Article

The regional geography of alcohol consumption in England: Comparing drinking frequency and binge drinking

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Alcohol consumption frequency and volume are known to be related to health problems among drinkers. Most of the existing literature that analyses regional variation in drinking behaviour uses measures of consumption that relate only to volume, such as ’binge drinking’. This study compares the regional association of alcohol consumption using measures of drinking frequency (daily drinking) and volume (binge drinking) using a nationally representative sample of residents using the Health Survey for England, 2011–2013. Results suggest the presence of two differentiated drinking patterns with relevant policy implications. We find that people in northern regions are more likely to binge drink, whereas people in southern regions are more likely to drink on most days. Regression analysis shows that regional variation in binge drinking remains strong when taking into account individual and neighbourhood level controls. The findings provide support for regional targeting of interventions that aim to reduce the frequency as well as volume of drinking.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Compared to other regions in England, living in the North East had the strongest association with binge drinking in men and women after adjustment for age, ethnicity, socioeconomic status and area deprivation in analyses of the HSE using all ages (296)(297)(298). The North East, followed by the North West also had the strongest association with AUDIT scores of at least 8 for men and 7 for women, which remained after adjustment for demographics and socioeconomic status (299). ...
... A statistically significant association of GOR with binge drinking was found in two studies using a population of all adult ages and one study using multilevel modelling that accounted for this hierarchical structure (296)(297)(298). However, no studies have considered the association of GOR in the middle-aged population for exceeding the low-risk guidelines. ...
... This suggests that the regional differences found in the descriptive statistics are better explained by the individual-level factors of the residents living within these regions rather than a larger regional effect. In the literature, the association of risk drinking with GOR has only been investigated in cross-sectional surveys using all ages suggesting that there was a statistically significant regional association for binge drinking in logistic regression models (296,297) and a multilevel model (298). For the middle-aged sample used in this study, GOR as a geographical measure may be too large to present differences in drinking behaviour at finer geographical scales (301). ...
Thesis
Drinking alcohol to excess is one of the largest modifiable causes of morbidity in middle-aged adults with a third of drinkers aged 45-64 years drinking above the UK low-risk guidelines (14+ units per week). Social-ecological frameworks suggest that alcohol behaviour is driven by both individual factors and wider level contexts. Evidence gaps for understanding risk alcohol use in this age group were identified for trends in intake, individual, transitional and regional associations and an age-relevant understanding of income and alcohol expenditure. The current middle-aged literature was found to be limited by inconsistent risk alcohol intake thresholds, a lack of late middle-aged adults in birth cohorts, and lack of adjustment for the wider determinants of health. This thesis addressed these research gaps using three independent but linked studies. The first study used cross-sectional data from the Health Survey for England (HSE) from 1998 (20,871 n pooled) to consider trends and demographic, socioeconomic and co-risk factors associated with exceeding the former UK guidelines (21/14+ units per week) and binge drinking (8/6+ units on heaviest day). The second study used two waves from Understanding Society (USoc), a UK panel study (12,737 n), to determine if transitions in socioeconomic or social status between waves were associated with binge drinking patterns. The final study used USoc longitudinally over 7 waves (17,407 households) to assess the relationship with income and household composition factors associated with expenditure on alcohol. Each study used multilevel regression modelling to account for shared characteristics of individuals within regional living areas, as Government Office Regions (GOR), and account for the nonindependence and correlation in repeated measures panel data. Non-drinkers were excluded from each study to avoid abstainer bias. Data from the HSE found a gender convergence in exceeding the former weekly guidelines with binge drinking increasing in both sexes since 1998. Exceeding the guidelines was associated with smoking, higher income and education, retirement, cohabiting marital status and having no children in the household for both sexes. Binge drinking was associated with smoking, higher body-mass index, higher income, divorced marital status, no religious belonging and urban residence in both sexes with associations for having friends and no educational qualifications in men only. Entering or leaving a relationship were both associated with maintaining binge drinking over time in men compared to a stable relationship status but not in women. Moving to a rural area in both sexes, changing to no reported friends in men only, becoming a non-smoker in women only and entering employment in women only, were all negatively associated with maintaining binge drinking. Living in the North East and North West of England contributed to increased binge drinking in men independently of individual characteristics and was associated with higher household expenditures on alcohol. A £100 increase in income was associated with a £0.40 increase in alcohol expenditure in middle-aged headed households, accounting for household composition factors including household size, child status, sources of income and housing tenure. Overall, this thesis contributes to the literature on excessive alcohol use by providing age and sex-specific analyses of a previously under-researched age group, discovering multiple risk factors associated with acute and chronic risk from alcohol use and spending on alcohol. These findings make use of multilevel modelling to account for regional contexts and individual trajectories of binge drinking and household spending over time, demonstrating the utility of secondary data to explore changing health behaviours.
... Using the average weekly consumption measure, men were regrouped into: A number of demographic characteristics were identified from the literature as potentially impacting upon alcohol consumption levels and the corresponding measures from the HSE were selected for the analysis to establish whether at-risk male drinkers were distinct from low risk male drinkers under both the previous and the new drinking guidelines and to establish whether the change in guidelines affected the demographic characteristics associated with being an at-risk drinker. Demographic characteristics that have been associated with differing levels of alcohol consumption and were included in the analysis are: age [43], grouped from 16 to 34, 35-54, 55-74 and 75+; social class [44,45], grouped using the National Statistics Socio-Economic Classification (NS-SEC) categorising the employment status of the participant (managerial and professional, intermediate, routine and manual, not classified); marital status [46,47] grouped as single, married/cohabiting, separated/divorced/ widowed; geographical region [6,[48][49][50], grouped by former Government Office Region; ethnicity [51,52], regrouped into white and non-white groups due to small sample sizes in the non-white groups; smoking status [53], grouped by never smoker, ex-occasional smoker, ex-regular smoker, current smoker; and physical health [54,55] measured as limiting long-lasting illness, non-limiting long-lasting illness, no long-lasting illness. The full HSE questionnaire (2015) can be accessed online [42]. ...
... This could also provide an age criterion with which to screen for at-risk drinkers. Under the previous, but not the new guidelines, men aged 35-54 had greater odds of being at-risk drinkers, a change which may be explained by the greater increase in the proportion of at-risk drinkers in the reference category (16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34) year olds, 13% increase in at-risk drinkers) compared to [35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54] year olds (11% increase in at-risk drinkers). Around a third of men in the younger age group would now be considered at-risk from their drinking and the youngest age group experienced the second largest increase in the number of people considered at-risk under the new guidelines, indicating that a considerable proportion of this age group were drinking between 14 and 21 units per week. ...
