes at a local or societal level may help to reduce 

problems among adolescents. Raising educational attainment and reducing poverty may help to reduce 

rates of teenage pregnancy and adverse outcomes. 


46 

The way forward 

This report has reviewed a range of adolescent health problems and has evaluated the effectiveness of 

interventions used to tackle them. In the light of the evidence, this section summarises possible 

approaches for improving adolescent health. 

Possible approaches for improving adolescent health 

• Early intervention in all areas of adolescent health should be encouraged to help prevent 

problems escalating. 

• Interventions to improve adolescent health should be especially targeted at the most vulnerable 

groups of adolescents. 

• Health services must be adequately funded if adolescent health is to improve. In particular, 

sexual health services, which are already over-stretched, should receive enough resources to 

minimise waiting times for assessment and treatment. 

• Improving access to health services is crucial: 

• services for adolescents should be provided in an age-appropriate environment and be seen 

to be user-friendly. 

• the continuity of services must be improved so that users do not fall in a gap between 

paediatric and adult care. 

• adolescents must be provided with the information, support and encouragement needed to 

access health services independently. 

• adolescents may need to be reassured of professional confidentiality in order to encourage 

use of health services. 

• Prevention strategies are not sufficient to improve adolescent health. Where prevention fails, 

effective clinical support and treatment must be available to help adolescents adopt healthier 

lifestyles. 

• Multifaceted approaches to intervention have the advantage of recognising the influence of, and 

complex interaction between, individual, social and environmental factors on adolescent 

behaviour. 

• There is a strong relationship between adolescent health and other aspects of adolescent life 

such as education, employment and housing. Moreover, school-based education may fail to 

reach the most vulnerable adolescents. Interventions in adolescent health should therefore be 

multiprofessional and involve cooperation between health, education and social services. 

• Interventions should recognise the structural and environmental influences on health 

behaviour. 

• Healthy, affordable food and opportunities for at least the recommended amount of physical 

activity should be available to all children and adolescents. 


• The media has an important role to play in forming adolescents attitudes to nutrition, 

exercise and substance misuse. There is scope to harness this potential and further regulate 

its more harmful impact. In the light of the damaging effect alcohol has on the health of our 

society and the rising levels of binge drinking among the young, the BMA has called for a ban 

on the advertising of alcohol, as there is for cigarettes. In order to protect adolescents, the 

BMA has also recommended that broadcasters adopt a more responsible approach towards 

body image and healthy eating patterns. 

• Messages to adolescents about healthy behaviour should be as consistent as possible. For 

example, where bans on smoking exist they should be enforced. School environments must be 

supportive in order to reinforce health education messages on nutrition, smoking and drinking. 

• Parents, children and adolescents should be made aware of the importance of good nutrition 

and exercise and should be equipped with the knowledge, skills and confidence necessary to 

integrate these into their lives. 

• When education is used to address smoking, drinking and drug use, it is important to 

understand adolescents’ attitudes and to acknowledge the perceived benefits of these 

behaviours. Peer education should be considered as part of health education strategies. 

• Health education should help promote awareness about, and better attitudes towards mental 

health problems. 

• Mental health services must be equipped to deal with substance abuse. 

• Screening should be considered for the detection of asymptomatic infections such as chlamydia. 

Where sexual health screening exists, it should be accompanied by appropriate partner 

notification, support and follow up. 

• Adolescent parents should receive help and support to reduce any possible adverse outcomes of 

teenage pregnancies. 


48 

Annex 1 

BMA policy on adolescent health 

The British Medical Association has policies on topics relating to adolescent health. Those that are most 

important to the topics discussed are listed below. The term ‘this Meeting’ refers to the annual meeting of 

the BMA’s representative body. The representative body is the BMA’s main policy making body made up 

of nearly 600 elected members. 


That this Meeting recognises the importance of diet to health and calls for national food and agricultural 

policies which take account of health issues in production, advertising, labelling and pricing of food. 

