The National Institute for Health and Care Excellence (NICE) has recently published an evidence update focussed on preventing harmful drinking. This update builds upon previous recommendations (NICE PH24, 2010) and is aimed at increasing awareness of the latest evidence available. Furthermore, the update indicates whether any new research may have potential impact on future NICE PH24 revisions.

Methods

A search for new evidence published between January 2008 and July 2013 was conducted, with 21,207 pieces of evidence identified. After automatic and manual sifts were completed a list of 79 relevant references was compiled. These were then appraised by the Evidence Update Advisory Group, who included 40 items for the evidence update. Evidence was selected that may have a potential impact on guidance: that is, a high-quality study, systematic review or meta-analysis with results that suggest a change in policy or practice.

Key points

Research was split into sections based on recommendations in NICE PH24, which suggested a combination of population and individual-based approaches are needed to reduce alcohol-related harm. Population-based approaches are generally focused on policy, whereas individual-based approaches are focused around best practice. Short summaries of the main recommendations in each research area are presented below.

Policy

NICE PH24 notes that population-based approaches to public-health can reduce the cumulative level of alcohol consumed and lower the population risk of alcohol-related harms. Two recommendations outlined for alcohol policy were increasing price and reducing availability. Research on alcohol pricing is focussed on affordability, minimum unit pricing and taxation all of which are not mutually-exclusive:

• Affordability
  • The reviewed evidence confirmed that alcohol-use disorders and related harm are associated with substantial costs
  • Increasing the prices of alcoholic drinks may lead to reductions in drinking and the harms associated
  • For example, longitudinal evidence from the Australian National Drug Strategy Household Survey demonstrated that an increase in the price of alcohol by 1% was associated with an increase of more than 6 non-drinking days per year in moderate drinkers (Byrnes et al, 2013)
• Minimum Unit Pricing
  • The evidence update outlined the positive effects of minimum unit pricing on reductions in harmful drinking
  • These include a reduction of drinking in high-risk drinkers (an excellent Elf blog by Suzi Gage summarises one of these modelling studies in more detail)
  • This evidence further supports the NICE PH24 call for consideration of a minimum price per unit
• Taxation
  • The guideline set out in 2010 included regular reviews of alcohol duties to ensure it does not become more affordable over time
  • This was supported in the current update by a number of studies demonstrating increases in tax on alcohol seem to be associated with reductions in drinking
• Availability
  • The evidence summarised in this update suggested that increased densities of premises licensed to sell alcohol were associated with various measures of alcohol-related harm including mortality, rates of hospital admission and domestic violence incidents (Livingston, 2011)
  • These findings strengthened recommendations for limiting availability of alcohol purchasing set out in NICE PH24

Practice

The practice guidelines support, complement and are reinforced by policy, but are more focused on individual-level interventions:

• Resources for screening and brief interventions
  • From the evidence available, the update suggests that healthcare professionals have a negative attitude towards people with alcohol-use disorders and that education and training is needed to improve this
• Screening and brief interventions for young people
  • Screening involves identifying people who are not seeking alcohol treatment, but in the view of the professional may have an alcohol-use disorder
  • No new evidence was selected for inclusion based on screening in young people
  • Evidence for brief interventions in young people was limited but generally positive
  • The review highlighted a number of studies that demonstrated support for extended brief interventions in young people (between 17 and 21 years old)
• Screening and brief interventions in adults
  • Current NHS recommendations suggest that professionals should routinely carry out alcohol screening where possible
  • Whilst this may not directly affect drinking behaviour, universal screening may detect risky drinking at an early stage
• The review examined research reporting on brief interventions in adults in a variety of healthcare settings
  • In sexual health clinics, brief interventions were unlikely to be effective in reducing hazardous or harmful drinking
  • In primary care settings, brief interventions are no better than personalised feedback based on screening
  • In emergency departments, brief interventions to reduce alcohol may not reduce subsequent alcohol-attributable injuries
  • However, the review did find some evidence that extended brief interventions (coupled with motivational interviewing or as part of a multi-contact intervention) were effective in reducing alcohol consumption within primary care settings (Jonas et al, 2012).
• Licensing
  • The guidance examined one systematic review, which demonstrated that environmental factors of licensed premises may be associated with increases in risky drinking, intoxication and violence (Hughes et al, 2011)
  • These factors included loud music, crowded premises, poor cleanliness and ventilation
  • However, due to limitations (lack of appropriate statistical data) these findings are unlikely to impact NICE PH24 updates
• Computer-based brief interventions and Social norms interventions
  • The review also looked at these two areas not currently covered by NICE PH24
  • To briefly summarise, the evidence base for both was inconsistent and unlikely to make an impact on future revisions of NICE PH24, until more high quality research is conducted

Conclusions

There is little research in this latest NICE evidence update that will have a potential impact on future guidance. However, the research identified generally served to reinforce the recommendations already in place, including minimum unit pricing and limiting the availability of alcohol.

Links

Alcohol-use disorders: preventing harmful drinking (PDF). NICE evidence update 54, Mar 2014.

Alcohol-use disorders: preventing harmful drinking. NICE PH24 (June 2010).

Byrnes, J. Shakeshaft, A. Petrie, D., Doran, C. (2013). Can harms associated with high-intensity drinking be reduced by increasing the price of alcohol? Drug Alcohol Rev, 32, 27-30.

Hughes, K., Quigg, Z., Eckley, L., Et al (2011). Environmental factors in drinking venues and alcohol-related harm: the evidence base for European intervention. Addiction, 106, 37-46.

Jonas, D., Garbutt, L., Amick, H., et al. (2012). Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med, 157, 645-54.

Livingston, M. (2011). Alcohol outlet density and harm: comparing the impacts on violence and chronic harms. Drug Alcohol Rev, 30, 515-23.