Article
Full-text available
Background: Alcohol guidelines enable individuals to make informed choices about drinking and assist healthcare practitioners to identify and treat at-risk drinkers. The UK Low Risk Drinking Guidelines were revised in 2016 and the weekly guideline for men was reduced from 21 to 14 units per week. This study sought to retrospectively establish 1) the number of additional at-risk male drinkers in England, 2) which demographic characteristics were associated with being an at-risk drinker under the previous versus new guidelines. Methods: Average weekly alcohol consumption for men aged 16+ from the cross-sectional nationally representative Health Survey for England were used to 1) calculate annual population prevalence estimates for newly defined at-risk (> 14 to ≤21 units/week) male drinkers from 2011 to 2015 (N = 3487-3790), and 2) conduct logistic regression analyses for at-risk vs low risk male drinkers under the previous (> 21 vs ≤21 units/week) and new (> 14 vs ≤14 units/week) guidelines to assess characteristics associated with being at-risk drinkers under each guideline using 2015 data (N = 2982). Results: Population prevalence estimates of newly defined at-risk drinkers ranged from 10.2% (2014 = 2,182,401 men)-11.2% (2011 = 2,322,896 men). Under the new guidelines, men aged 55-74 (OR = 1.63,95% CI = 1.25-2.12); men in managerial/professional occupations (OR = 1.64,95% CI = 1.34-2.00); current smokers (OR = 2.26,95% CI = 1.73-2.94), ex-regular smokers (OR = 2.01,95% CI = 1.63-2.47) and ex-occasional smokers (OR = 1.85,95% CI = 1.25-2.74); men from the North East (OR = 2.08,95% CI = 1.38-3.13) and North West (OR = 1.91,95% CI = 1.41-2.60) of England all had greater odds, and non-white men had reduced odds (OR = 0.53,95% CI = 0.34-0.80) of being at-risk drinkers, as they had under the previous guidelines. Under the new guidelines only: a higher percentage of at-risk drinkers aged 16-34 (32% vs 19%) attenuated the odds of men aged 35-54 being at-risk (OR = 1.18,95% CI = 0.92-1.51); a higher percentage of married at-risk drinkers (37% vs 24%) attenuated the odds of single men being at-risk (OR = 1.28,95% CI = 0.99-1.67); men from the West Midlands (OR = 1.68,95% CI = 1.17-2.42) and London (OR = 1.53,95% CI = 1.03-2.28) had greater odds of being at-risk drinkers. Conclusions: The change to the Low Risk Drinking Guidelines would have resulted in more than 2 million additional male at-risk drinkers in England. Most groups with greater odds of being at-risk drinkers under the new guidelines were those already known to be drinking the most, strengthening the case for targeted screening and education. Additionally, under the new guidelines, a marked proportion of 16-35 year olds and married men were at-risk and men in the West Midlands and London had greater odds of being at-risk drinkers. These groups may benefit from specific education around the new Low Risk Drinking Guidelines.
... However, ecological models have emphasised that problem drinking is influenced by both individual and environmental variables. Where attention has been paid to contextual influences on alcohol consumption, with few exceptions (eg Castillo et al., 2017;Foster et al., 2016), these have primarily been at the local neighbourhood rather than at the urban or regional scale. Most of this literature has focused on the effects of neighbourhood deprivation (Fone et al., 2013), alcohol outlet densities , and neighbourhood incivilities (Hill and Angel, 2005) upon heavy drinking. ...
... Thirdly, the causes of environmental and social stressors, along with their links to problem health behaviours, such as heavy drinking, need to be further understood since geographic differences in their prevalence may be amenable to policy intervention. This will be particularly true when the negative effects of stress on undesirable health behaviours are not universal but context specific or where different contexts lead to different types of drinking behaviour (Castillo et al., 2017). To achieve the above objectives the paper is organised as follows. ...
Article
Objectives: The objective of this study was to examine the association between individual and environmental stressors and problem alcohol use among Chinese university students. Methods: Participants were 11,942 students, who were identified through a multistage survey sampling process that included 50 universities. Individual information, including feelings of stress and perceptions of problem alcohol use, was obtained by self report. Urban and regional variables were retrieved from the National Bureau of Statistics database. Both unadjusted and adjusted methods were considered in the analyses. Results: Almost one third (32.6%) of the students suffered from some form of severe stress while problem alcohol use prevalence was 7.3%, (95% CI: 4.1-10.4%). The multilevel logistic regression model found that uncertainty stress, gender, father's occupation and monthly expenses were associated with problem alcohol use. Of the contextual factors home region and the university city GDP and unemployment rate were important. When interactions were considered, the relationship between monthly expenses and financial uncertainty and problem drinking was most evident in high level universities. By contrast, the effects of uncertainty stress on problem drinking were most evident in middle and low level universities. Conclusions: The findings underscore that efforts to control problem alcohol use among students in China should pay greater attention to environmental determinants of stress and particularly to improvements in stress management in university settings.
... The pattern is somewhat different for frequency of drinking, with those in Southern regions more likely to report that they drink on most days. 31 Data from the British Health and Lifestyle Survey noted that individual characteristics have an independent effect on neighbourhood variations in smoking but that significant between-ward differences in smoking behaviour remain which cannot be explained either by population composition or ward-level deprivation. 32 However, there are several issues with these previous studies. ...
... For example, previous studies suggest that regional variations differ according to the measure of alcohol consumption used (eg, volume vs frequency). 31 Finally, although these findings relate to England specifically, which has the largest difference in economic output between regions of any country in Europe, it is most likely that comparable variation would be found in other countries. 34 In conclusion, smoking and high-risk drinking appear to be less common in 'central England' than in the rest of the country. ...
