Public Health Wales

Briefing Paper Delivering Alcohol Brief Advice

Contents

1Background

The Welsh Assembly Government’s 10 year strategy ‘Working Together to Reduce Harm’³² describes how the harm associated with substance misuse in Wales will be tackled. In respect of alcohol, the focus is set on those drinkers whose drinking levels or patterns are causing them longer term damage or are causing problems for the wider community but who may not need specialist treatment for addiction.

There is a clear consensus of the need to prevent longer term health damage caused by hazardous and harmful consumption of alcohol, recognising that the harmful use of alcohol in Wales is far more widespread than that of illicit drugs. Those at risk of harm from alcohol misuse come from across the spectrum of society. They include chronic heavy drinkers, adults at home drinking at hazardous or harmful levels, and children and young adults who suffer from, and who cause, much of the alcohol related violence and disorder on our streets – often as result of binge drinking³².

The Welsh Assembly Government are providing guidance and support to the NHS and others to promote the appropriate provision of alcohol brief advice, which has been shown to be effective in reducing people’s drinking.^{18 + 25}

This briefing paper is intended to support practitioners in delivering brief advice on alcohol (see below for a description of alcohol brief advice). This paper seeks to establish a common national understanding of key terms and background information, in order to assist practitioners, Health Boards and others with the planning and implementation of brief advice for reducing alcohol misuse at a local level. Information on how to deliver brief advice and a section on frequently asked questions are also included.

2The Scale of Alcohol Misuse in Wales: why is it a Public Health priority

A Profile of Alcohol and Health in Wales³⁰, provides a detailed analysis of the position in respect of alcohol consumption and harm in Wales. Nearly 45 per cent of adults in Wales admit to consuming more than the recommended limits and 27 per cent admit to binge drinking³¹.

The comparison of alcohol sales with the reported alcohol use also suggests that people are consuming more alcohol than they estimate they are¹⁷. Alcohol consumption in the UK has increased over the past decade, as have deaths and diseases related to alcohol ^{16, 14}. The estimated health service cost in Wales of alcohol related chronic disease and acute incidents is between £70 million and £85 million each year⁶.

2.1Morbidity and Mortality

Morbidity and mortality related to conditions most directly linked to alcohol are referred to as “alcohol-related”, whilst “alcohol attributable” mortality and morbidity refers to a new wider definition that includes conditions in part linked to alcohol³⁰.

The Patient Episode Database Wales provides information on hospital admissions in the population of Wales:

• The number of hospital discharges with an alcohol related diagnosis increased by 20per cent from 2000 to 2005 with the most significant increase occurring in the 35–44 age range.

• A significantly higher level of individuals in the 50–54 age range is being discharged from hospital with alcohol-induced (main or contributory factor) chronic pancreatitis³².

• The trend in both alcohol-related and alcohol-attributable hospital admission rates is upwards, with rates approximately twice as high for males than females. The average annual number of alcohol-related hospital admissions for residents of Wales was around 8,400 for males and 4,500 for females (1.5per cent of all admissions).

• Around 30,000 hospital bed days are related to alcohol every year⁶.

• Liver disease (of which alcohol is a major cause) is responsible for around 1,600 admissions every year ²¹. Hospital admissions for alcohol related liver disease rose by over 25 per cent between 2000 and 2006³².

• Alcohol is a major contributing factor to the risk of cancer of the breast, mouth, gullet, stomach, liver, pancreas, colon and rectum ²¹

• There were around 15,300 referrals for treatment of alcohol misuse in Wales in the year 2007-08; around 1,600 were for patients of age. 19 and younger³⁰. The medical profession in Wales are reporting increasing numbers of younger people in the 25–34 age group presenting with symptoms of alcohol related diseases³².

• More people die from alcohol related causes than from breast cancer, cervical cancer, and MRSA infection combined¹¹.

• Around 1,000 deaths are attributable to alcohol per year in Wales ³⁰. There were 260 alcohol-related deaths per year amongst males in Wales compared to 670 alcohol-attributable deaths (4.3 per cent of all male deaths) ³⁰.

• The alcohol-related mortality rate for males almost doubled in the period of 1991-1993 to 2004-2006, although the trend has been levelling out in the latest UK rates released by the Office for National Statistics ³⁰. The rate for persons in Wales in 2007 was slightly higher than the rate for England, and just over half the rate for Scotland ³⁰.

