Helen Salisbury: Alcohol excess—time for new measures?BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2246 (Published 21 May 2019) Cite this as: BMJ 2019;365:l2246
All rapid responses
Alcohol consumption is an integral part of modern culture in this country and many others, and provides pleasure to many consumers. However, it also continues to be one of the leading risk factors for poor health globally and its harmful use has considerable social consequences.(1-4) We agree with Dr Salisbury that new measures are needed to promote sensible attitudes towards drinking and are pleased that her brief article took a balanced approach.(5) We firmly believe that a positive and multifaceted strategy is needed that targets different settings and supports different age groups.
Primary care is a key setting where much more could be done.(1,3,6) Early identification and brief advice provided by doctors and nurses can be effective in reducing alcohol consumption amongst heavy drinkers. It will not only prevent future health problems but also save the need for costly future NHS services, particularly in the acute sector. Working with housing, voluntary agencies and social services can also improve health and social care.
Although potentially there are considerable opportunities for primary care teams to improve the quality of life of people who misuse alcohol, in many cases this will not be turned into reality if investments are not made.(7,8) Factors limiting health education include: competing demands; time constraints; insufficient training; and lack of support. General practice needs to be made fit for current needs and “Fit for the Future”.(9)
Schools are another vital setting where high quality and effective alcohol education approaches are needed such as those developed by the Alcohol Education Trust.(10,11) NICE is currently updating its guideline on alcohol interventions in secondary and further education which will support the Department for Education’s plan to make alcohol education a compulsory component of personal, social and health education (PSHE) in all state-funded schools in England from September 2020.
Although some schools can receive good support from organisations such as The Alcohol Education Trust, much more is needed if all young people are to be provided with age-appropriate and accurate information and the opportunity to develop healthy attitudes and skills. Public health specialists in local authorities could provide support to ensure that teachers and nurses are properly trained about alcohol so that they become competent and confident. Funding will be needed from central government to enable this.
Though we have concentrated on professionals from two settings, primary care and schools, others need to be involved in a positive multifaceted strategy, including, the police, mental health services, housing, licensees and the media. At a local level, public health professionals are crucial to success as they could coordinate, support and galvanise people into action. At a national level they should be involved in addressing, marketing, pricing, and legislation.
It is important that the forthcoming Green Paper on Prevention not only includes alcohol as an essential element but that it also includes sufficient resources. Investment in public health must be increased so that it is adequate for local and national population health needs.(12-17)
1) BMA. Alcohol misuse: tackling the UK epidemic. London: BMA, 2008.
2) Watson M C and Lloyd J. Re: Alcohol—who is paying the price? British Medical Journal Rapid Response 17th June 2015.
3) Public Health England. The Public Health Burden of Alcohol and the Effectiveness and Cost-Effectiveness of Alcohol Control Policies An evidence review. London: Public Health England, 2016.
4) World Health Organization. Global status report on alcohol and health 2018. Geneva: World Health Organization, 2018.
5) Salisbury H. Helen Salisbury: Alcohol excess—time for new measures? BMJ 2019;365:l2246 doi: 10.1136/bmj.l2246
6) Rao R, Crome I and Crome P. Managing older people’s alcohol misuse in primary care. British Journal of General Practice 2016; 66 (642): 6-7. DOI: https://doi.org/10.3399/bjgp16X683041
7) Watson M C and Forshaw M. TACKLING THE CRISIS IN GENERAL PRACTICE. Prioritising prevention and health promotion. BMJ 2016;352:i1333. https://www.bmj.com/content/352/bmj.i1333
8) Watson M C and Lloyd J. Time to put GPs first by investing in general practice. British Medical Journal Rapid Response 10 May 2019.
9) RCGP Fit for the Future: a Vision for general practice. London: RCGP, 2019.
10) Lynch, S., Styles, B., Dawson, A., Worth, J., Kerr, D. and Lloyd, J. Talk About Alcohol: an Evaluation of the Alcohol Education Trust’s Intervention in Secondary Schools. Slough: NFER, 2013.
11) Lynch, S., Worth, J. and Bradshaw, S. Evaluation of the Alcohol Education Trust’s Talk about Alcohol Intervention: Longer-Term Follow up. Slough: NFER, 2015.