Article
Full-text available
Objectives This paper compares patterns of smoking and high-risk alcohol use across regions in England, and assesses the impact on these of adjusting for sociodemographic characteristics. Design Population survey of 53 922 adults in England aged 16+ taking part in the Alcohol and Smoking Toolkit Studies. Measures Participants answered questions regarding their socioeconomic status (SES), gender, age, ethnicity, Government Office Region, smoking status and completed the Alcohol Use Disorders Identification Test (AUDIT). High-risk drinkers were defined as those with a score of 8 or more (7 or more for women) on the AUDIT. Results In unadjusted analyses, relative to the South West, those in the North of England were more likely to smoke, while those from the East of England, South East and London were less likely. After adjustment for sociodemographics, smoking prevalence was no higher in North East (RR 0.97, p>0.05), North West (RR 0.98, p>0.05) or Yorkshire and the Humber (RR 1.03, p>0.05) but was less common in the East and West Midlands (RR 0.86, p<0.001; RR 0.91, p<0.05), East of England (RR 0.86, p<0.001), South East (RR 0.92, p<0.05) and London (RR 0.85, p<0.001). High-risk drinking was more common in the North but was less common in the Midlands, London and East of England. Adjustment for sociodemographics had little effect. There was a higher prevalence in the North East (RR 1.67, p<0.001), North West (RR 1.42, p<0.001) and Yorkshire and the Humber (RR 1.35, p<0.001); lower prevalence in the East Midlands (RR 0.69, p<0.001), West Midlands (RR 0.77, p<0.001), East of England (RR 0.72, p<0.001) and London (RR 0.71, p<0.001); and a similar prevalence in the South East (RR 1.10, p>0.05) Conclusions In adjusted analyses, smoking and high-risk drinking appear less common in ‘central England’ than in the rest of the country. Regional differences in smoking, but not those in high-risk drinking, appear to be explained to some extent by sociodemographic disparities.
... During this century, the limitations of prevalence have driven the adoption of other indicators, including the rate of binge-drinking episodes per person-time in the population or in binge drinkers (Makela et al., 2006;Naimi et al., 2003;Soler-Vila et al., 2014;Valencia-Martín et al., 2007). However, most research monitoring binge drinking worldwide (including international organizations) continues based exclusively on prevalence (Bosque-Prous et al., 2015;Castillo et al., 2017;Dwyer-Lindgren et al., 2015;Grucza et al., 2018;IARD, 2019;Im et al., 2019;Manthey et al., 2019;Peacock et al., 2018;Sherk et al., 2017;WHO, 2018;Willmore et al., 2017). Only the USA clearly deviates from this practice (Kanny et al., 2020(Kanny et al., , 2018. ...
Article
Background The public health impact of binge drinking depends on its population prevalence and its frequency and intensity among binge drinkers. The objective is to assess the consistency of time trends and age-sex disparities between binge-drinking prevalence and binge-drinking exposure indicators that combine such prevalence with the number of binge-drinking days among binge drinkers. Methods Data come from 11 biennial national household surveys from 1997 to 2017 in young (15-34 years) and middle-aged adults (35-64 years) in Spain (n = 211,961). Binge-drinking was the intake of 5+ standard drinks (4+ in women from 2009 onwards) in approximately two hours. Three monthly indicators were analyzed: binge-drinking prevalence, population rate of binge-drinking days, and proportion of drinking days with binge drinking. Results were stratified for sex and two age groups. Annual percent changes (APCs), ratios of young to middle-aged people (age ratios) and men-to-women ratios were obtained from negative binomial regression. Results Although the three indicators showed considerable consistency as an intense increase in binge drinking from 2009 to 2017 among middle-aged people, especially women, there were relevant inconsistencies. In 2009-2017 the APCs for prevalence and rate were +1.3% and −1.6%, respectively, in young women, and -0.6% and −3.0% in young men. Age ratios were significantly higher for prevalence and proportional ratio than rates, while men-to-women ratios were lower, especially in middle-aged people. Conclusions Adequate monitoring of binge drinking should incorporate indicators of absolute exposure, which better reflect its impact on public health, such as the population rate of binge-drinking days.
... All studies in this category used survey data, including 30 articles that used national/state surveillance and/or census data [21,[23][24][25][26][27]29 [23,28,32,45,46,54,55]. Three studies examined patterns of alcohol use from adolescence through young adulthood [32,41,55]. ...
Article
Purpose of Review To summarize the recent literature on social and physical environments and their links to alcohol use and identify empirical research strategies that will lead to a better understanding of alcohol use in contexts. Recent Findings Recent research has continued to describe the importance of neighborhood and regional contexts on alcohol use, while a smaller emerging scientific literature assesses the impacts of contexts on drinking. Summary The dynamic, longitudinal, and multiscale processes by which social and physical structures affect social interactions and substance use have not yet been uncovered or quantified. In order to understand and quantify these processes, assessments of exposures (e.g., how individuals use space) and risks within specific locations are essential. Methods to better assess these exposures and risks include model-based survey approaches, ecological momentary assessment (EMA), and other forms of ecologically and temporally specific analyses, affiliation network analyses, simulation models, and qualitative/multimethods studies.
... Other instances of subnational patterns of spatial non-stationarity in unequal environmental health exposures are documented in the United States (Gilbert and Chakraborty 2011;Grineski et al. 2015;Liévanos 2018b;Mennis and Jordan 2005) and the United Kingdom (Jephcote and Chen 2012). In addition, geographers demonstrate how health conditions and inequalities vary regionally and locally throughout the world (Bambra et al. 2015;Castillo et al. 2017;Grady and Wadhwa 2015;Ruiz-Muñoz et al. 2012;Sun et al. 2011;White et al. 2011). The present study does not formally test for the presence of spatial non-stationarity in racialized intercategorical environmental inequality outcomes in the United States. ...
Article
The research on quantitative intersectional environmental inequality outcomes examines how the spatial concentration of individuals occupying multiply marginalized social identities is associated with unequal exposure to environmental hazards. One recent exemplar study analyzed racialized and “intercategorical” environmental inequality outcomes in cancer-causing air pollution exposures for Whites, Blacks, Latinxs, and Asian/Pacific Islanders (APIs) at the census tract level in the continental United States. That study found that—net of region, urban-industrial context, and other intercategorical variables—a variable representing elevated concentrations of economically deprived and foreign-born Latinxs, Latina single-mother families, and primarily Spanish-speaking households was the most consistent intercategorical predictor of tract exposure to spatial clusters of carcinogenic air pollution in 2005. The present study reproduces that nationwide analysis while being the first to include disadvantaged Indigenous peoples in the examination of intercategorical environmental inequality outcomes in the continental United States and for the ten U.S. Environmental Protection Agency (EPA) regions. Logistic regression analyses indicate that the spatial concentration of disadvantaged Indigenous peoples was not a significant nationwide predictor of tract exposure to the carcinogenic air pollution clusters. However, the regional analyses revealed eight new patterns of intercategorical environmental inequality outcomes across the U.S. EPA regions, and the spatial concentration of disadvantaged Indigenous peoples was a significant positive predictor of tract exposure to carcinogenic air pollution clusters in the Mid-Atlantic region. These findings have implications for future environmental justice research, policy, and activism.