[1984] 

Smoking 

That this Meeting regrets that the government is not acting forcefully or rapidly enough to reduce 

cigarette smoking in the country. It suggests: 

(i) a ban on smoking in public places 

(ii) a ban on advertising in or on shops 

(iii) stronger penalties for shopkeepers who serve under 16s with cigarettes. [1999] 

That this Meeting views with increasing concern the apparent indifference of teenagers to the dangers of 

smoking and calls upon the BMA to press the new government to redouble its effort in campaigns to curb 

smoking in this age group. [1997] 

That this representative body asks that: 

(i) the BMA should press for a significant health tax to be added to the cost of each packet of 

cigarettes 

(ii) government should legislate to ensure tobacco smoke-free public buildings. [1994] 

That this Meeting asks the government to do everything in its power to reduce tobacco smoking by: 

(a) complying with EC directive on tobacco advertising 

(b) removing tobacco from the cost of living index so that fiscal measures could be taken without 

detriment 

(c) specifically targeting anti-smoking in primary schools 

(d) reducing smoking in public places. [1992] 

That the minimum legal age for the sale of tobacco and tobacco products should be raised to 18 years. 

[1984] 

That this Meeting puts its full weight behind the BMA in pressing the government for immediate 

implementation of the tobacco advertising directive. [1998] 

That this Meeting recommends a total ban on tobacco advertising. [1997] 

That this representative body believes that the advertising of tobacco should cease. [1992] 


Drinking 

That this Meeting believes that because of the damaging effect alcohol has on the health of our society 

and the rising levels of binge drinking among the young that the government should legislate a ban on 

the advertising of alcohol as it has for cigarettes. [2003] 

That this Meeting is concerned about the proliferation of sweetened, flavoured spirits sold in predispensed 

shot glasses. [2002] 

That the BMA should work to ensure that alcoholic drinks should not be advertised in cinemas, unless 

shown with a film having an ‘18’ certificate. [1999] 

That this Meeting calls for tough action to protect children from the dangers of alcohol. [1999] 

That this Meeting is concerned that unacceptable levels of alcohol is present in some of the drinks which 

are aimed at the teenage market and believes that the deliberate targeting of this group by purveyors of 

alcohol should be made illegal. [1997] 

Drug use 

That, while recognising that alcohol is a major factor, this Meeting is concerned that an increasing number 

of road traffic accidents is due to drivers using illicit drugs and requests the board of science and education 

to consider ways of supporting the police in their fight against ‘Drug Driving’ by raising awareness and 

educating the public on the dangers. [2001] 

Sexual health 

That this Meeting feels that patients should continue to have the choice of attending either a family 

planning clinic or general practitioner for contraceptive advice. [1992] 

That in view of the increasing numbers of teenage pregnancies, this Meeting recommends that the BMA 

initiate talks with the Department of Education to include teaching on reproductive health and 

responsible relationships in the national curriculum. [1992] 

That this association believes that the correct interpretation of the House of Lords judgement in the case 

of Gillick v Wisbech Health Authority is as follows: 

(1) that children of under 16 must be entitled to expect that both the existence and the content 

of a consultation in connection with pregnancy or contraception will normally remain secret 

(2) that in the case of any departure from this rule doctors should be liable to justify their action. 

[1986] 

That the government must, as a matter of urgency, invest resources in preventative health care for the 

young and adolescent to reduce unwanted pregnancies, drug dependency and addiction. [1998] 

Mental health 

That this Meeting fears that some forms of advertising may be contributing to an increase in the incidence 

and prevalence of anorexia nervosa. It calls for greater responsibility in the use of such images in the 

media. [1998] 

Health inequalities 

That this Meeting congratulates the government on its commitment to improve and reduce inequalities 

in the public’s health, but emphasises that a ‘healthier nation’ can only be achieved with policies to reduce 

the gross disparity of income distribution and wealth in the British population. [1998] 

That government should continue to confront the most potent cause of poor health – poverty. [1998] 


50 

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Copies of this report can be obtained from: 

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BMA House 

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London 

WC1H 9JP 

Tel: 020 7383 6164 

Email: info.science@bma.org.uk 

A PDF of the report is available on the website: www.bma.org.uk

Subject: Young People and Alcohol 

Dear Ms Hurcombe and colleagues, 

Please find below my responses to your questions: 

1. Is alcohol misuse by young people a problem amongst your friends, within your 

family or in your community? Are you a young person who regularly drinks alcohol? 