12) Marmot M, Allen J, Goldblatt P et al. Fair society, healthy lives: strategic review of health inequalities in England post 2010. London: Marmot Review Team, 2010
13) Watson M C and Lloyd J. Need for increased investment in public health BMJ 2016;352:i761. https://www.bmj.com/content/352/bmj.i761
14) Watson M and Tilford S, 2016. Directors of public health are pivotal in tackling health inequalities. BMJ 2016;354:i5013.
15) House of Commons Health Committee. Public health post-2013: second report of session 2016-17. House of Commons Paper No 140, 2016-17.
16) BMA. Funding for ill-health prevention and public health in the UK. London: BMA, 2017.
17) Watson M C and Thompson S, 2018. Government must get serious about prevention. BMJ 2018;360:k1279.
Competing interests: No competing interests
Why are there non-drinkers in societies who see every “Party”, or even a main meal, as a reason for drinking alcohol? By age 35 some people have become members of “Alcoholics Anonymous”. Other non-drinkers have discovered they are alcohol intolerant and some have the auto-brewery syndrome. Ingested sugary foods or drinks turn into alcohol because of increases in fungal or bacterial gut fermentation. Other non-drinkers may have seen the destructive effect of regular alcohol drinking in their families.
Obad and colleagues concluded that alcohol's action are complex and chronic alcohol consumption can increase the risk of heart disease, brain damage, dementia, neuropathy, metabolic disturbances, nutritional deficiencies, certain cancers, liver, and other faces of morbidity and mortality. They highlight the contribution of inflammatory process in alcohol-mediated tissue damage and organ dysfunction. A full understanding of the related cytokine signalling pathways in alcoholic injuries is needed to understand the complex biological effects on alcohol-induced organ damage. The antioxidant effect of bioflavonoids in red wine may not compensate even for an alcohol-induced increased excretion of zinc. I found most women first attending a London hospital migraine clinic had already stopped drinking red wine because it had induced migraine attacks. Red wine can be major cause of migraine and increased risk of cardiovascular diseases.[3,4]
Just one bout of drinking can damage sperm during the three months before conception, and alcohol-induced sperm damages is simple to investigate.
1 When the average daily alcohol consumption was 40 g or less 31 (34%) had partial spermatogenic arrest (SA).
2 Of the 31 men with average daily intake between 40 and 80 g, 17 (54%) showed normal spermatogenesis, 13 (42%) had partial or complete SA, and 1 man exhibited more severe testicular damage - "Sertoli cell only" (SCO) syndrome
3 Among men with daily intake between 80 and 160 g, 19 (54%) had partial or complete SA (odds ratio = 2.92), and 3 (9%) had the SCO syndrome (odds ratio = 16.85).
4 The frequencies of spermatogenic disorders were similar in men drinking in excess of 160 g.
Both SA and the SCO syndrome showed a clear dependence on daily dose; p < 0.0001 and p < 0.0004, respectively.
One in three pregnancies are unplanned and many women continuing to drink in early pregnancy when most foetal brain development is happening and alcohol can cause brain and heart damage.
As ever more children suffer from autism, hyperactivity, asthma, diabetes and dyslexia, society must take some responsibility for encouraging a culture of frequent alcohol drinking. Surely, no amount of pleasure from brain-numbing alcohol can compensate for damaging a child’s health for life. The price of alcohol has become relatively cheaper and alcoholic drinks are a profitable source of revenue for governments and companies but the cost of child care has also increased. Not drinking any alcohol before or during pregnancy is much more sensible than merely cutting down.
1 Hunnisett A, Howard J, Davies S.J. Gut fermentation (or the 'Autobrewery') Syndrome: A New Clinical Test with Initial Observations and Discussion of Clinical and Biochemical Implications. J.Nutr.Med. 1990;1:338.
2 Obad A1, Peeran A1, Little JI1, Haddad GE1, Tarzami ST1.Alcohol-Mediated Organ Damages: Heart and Brain .Front Pharmacol. 2018 Feb 13;9:81. doi: 10.3389/fphar.2018.00081. eCollection 2018.
3 Grant ECG. Food allergies and migraine. Lancet 1979; 1: 966-69.
4 Kasper A, Komjáthiné Szépligeti S, Holland-Bill L, et al. Migraine and risk of cardiovascular diseases: Danish population based matched cohort study. BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k96 (Published 31 January 2018) BMJ 2018;360:k96
5 Pajarinen J, Karhunen PJ, Savolainen V et al. Moderate alcohol consumption and disorders of human spermatogenesis. Alcohol Clin Res 1996:20:332-7.
Competing interests: No competing interests