Article
The use of alcohol, cigarettes and marijuana among adolescents are major public health concerns, and a number of epidemiological studies have been conducted to understand the drivers of these individual health behaviours. However, there is no literature that jointly models these health behaviours with the aim of understanding the relative importance of individual factors, friendship effects and spatial effects in determining the prevalence of alcohol, cigarette and marijuana use among adolescents. To address this gap in the literature, we propose a novel multivariate spatio‐network model for jointly modelling all three of these behaviours, with inference conducted in a Bayesian setting using Markov chain Monte Carlo simulation. The model is motivated by survey data from five schools in Los Angeles, California, and the results indicate the important roles that individual factors and friendship networks play in driving the uptake of these health behaviours.
Article
Driving under alcohol or while under the influence of a medication that impedes the ability to control a car are punishable offenses. The study asks if the perceived legitimacy of law, the perceived dangers of driving, including detection by the police, and the individual inclination to engage in risky and imprudent behaviour influence the likelihood of committing those offenses. At a British university, 337 students took part in a questionnaire study. The results show that students are less inclined to drive under alcohol than under medication. Both are variously influenced by practical circumstances like the frequency of driving, of drinking and the actual taking of such medication, even pressures to drive regardless. Driving under medication is also related to legitimacy of law. The difference may come from the absence of a public narrative for driving under medication: some students fall back to their attitude to the law. Conducir bajo los efectos del alcohol o de algún medicamento que obstaculice la capacidad de conducir un automóvil son delitos punibles. Este estudio se pregunta si la legitimidad percibida de la ley, los peligros percibidos de conducir (incluida la detección por parte de la policía) y la inclinación a mantener conductas arriesgadas e imprudentes influyen en la probabilidad de cometer dichos delitos. En una universidad británica, 337 estudiantes respondieron en un cuestionario. Los resultados muestran que los estudiantes son menos propensos a conducir bajo los efectos del alcohol que de medicamentos. Ambos casos están influidos por circunstancias prácticas, como la frecuencia de la conducción, de beber y de tomar dicho medicamento, incluso presiones para conducir en cualquier caso. Conducir bajo los efectos de medicamentos está relacionado con la legitimidad de la ley. La diferencia puede radicar en la ausencia de una narrativa pública sobre conducir bajo los efectos de medicamentos: algunos estudiantes se amparan en su actitud hacia la ley.
Book
Full-text available
Drinking (alcohol) is a social activity for most people and has an important human health dimension. Is social drinking described in the Bible? What drinking patterns are described? What are the causes of social drinking? What is the effect of socioeconomic factors? What is the age of onset? What types of occasions involve drinking? Are parents involved in drinking? What is risky drinking? What are the motives? What are family drinking patterns? What are the characteristics of binge drinking? Biblical verses dealing with social drinking were examined from a contemporary viewpoint.
Article
Full-text available
Regional differences in population levels of alcohol-related harm exist across Great Britain, but these are not entirely consistent with differences in population levels of alcohol consumption. This incongruence may be due to the use of self-report surveys to estimate consumption. Survey data are subject to various biases and typically produce consumption estimates much lower than those based on objective alcohol sales data. However, sales data have never been used to estimate regional consumption within Great Britain (GB). This ecological study uses alcohol retail sales data to provide novel insights into regional alcohol consumption in GB, and to explore the relationship between alcohol consumption and alcohol-related mortality. Alcohol sales estimates derived from electronic sales, delivery records and retail outlet sampling were obtained. The volume of pure alcohol sold was used to estimate per adult consumption, by market sector and drink type, across eleven GB regions in 2010-11. Alcohol-related mortality rates were calculated for the same regions and a cross-sectional correlation analysis between consumption and mortality was performed. Per adult consumption in northern England was above the GB average and characterised by high beer sales. A high level of consumption in South West England was driven by on-trade sales of cider and spirits and off-trade wine sales. Scottish regions had substantially higher spirits sales than elsewhere in GB, particularly through the off-trade. London had the lowest per adult consumption, attributable to lower off-trade sales across most drink types. Alcohol-related mortality was generally higher in regions with higher per adult consumption. The relationship was weakened by the South West and Central Scotland regions, which had the highest consumption levels, but discordantly low and very high alcohol-related mortality rates, respectively. This study provides support for the ecological relationship between alcohol-related mortality and alcohol consumption. The synthesis of knowledge from a combination of sales, survey and mortality data, as well as primary research studies, is key to ensuring that regional alcohol consumption, and its relationship with alcohol-related harms, is better understood.
Article
Full-text available
www.jrf.org.uk Drinking in the UK An exploration of trends Lesley Smith and David Foxcroft May 2009 Reviews research and highlights trends in alcohol consumption over the last 20 to 30 years. A key part of the Government’s alcohol harm reduction strategy is to monitor changes in drinking habits over time and to identify what factors are potentially contributing to the rising levels of consumption. This study is a systematic review of research relevant to trends in alcohol consumption over the last 20 to 30 years in the UK. The review: • assesses the number, types and quality of existing research studies; • synthesises the findings to evaluate alcohol drinking trends in the UK, highlighting key changes; • discusses possible explanations for the trends observed, assessing what factors may have contributed to changes; • explores implications for policy; • makes recommendations for future research
Article
Full-text available
Objective To use the rs1229984 variant in the alcohol dehydrogenase 1B gene (ADH1B) as an instrument to investigate the causal role of alcohol in cardiovascular disease. Design Mendelian randomisation meta-analysis of 56 epidemiological studies. Participants 261 991 individuals of European descent, including 20 259 coronary heart disease cases and 10 164 stroke events. Data were available on ADH1B rs1229984 variant, alcohol phenotypes, and cardiovascular biomarkers. Main outcome measures Odds ratio for coronary heart disease and stroke associated with the ADH1B variant in all individuals and by categories of alcohol consumption. Results Carriers of the A-allele of ADH1B rs1229984 consumed 17.2% fewer units of alcohol per week (95% confidence interval 15.6% to 18.9%), had a lower prevalence of binge drinking (odds ratio 0.78 (95% CI 0.73 to 0.84)), and had higher abstention (odds ratio 1.27 (1.21 to 1.34)) than non-carriers. Rs1229984 A-allele carriers had lower systolic blood pressure (−0.88 (−1.19 to −0.56) mm Hg), interleukin-6 levels (−5.2% (−7.8 to −2.4%)), waist circumference (−0.3 (−0.6 to −0.1) cm), and body mass index (−0.17 (−0.24 to −0.10) kg/m2). Rs1229984 A-allele carriers had lower odds of coronary heart disease (odds ratio 0.90 (0.84 to 0.96)). The protective association of the ADH1B rs1229984 A-allele variant remained the same across all categories of alcohol consumption (P=0.83 for heterogeneity). Although no association of rs1229984 was identified with the combined subtypes of stroke, carriers of the A-allele had lower odds of ischaemic stroke (odds ratio 0.83 (0.72 to 0.95)). Conclusions Individuals with a genetic variant associated with non-drinking and lower alcohol consumption had a more favourable cardiovascular profile and a reduced risk of coronary heart disease than those without the genetic variant. This suggests that reduction of alcohol consumption, even for light to moderate drinkers, is beneficial for cardiovascular health.