Alcohol misuse is a problem in my community - a combination of middle class kids 

hanging around in Hoxton/Old Street (16-21 yos) as well as less affluent kids hanging 

round the estates (both age groups). 

2. What impact does it have on your friends, family and local community? 

Anti-social behaviour around Old Street bars and clubs; assaults and arguments late at 

night on the streets; vomit and urine on streets/around entrances to flats etc 

3. Why do you think some young people misuse alcohol? 

I think that you cannot prevent young people from experimenting, and whilst alcohol 

and drugs retain a degree of taboo about them, they will always have an appeal to 

young people. For others, it is an attempt to escape from harsh reality. Yet there are 

different degrees of acceptability. Those who go out around Old Street do mix with a 

crowd of various ages, but their drinking is actively encouraged by businesses and the 

local council. Those who are not able to do so are seen as being 'anti-social' as they 

are hanging around on the streets. 

4. Where do young people drink? 

In my neighbourhood, the more affluent middle class young people tend to go to the 

bars and clubs around Old Street, whilst their less affluent counterparts drink on the 

streets, at each others' houses, parties, by the canal etc. 

5. How do young people get access to alcohol? 

The classic, age-old combination of getting someone older to buy it for you, faking ID 

cards etc, sending in the person who looks older to the bar/off-licence to buy it. 

6. What can be done to encourage young Londoners to drink more sensibly? 

A bold policy to stop chain pubs etc having promotions to encourage people (of all 

ages, not just the young ones!) to drink more than they may intend to; the provision of 

interesting and affordable leisure activities for young people. This is not just about 

having more youth clubs (although these have always had an important role to play in 

helping to reduce youth crime/anti-social behaviour generally) but about making sure 

the young can afford cinema tickets, are encouraged to take part in sports, and are 

offered more options than hanging around in McDonalds of an evening. The solution 

is all about having more respect for young people generally rather than trying to 

penalise them. But, most importantly, adults should look to their own behaviour and 

decide if they are truly setting an example they would like young people to follow. 

Yours sincerely, 

Dr K Bradley

Mr James Cleverly 

Chair of Health and Public Service committee 

City Hall 

Queeens Walk 


SE1 2AA 

Dear James 

Royal College of Nursing 

London Region 

13 Cavendish Square 


W1G 0PQ 

B Bussue 

Director, RCN London 

Telephone: 0 

Fax: 0 

Email: 

Re: Call for evidence – investigation into alcohol misuse by young people in London 

Please accept the paper attached as the RCN London response to the London Health Commission 

committee call for evidence. In responding to your request we sought the views of our members 

through our Specialist Nursing Advisors. 

In particular I am grateful to Ian Hullett our RCN Mental Health advisor and also Fiona Smith, 

RCN Adviser in Children’s and Young People’s Nursing who collated the evidence. Should you 

require us to present oral evidence, we would no doubt be able to call on these experts and others 

from our Children and Young Peoples’ special interest group. 

Should you require further assistance please contact me as detailed above or my communications 

officer, J Tierney 

Kind regards 

Yours sincerely 

B Bussue (Mr) 

Director, RCN London

Call for Evidence: Children and Young People and alcohol consumption 

1. How common-place is alcohol misuse by young people in your area? [11-15 year 

olds] or [16-21 year olds] 

Members highlight a high incidence of admission to Emergency departments for 

both age ranges. Over the last year members reported that alcohol misuse is 

becoming more of an issue as young people are drinking larger quantities and 

more often. 

2. What impact does young people's alcohol misuse have on: 

• Their health 

Alcohol consumption can affect physical, emotional and mental health 

depending on severity of use and whether alcohol is used with other 

substances. Many young people may complain of feeling unwell i.e. with a 

headache, nausea, feeling tired but many do not realize the consequences. 

Long term effects include liver failure and kidney damage, while they are also 

at risk of life-threatening accidents while under the influence of alcohol, as 

well as assault, rape, self-harm and minor injuries. Alcohol use may lower self 

esteem despite appearing to increase confidence at the time of ingestion and 

thereby lead to mental health problems such as depression 

• Their families 

Members highlighted that families are often worried but noted that some 

parents do not seem to be bothered. Alcohol use does however impact on 

families as often young people can become aggressive which causes 

tensions within the family home. In circumstances of covert drinking in the 

family home, there may be no impact to families what so ever. A range of 

other consequences for families include involvement/intrusion of police into 

family home due to anti-social behaviour or stealing, financial consequences 

of stealing, anxiety on part of family about the well-being of the young person 

concerned. 

• Local communities 

It was noted that alcohol can cause aggression and anti social behaviour, 

including vandalism, arson, graffiti, burglaries, shoplifting, and joyriding. 

Drinking is often done in public places which make them difficult or scary to 

access to other community members. Young people can also feel stigmatised 

by the community for the behaviour of a few other young people. 

• Public services 

Many members highlighted the impact upon the increase in attendances at 

Emergency Departments and the increased pressure on hospital services as 

a result of alcohol related diseases, as well as police and ambulance service 

personnel. Others noted the unruly intimidating behaviour of young people on 

public transport. 

RCN London - 30 September 2008 1

3. Why do you think young people drink and why do you think some young people 

misuse alcohol? 

Drinking alcohol is perceived as cool and trendy in the UK, encouraged by the UK 

media and celebrities. In many instances a lack of opportunities to channel 

activities, particularly for children from a lower socio-economic class, is a major 

contributing factor. The reasons for young people drinking are noted to be 

complex and may primarily involve an aspiration to ‘be adult’, may reflect drinking 

practices observed in the home, may arise as a result of unleashing tight parental 

reigns upon leaving home, or boredom through a lack of activities for young 

people. 

Members highlighted a whole range of issues based on their experiences in 

working with children and young people. These included: 

Peer pressure - 'alcohol is fun & forbidden' and more because it's becoming 

normal- people who don't drink are odd. 

A way of coping with personal problems. 

Poor family support and cohesion. 

To make them feel more confident when they are drunk 

Parents have problems with alcohol or drugs 

Depressed and use alcohol to manage this 

They think it makes them appear older / more worldly. 

Alcohol is legal and cheap so they can purchase it with pocket money or it is 

readily available within households. 

4. What can be done to prevent young people's alcohol misuse and what ways 

are there to encourage them to drink sensibly as adults? What initiatives are 

you prioritising in your area? 

Many members highlighted the importance of health education in schools, as well 

as adverts on TV showing the detrimental effects of Alcohol. There is a need to 

look very carefully at the mixed messages being given to young people. The 

message the media often promotes is "if you drink you are sexy, grown up, witty 

or funny, sophisticated, glamorous etc. Others emphasized the need to 

increase the cost of alcohol in shops and to raise the legal drinking age to 21 

years. Access to cheap alcohol is easy for young people. There has been a huge 

issue about alco-pops encouraging young people to drink, but a bottle of vodka 

can be bought for less than ten pounds and it can be shared by several people. 

It was highlighted that there were insufficient school nurses to provide 

adequate health promotion education and advice to children and young 

people, as well as enabling the development of emotional resilience and the 

ability to say ‘no’. A focus on early interventions and support mechanisms may 

help young people to make healthier choices. 