Article
Full-text available
The influence of neighbourhood deprivation on the risk of harmful alcohol consumption, measured by the separate categories of excess consumption and binge drinking, has not been studied. The study objective was to investigate the effect of neighbourhood deprivation with age, gender and socioeconomic status (SES) on (1) excess alcohol consumption and (2) binge drinking, in a representative population survey. Cross-sectional study: multilevel analysis. Wales, UK, adult population ∼2.2 million. 58 282 respondents aged 18 years and over to four successive annual Welsh Health Surveys (2003/2004-2007), nested within 32 692 households, 1839 census lower super output areas and the 22 unitary authority areas in Wales. Maximal daily alcohol consumption during the past week was categorised using the UK Department of Health definition of 'none/never drinks', 'within guidelines', 'excess consumption but less than binge' and 'binge'. The data were analysed using continuation ratio ordinal multilevel models with multiple imputation for missing covariates. Respondents in the most deprived neighbourhoods were more likely to binge drink than in the least deprived (adjusted estimates: 17.5% vs 10.6%; difference=6.9%, 95% CI 6.0 to 7.8), but were less likely to report excess consumption (17.6% vs 21.3%; difference=3.7%, 95% CI 2.6 to 4.8). The effect of deprivation varied significantly with age and gender, but not with SES. Younger men in deprived neighbourhoods were most likely to binge drink. Men aged 35-64 showed the steepest increase in binge drinking in deprived neighbourhoods, but men aged 18-24 showed a smaller increase with deprivation. This large-scale population study is the first to show that neighbourhood deprivation acts differentially on the risk of binge drinking between men and women at different age groups. Understanding the socioeconomic patterns of harmful alcohol consumption is important for public health policy development.
Article
Full-text available
Background: This study predicts the implications of under-reporting of alcohol consumption in England for alcohol consumption above Government drinking thresholds. Methods: Two nationally representative samples of private households in England were used: General LiFestyle survey (GLF) and Health Survey for England (HSE) 2008. Participants were 9608 adults with self-reported alcohol consumption on heaviest drinking day in the last week (HSE) and 12 490 adults with self-reported average weekly alcohol consumption (GLF). Alcohol consumption in both surveys was revised to account for under-reporting in three hypothetical scenarios. The prevalence of drinking more than UK Government guidelines of 21/14 (men/women) alcohol units a week, and 4/3 units per day, and the prevalence of binge drinking (>8/6 units) were investigated using logistic regression. Results: Among drinkers, mean weekly alcohol intake increases to 20.8 units and mean alcohol intake on heaviest drinking day in the last week increases to 10.6 units. Over one-third of adults are drinking above weekly guidelines and over three-quarters drank above daily limits on their heaviest drinking day in the last week. The revision changes some of the significant predictors of drinking above thresholds. In the revised scenario, women have similar odds to men of binge drinking and higher odds of drinking more than daily limits, compared with lower odds in the original survey. Conclusion: Revising alcohol consumption assuming equal under-reporting across the population does not have an equal effect on the proportion of adults drinking above weekly or daily thresholds. It is crucial that further research explores the population distribution of under-reporting.
Article
Full-text available
A number of commentators have argued that there is a distinctive geography of health-related behaviour. Behaviour has to be understood not only in terms of individual characteristics, but also in relation to local cultures. Places matter, and the context in which behaviour takes place is crucial for understanding and policy. Previous empirical research has been unable to operationalize these ideas and take simultaneous account of both individual compositional and aggregate contextual factors. The present paper addresses this shortcoming through a multi-level analysis of smoking and drinking behaviours recorded in a large-scale national survey. It suggests that place, expressed as regional differences, may be less important than previously implied.
Article
Full-text available
To assess the risk of death associated with various patterns of alcohol consumption. Prospective study of mortality in relation to alcohol drinking habits in 1978, with causes of death sought over the next 13 years (to 1991). 12,321 British male doctors born between 1900 and 1930 (mean 1916) who replied to a postal questionnaire in 1978. Those written to in 1978 were the survivors of a long running prospective study of the effects of smoking that had begun in 1951 and was still continuing. Men were divided on the basis of their response to the 1978 questionnaire into two groups according to whether or not they had ever had any type of vascular disease, diabetes, or "life threatening disease" and into seven groups according to the amount of alcohol they drank. By 1991 almost a third had died. All statistical analyses of mortality were standardised for age, calendar year, and smoking habit. There was a U shaped relation between all cause mortality and the average amount of alcohol reportedly drunk; those who reported drinking 8-14 units of alcohol a week (corresponding to an average of one to two units a day) had the lowest risks. The causes of death were grouped into three main categories: "alcohol augmented" causes (6% of all deaths: cirrhosis, liver cancer, upper aerodigestive (mouth, oesophagus, larynx, and pharynx) cancer, alcoholism, poisoning, or injury), ischaemic heart disease (33% of all deaths), and other causes. The few deaths from alcohol augmented causes showed, at least among regular drinkers, a progressive trend, with the risk increasing with dose. In contrast, the many deaths from ischaemic heart disease showed no significant trend among regular drinkers, but there were significantly lower rates in regular drinkers than in non-drinkers. The aggregate of all other causes showed a U shaped dose-response relation similar to that for all cause mortality. Similar differences persisted irrespective of a history of previous disease, age (under 75 or 75 and older), and period of follow up (first five and last eight years). Some, but apparently not much, of the excess mortality in non-drinkers could be attributed to the inclusion among them of a small proportion of former drinkers. The consumption of alcohol appeared to reduce the risk of ischaemic heart disease, largely irrespective of amount. Among regular drinkers mortality from all causes combined increased progressively with amount drunk above 21 units a week. Among British men in middle or older age the consumption of an average of one or two units of alcohol a day is associated with significantly lower all cause mortality than is the consumption of no alcohol, or the consumption of substantial amounts. Above about three units (two American units) of alcohol a day, progressively greater levels of consumption are associated with progressively higher all cause mortality.
Article
Full-text available
To address three questions (Is moderate drinking good for health? Should people drink to prevent heart disease? What is moderate drinking?) and to examine and compare two recent Canadian guidelines on low-risk drinking in the context of counseling patients. English-language data sources were searched, particularly peer-reviewed health and social science literature and recent expert reports. Studies and reports were selected for their scientific merit and direct relevance to the three questions addressed and to the formulation of guidelines on low-risk drinking. While moderate drinking might protect some older people against coronary heart disease, it is associated with increased risk of hemorrhagic stroke, certain cancers, accidents and injuries, and a range of social problems. For most health outcomes, risk increases as consumption of alcohol increases. While the data have limitations, they provide a basis for formulating guidelines on low-risk drinking. The two Canadian guidelines, one developed from the perspective of health recovery, the other from the perspective of health promotion, complement each other in the context of counseling patients.
Article
Full-text available
We use data from the National Longitudinal Survey of Youth to estimate changes in binge drinking, marijuana use, and cigarette smoking surrounding young adults' first experiences of cohabitation and marriage. Both marriage and cohabitation are accompanied by decreases in some risk behaviors, but reductions surrounding marriage are larger and most consistent, particularly for men. Binge drinking and marijuana use respond to these events, especially marriage, but smoking does not.
Article
Full-text available
Alcohol-related deaths in the UK increased substantially between 1991 and 2004, from 4144 to 8221. Overall rates increased in all parts of the UK. There were, however, large differences in rates between countries and regions. This article presents these differences and also looks at patterns of alcohol-related mortality by deprivation within England and Wales. The article considers changes over time for males and females and for different age groups.
Article
Full-text available
Alcohol has been reported to be a common and modifiable risk factor for hypertension. However, observational studies are subject to confounding by other behavioural and sociodemographic factors, while clinical trials are difficult to implement and have limited follow-up time. Mendelian randomization can provide robust evidence on the nature of this association by use of a common polymorphism in aldehyde dehydrogenase 2 (ALDH2) as a surrogate for measuring alcohol consumption. ALDH2 encodes a major enzyme involved in alcohol metabolism. Individuals homozygous for the null variant (*2*2) experience adverse symptoms when drinking alcohol and consequently drink considerably less alcohol than wild-type homozygotes (*1*1) or heterozygotes. We hypothesise that this polymorphism may influence the risk of hypertension by affecting alcohol drinking behaviour. We carried out fixed effect meta-analyses of the ALDH2 genotype with blood pressure (five studies, n = 7,658) and hypertension (three studies, n = 4,219) using studies identified via systematic review. In males, we obtained an overall odds ratio of 2.42 (95% confidence interval [CI] 1.66-3.55, p = 4.8 x 10(-6)) for hypertension comparing *1*1 with *2*2 homozygotes and an odds ratio of 1.72 (95% CI 1.17-2.52, p = 0.006) comparing heterozygotes (surrogate for moderate drinkers) with *2*2 homozygotes. Systolic blood pressure was 7.44 mmHg (95% CI 5.39-9.49, p = 1.1 x 10(-12)) greater among *1*1 than among *2*2 homozygotes, and 4.24 mmHg (95% CI 2.18-6.31, p = 0.00005) greater among heterozygotes than among *2*2 homozygotes. These findings support the hypothesis that alcohol intake has a marked effect on blood pressure and the risk of hypertension.
Article
This paper shows that, despite receiving significant attention, the relationship between alcohol, drunkenness and public space has been undertheorized. We show that where drinking has been considered it has generally been as a peripheral concern of political-economy accounts that have sought to conceptualize the development of the modern city, or more recently the impact of global economic restructuring on urban life and public space. Moreover, such work has posited the relationship between drinking and the political, economic, social, cultural and spatial practices and processes bound up with, for example, social control in modern city or with contemporary gentrification, corporatization, fragmentation and regulation of the night-time economy, public space and revanchist urban policy in very general terms. While drawing on evidence from around the world, this paper focuses on the UK and highlights the need for a research agenda underpinned by a more specific consideration of urban drinking. We suggest that such a project must seek to unpack the connections and differences between supranational, national, regional and local drinking practices and related issues, and in particular pursue a more nuanced understanding of the social relations and cultural practices associated with the emergence of particular kinds of urban drinking spaces.
Article
Binge drinking has been linked to escalating costs of hospitalisation and to premature mortality, and implicated in a range of acute and chronic health problems as well as crime, violence and other negative aspects of the wider well-being agenda. Variously defined, it can be characterised as brief periods of heavy drinking (across one day or evening) within a longer time-frame of lower consumption or even abstinence (across a week or several weeks). In England the current binge drinking epidemic has become particularly salient in the past decade and has been seen largely in terms of excessive consumption by younger people, particularly women in urban centres. It has also been linked to the liberalisation of licencing laws and the promotion of 24 h club cultures. This paper presents an observational study of the regional development of binge drinking between 2001 and 2009 as evidenced in the Health Survey for England. We innovate by using two different definitions of binge drinking within a multivariate multilevel modelling framework, with a focus on the random effects attributable to the year of study and region. We control for age, sex, ethnicity, marital status and individual socio-economic status, and confounding by neighbourhood deprivation and urbanisation. The paper identifies pronounced regional geographies that persist in the face of controls and vary little over time, and strong spatio-temporal gender differences which reflect the definition of binge drinking.
Article
While parallels can be drawn between contemporary problem drinking in Britain and apparently similar cases from the late-nineteenth and early-twentieth centuries, little attention has been paid to the ways in which drink is represented as a spatial problem. Closer analysis reveals that the mapping of ‘clusters’ of alcohol outlets or trouble spots has waxed and waned over the last hundred and fifty years, and that the appearance, disappearance and re-emergence of the cluster in policy discussions owes a good deal to changing understandings of the nature of public drinking. Both temperance and contemporary epidemiological approaches favour the cluster because they assume that the supply of alcohol lies at the root of the problems seen to be associated with drink, and mapping clusters makes this supply visible. In contrast the disease theory of alcoholism favours individual rather than social causes, and has little use for maps of clusters; as a consequence the cluster seems to disappear from discussions in the middle years of the twentieth century. The paper concludes that the history of problem drinking demonstrates the need to pay closer attention to changing constructions of drink as problem and the need for a more sophisticated understanding of the history of medicine and public health. It also makes clear the need to look beyond the State and the market as spaces in which the risks of alcohol are calculated.