Some felt that there is lots of education and information given to young people 

regarding alcohol but most think that they are indestructible and it only happens 

to 'old people'. The need to ensure that there are more activities so groups of 

young people aren't hanging around street corners or in parks was highlighted 

by many. There is some evidence that peer mentorship schemes work and it 

maybe that such schemes could promote ‘sensible’ drinking amongst young 

people. 


5. Do you know of any international, regional or local good practice targeting young 

people's alcohol misuse? 

Members advised that those children and young people following alcohol 

intoxication, who were admitted to hospital for assessment and support, were 

seen by social services and where appropriate adolescent support teams. It has 

been noted that such measures result in very few repeat attendances. Alcohol 

Alert was cited as a particular initiative, along with additional police presence to 

proactively discourage drinking in public places. It was felt that the media could 

send stronger messages to young people. Some members highlighted resource 

packs for teachers about drugs, smoking and alcohol for use in primary and 

secondary schools. 

Nurses working in CAMHS highlighted that alcohol use has become a large part 

of intervention/treatment work with young people, with many school nurses 

highlighting a number of interventions aimed at children and families as part of an 

alcohol education and prevention strategy: 

Specific campaigns and initiatives cited by our members included: Healthy 

Schools Plus, FRANK Campaign, Health Promotion Agency, Tesco's 21 prove it 

scheme, community wardens. NHS Know your units. It was noted that Alcohol 

Concern has published information on the impact of alcohol and family problems, 

including the particular impact of parental alcohol misuse on children 

http://www.alcoholandfamilies.org.uk/documents/7/lit_review/lit_review_index.htm 

Additionally Liverpool John Moores University has produced a series of factsheets 

from research, including one on the availability of alcohol to under-age 

persons, which includes what is known to motivate young people to drink. Other 

fact-sheets in the series provide information evidence based interventions. 

http://www.cph.org.uk/publications.aspx 

It was noted that Trading Standards and local police regularly carry out test 

purchases for under-age sales in off-licences, and the Parks Service escort 

young people found drinking alcohol home and raise awareness among parents. 

Many members felt that the all day opening had sent out the wrong messages. 

Nurses who trained in Germany advised that changes afoot there included the 

introduction of stricter restrictions to purchase alcohol in supermarkets and 

elsewhere after 10pm http://www.lzg-bayern.de/aktionswoche/ In addition it was 

noted that within clubs and bars ‘breath test machines’ are available to anyone 

who wishes to check their alcohol level in their breath before driving home, and 

an organization which goes into clubs to promote sensitive drinking, provide 

information and leaflets http://mindzone.info/projekt/profil/ There is also tighter 

legislation for new drivers (first 2 years) and until the end of the 21st year of age 

in which the driver not to allow to have any alcohol when driving the 0- promil- 

plan [Fine 125 euros and 2 points on licence] http://www.disco-fieber.de/ There 

could also be TV advertising promoting safe plans of action if a driver/friend is not 

fit to drive anymore http://www.disco-fieber.de/no_kompromille/index.html 

It was noted that some LSCBs have ensured local clubs known for allowing 

underage drinking did not have their alcohol licence renewed 

Additional comments 


Many of our members felt strongly that there was a need to increase the drinking age 

to 21 years. It was felt that at this age young adults will hopefully be more informed 

and better able to make sensible choices about alcohol consumption. 

Some of our members felt that utube, MSN and facebook could perhaps be used to 

relay messages about the effects of alcohol. Examples of PSHE programmes in 

schools encompassing work about alcohol, with discussions about whether it should 

be banned, or whether parents should be punished if their children drink, or whether 

it should be introduced at an early age in small quantities. 

There was concern that there is a tendency to focus on binge and heavy drinking in 

adolescence without in-depth insight of how such young people develop in the longterm. 

It was also felt that there are currently fewer opportunities for activities where 

alcohol is not a part. 

For further information contact: 

J Tierney, Communications Officer, RCN London

Alcohol misuse: tackling the UK epidemic - London

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