Article
To determine the role of alcohol-related knowledge, behaviours and attitudes in regional inequalities of binge drinking in England. Adults in all regions except West Midlands and men in the East of England had significantly higher odds of binge drinking than in London. Odds of binge drinking were significantly higher among adults who had had an alcoholic drink in the last 7 days in the North East, Yorkshire and the Humber, and women in the South West. Alcohol-related risk factors for binge drinking were heaviest drinking day being a Friday for men, or Saturday; on heaviest drinking day drinking 2+ drink types, or strong beer only for men, alcopops only for women; drinking more on heaviest drinking day; wanting to drink less alcohol; and thinking it acceptable to get drunk. Protective factors were drinking spirits only on the heaviest day; drinking the same on more than one day compared with drinking on one day only for women; disagreeing it was easier to enjoy a social event if had a drink; supporting alcohol taxation; and not having heard of alcohol units for men. Alcohol-related attitudinal and behavioural factors were associated with regional variations in binge drinking.
Article
Despite lower alcohol drinking rates of UK ethnic minority people (excluding Irish) compared with those of the white majority, events of racial discrimination expose ethnic minorities to unique stressors that elevate the risk for escapist drinking. Studies of ethnic density, the geographical concentration of ethnic minorities in an area, have found racism to be less prevalent in areas of increased ethnic density, and this study hypothesises that ethnic minority people living in areas of high ethnic density will report less alcohol use relative to their counterparts, due to decreased experienced racism and increased sociocultural norms. Multilevel logistic regressions were applied to data from the 1999 and 2004 Health Survey for England linked to ethnic density data from 2001 census. Respondents living in non-White area types and areas of higher coethnic density reported decreased odds of being current drinkers relative to their counterparts. A statistically significant reduction in the odds of exceeding sensible drinking recommendations was observed for Caribbeans in Black area types, Africans in areas of higher coethnic density and Indian people living in Indian area types. Results confirmed a protective ethnic density effect for current alcohol consumption, but showed a less consistent picture of an ethnic density effect for adherence to sensible drinking guidelines. Previous research has shown that alcohol use is increasing among ethnic minorities, and so a greater understanding of alcohol-related behaviour among UK ethnic minority people is important to establish their need for preventive care and advice on safe drinking practices.
Article
To examine the hypothesis that increases in UK liver deaths are a result of episodic or binge drinking as opposed to regular harmful drinking. A prospective survey of consecutive in-patients and out-patients. The liver unit of a teaching hospital in the South of England. A total of 234 consecutive in-patients and out-patients between October 2007 and March 2008. Face-to-face interviews, Alcohol Use Disorders Identification Test, 7-day drinking diary, Severity of Alcohol Dependence Questionnaire, Lifetime Drinking History and liver assessment. Of the 234 subjects, 106 had alcohol as a major contributing factor (alcoholic liver disease: ALD), 80 of whom had evidence of cirrhosis or progressive fibrosis. Of these subjects, 57 (71%) drank on a daily basis; only 10 subjects (13%) drank on fewer than 4 days of the week--of these, five had stopped drinking recently and four had cut down. In ALD patients two life-time drinking patterns accounted for 82% of subjects, increasing from youth (51%), and a variable drinking pattern (31%). ALD patients had significantly more drinking days and units/drinking day than non-ALD patients from the age of 20 years onwards. Increases in UK liver deaths are a result of daily or near-daily heavy drinking, not episodic or binge drinking, and this regular drinking pattern is often discernable at an early age.
Article
Regional variations in British smoking and drinking habits were investigated using the General Household Survey. Heavy smoking was highest in Scotland followed by the Northern Region, Wales and the North West Region. Excessive drinking was highest in the Northern Region followed by the North West Region and Wales. Women in Greater London showed significantly higher ratios for heavy drinking. High risk groups, as identified by both heavy drinking and smoking, were again higher in the North West than the South East. The Scottish figures, though higher than for Central and South East England, were not as high as for the North West of England.
Article
In 7735 men aged 40-59, selected at random from general practices in 24 towns throughout Britain, pronounced differences were noted in the prevalences of smoking and drinking between the social classes. Social class differences also existed for frequency and quantity of drinking, type of beverage, and several aspects of smoking behaviour. Increasing amounts of smoking were associated with higher prevalences of moderate to heavy drinking, particularly in daily rather than weekend drinkers. Between drinking groups, however, the relation with smoking was more U-shaped, with light and heavy drinkers smoking more than moderate drinkers. The lowest rates of moderate to heavy smoking were observed in frequent light drinkers, particularly in the nonmanual workers. The proportion of moderate to heavy drinkers was no higher among ex-cigarette smokers than among current smokers. When the data were examined by town of residence social class differences persisted. Controlling for social class still showed pronounced differences between towns in both smoking and drinking behaviour. These data confirm that town of residence and social class have independent effects on smoking and drinking. The established regional and social class differences in cardiovascular disease may be due in part to the independent influences of town and social class on smoking and drinking behaviour.
Article
The nature and extent of regional variations in levels of alcohol-related problems in Britain are reviewed. Results confirm that considerable differences exist in officially recorded levels of alcohol-related mortality, crimes and alcoholism admissions. The established view, that such rates are much higher in the North-West, was also confirmed. In England and Wales levels of alcohol-related problems were all positively intercorrelated and were also positively correlated with unemployment rates. In Scotland mortality data were negatively correlated with alcoholism admissions and crimes. It is suggested that, to a large extent, such official data reflect differences in provision of services or of detection. In particular, the anomalous Scottish data are concluded to be artefacts of regional idiosyncracies of recording alcohol-related mortality.
Article
To identify developmental trajectories of drinking between the ages of 18 and 26 years and to identify variables, amenable to policy influence, which predict these trajectories. Longitudinal data were analysed using latent class mixture modelling. Participants were interviewed in a central location. Provincial city birth cohort, cross-national studies suggest findings are generalizable to other similar market economies. The frequency of drinking over the past year and the typical quantity consumed per drinking occasion were computed from five location-specific questions. Measures used to predict membership of trajectory groups were ease of access to alcohol, drinking on licensed premises, response to alcohol advertising, educational achievement, parental consumption, age of onset of regular drinking and living arrangements. Three trajectories of quantities consumed showed reduced consumption after age 21 but one trajectory showed marked increases. Three trajectories of frequency of drinking increased or remained stable over time. Access to licensed premises at age 18 had the most significant impact on membership of the trajectory groups and educational achievement had a significant impact on membership of the heavier quantity trajectory groups. Parental alcohol consumption, access to alcohol at 15 years, liking for alcohol advertising, living arrangement and age of onset of regular drinking also influenced trajectory membership. Quantity and frequency of drinking in adolescence and early adulthood had different trajectories. Membership of heavier drinking groups was affected by environmental influences which are subject to policy change, particularly that of earlier access to licensed premises. In a small group high-quantity consumption did not decrease at age 26.
Article
The aim of this study was to explore the associations of physical activity with smoking and alcohol consumption. It examined whether these associations are due to people participating in organized sports (the sport hypothesis), and/or reflect the concentration of drinking and smoking in manual occupational groups (the occupation hypothesis). Data from the 2003 Health Survey for England (n=11,617) were analyzed from a multilevel perspective. Four models were specified to examine the variation of heavy drinking, smoking, sports activity, and occupational activity across different sociodemographic groups; and four sets of analyses further explored the associations of sports and occupational activity with heavy drinking and smoking. Some support was found for both the sport and occupation hypothesis. Sports activity and heavy drinking were more prevalent among sportsclub members, and occupational activity and heavy drinking were more prevalent among manual occupational groups. Sportsclub membership accounted for some of the association between sports activity and heavy drinking; and occupational position partly accounted for the association between occupational activity and heavy drinking. The occupation hypothesis is the more likely explanation for the association between physical activity and smoking. This study shows that it is worthwhile to distinguish between different types of physical activity; and that multiple processes underlie the clustering of health behaviors.
Alcohol in Moderation: Sensible drinking guidelines
AIM, 2012. Alcohol in Moderation: Sensible drinking guidelines. Retrieved from〈http:// www.drinkingandyou.com/site/pdf/sensible%2520drinking.pdf〉 14th April 2015.
How is alcohol consumption affected if we account for under-reporting? A hypothetical scenario
  • S Bonniface
  • N Shelton
Bonniface, S., Shelton, N. (2013). How is alcohol consumption affected if we account for under-reporting? A hypothetical scenario. European Journal of Public Health, 23(6), 1076-81.
Health Survey for England (HSE). London: The Information Centre
  • R Craig
  • J Mindell
Craig, R., Mindell, J. (2012) Health Survey for England (HSE). London: The Information Centre.
Methodology and Documentation. Health and Social Care Information Centre
  • R Craig
  • N J Shelton
Craig, R., Shelton, N.J. (2008). Health Survey for England 2007, Volume 3: Methodology and Documentation. Health and Social Care Information Centre, Leeds.
Sensible Drinking. The Report of an Inter-Departmental Working Group. Department of Health
  • Doh
DoH, 1995. Sensible Drinking. The Report of an Inter-Departmental Working Group. Department of Health, London, (Retrieved from)〈https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/489795/summary.pdf〉.
Safe sensible social: the next steps in the National Alcohol Strategy. London: Department of Health
  • Doh
DoH (2007). Safe sensible social: the next steps in the National Alcohol Strategy. London: Department of Health. Retrieved http://www.asb.homeoffice.gov.uk/uploadedFiles/Members_site/Documents_and_images/ Drinking/AlcoholStrategyJune07_009.pdfS 17 th December 2014.
EU citizens attitudes towards alcohol
European Commission. (2010). EU citizens attitudes towards alcohol. Retrieved from/http://ec.europa. eu/public_opinion/archives/ebs/ebs_331_en.pdfS 17 th December 2014.
Socioeconomic patterning of excess alcohol consumption and binge drinking: a cross-sectional study of multilevel associations with neighborhood deprivation
  • D Fone
  • F Lawrence
  • D White
  • J Lyons
  • R Dunstan
  • F David
  • J John
Fone, D., Lawrence, F., White, D., Lyons, J., Dunstan, R., David, F., John, J., 2013. Socioeconomic patterning of excess alcohol consumption and binge drinking: a cross-sectional study of multilevel associations with neighborhood deprivation. Br. Med. J. 3 (4), 1-9. http://dx.doi.org/10.1136/bmjopen-2012-002337.
Drinking patterns, dependency and life-time history in alcohol-related liver disease
  • J Hatton
  • A Burton
  • H Nash
  • E Munn
  • L Burgoyne
  • N Sheron
Hatton, J., Burton, A., Nash, H., Munn, E., Burgoyne, L., Sheron, N. (2009). Drinking patterns, dependency and life-time history in alcohol-related liver disease. Addiction, 104 (4), 587-594. Doi: 10.1111/j.1360-0443.2008.02493.x
NHS advice on drinking limits
  • Nhs
NHS, 2010. NHS advice on drinking limits. Retrieved from〈http://www.drinking.nhs. uk/questions/recommended-levelsS〉 15th March of 2015.
Adult drinking habits in Great Britain
ONS, 2013. Adult drinking habits in Great Britain. Office for National Statistics, (Retrieved from)〈http://www.ons.gov.uk/ons/dcp171778_395191〉.
Smoking and drinking among adults
  • S Robinson
  • H Harris
  • S Dunstan
Robinson, S., Harris, H. & Dunstan S. (2009). Smoking and drinking among adults. Office for National Statistics. Retrieved from http://www.esds.ac.uk/doc/6737%5Cmrdoc%5Cpdf%5C6737report.pdf 17 th December 2014.
Global status report on alcohol and health
WHO (2014). Global status report on alcohol and health 2014. Geneva: World Health Organization. Retrieved from http://apps.who.int/iris/bitstream/10665/112736/1/9789240692763_eng.pdf.
Health Survey for England (HSE) 2013. The Health and Social Care Information Centre
  • R Craig
  • J Mindell
Craig, R., Mindell, J., 2014. Health Survey for England (HSE) 2013. The Health and Social Care Information Centre, London.
UK Chief Medical Officers' Alcohol Guidelines Review Summary of the Proposed New Guidelines. Department for Health
  • Doh
DoH, 2016. UK Chief Medical Officers' Alcohol Guidelines Review Summary of the Proposed New Guidelines. Department for Health, London, (retrieved 21.11.16) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/ 489795/summary.pdf.
Health survey for England. Health and Social Care Information Centre Leeds
  • E Fuller
Fuller, E., 2008. Adult alcohol consumption. In: Craig, R., Shelton, N.J. (Eds.), Health survey for England. Health and Social Care Information Centre Leeds, 2007.