2.2Effect of alcohol misuse on others

Excessive alcohol consumption can also affect non-drinkers in many different ways. This includes the impact of parental drinking on children, the contribution of alcohol consumption to violent behaviour, drink driving, fires and injuries, and the effect of drinking on relationships, families and employment.

• Alcohol is perceived to be a major cause of crime by around half of respondents to the British Crime Survey. There were an estimated 18,000 incidents of violent crime attributable to alcohol in Wales in the year 2007/08 ³⁰.

• Almost half (46 per cent) of all incidents of domestic abuse are linked to alcohol¹⁴.

• 44 per cent of 18-24 year olds in England and Wales report feeling very drunk at least once month, two thirds of those, admit to criminal and or disorderly behaviour during or after drinking¹⁵.

• As many as 64,000 Welsh children may be adversely affected by parental alcohol problems ²¹

3Defining Alcohol Brief Advice

Alcohol brief advice is described as a short, evidence-based, structured conversation about alcohol consumption with a client to motivate and support the individual to think about and/or plan a change in their drinking behaviour in order to reduce their consumption ²².

Brief advice is more than giving a patient/ client a leaflet and telling them to read it.

Providing brief advice must have a structure and style that distinguishes it from simply advising a person to drink less ^1,29.

The provision of brief advice for alcohol misuse uses motivational interviewing techniques, but does not require specialist expertise in these techniques to guarantee effectiveness ²⁵. FRAMES provides a useful mnemonic to describe the approach.

FRAMES – stands for Feedback, Responsibility, Advice, Menu (of options), Empathic interviewing, Self efficacy  ^25,29.

Motivational interviewing is a collaborative style of conversation that practitioners can use to help patients explore and resolve their mixed feelings about behavioural change in a way that enhances their motivation and ability to make positive choices¹¹. Brief advice is not the same as alcohol counselling and the evidence suggests that brief advice on alcohol can be effectively delivered by health professionals in a range of settings.

Practitioners should identify which of their clients could benefit from brief advice – that is, they should ask a set of questions about the person’s drinking, in order to make an objective assessment of their level of risk of harm linked to their drinking behaviour. This enables the practitioner to determine whether the client is a hazardous, harmful or dependent drinker. This is referred to as ‘identification’ or ‘screening’.

3.1Hazardous and harmful drinking

Recent developments in the terminology to describe drinking behaviours, to enhance public understanding, are reflected in the following diagram (see page 6). These are adapted from the Department of Health website http://www.dh.gov.uk/en/index.htm (Accessed 28/09/09)

Figure 1. The Risks of Alcohol

4Calculating a unit of alcohol

The strength of alcoholic drinks is measured in terms of the percentage of alcohol by volume (% abv), which is the number of millilitres (ml) of pure alcohol in 100ml of a particular drink. The average strength of a range of alcoholic drinks has been increasing in recent years⁵. A unit of alcohol in the UK has 10ml (8g) of pure alcohol (ethanol). This corresponds to approximately:

• one 25ml measure of spirits (40% abv)

• half a 175ml glass (i.e. half a standard glass in most pubs) of average-strength wine (12.5% abv)

• half a pint of normal-strength beer or lager (4 %).

It is generally more useful to think in terms of the approximate number of units that are contained in a variety of common drinks, rather than what constitutes one unit. For example:

• a 175ml glass of wine (12.5% abv) contains 2.2 units of alcohol

• a home measure of spirits typically contains almost 2.5 units of alcohol

• a pint of normal strength beer, lager or cider (4% abv) contains 2.2 units of alcohol, whereas a pint of strong beer, lager or cider (6.5% abv) contains 3.6 units of alcohol

• a 275ml bottle of alcopop (5% abv) contains 1.4 units of alcohol

Drink Calculators, which can be used to calculate the number of units in most alcoholic drinks, can be obtained from NHS Choice at http://units.nhs.uk/ More information on alcohol units and how to calculate them can be found at www.drinkwisewales.org.uk and www.yfeddoethcymru.org.uk

Units = volume (ml) x abv (%) /1000

5The Approach

When discussing alcohol with a client or asking them about their drinking in order to provide brief advice, the purpose of the conversation is to:

• give them an opportunity to discuss their drinking if they wish to do so;

• offer them feedback on how their drinking may affect their health, particularly in relation to an issue or condition about which they are concerned;

• explore how they feel about cutting down their alcohol consumption or changing their drinking behaviour;

• help them to make changes if they want to do so²².

The patient is the expert on what changes, if any, are right for them. Any reduction in drinking will reduce the health risks, but if the individual is not interested in discussing their drinking, the practitioner should not continue the conversation²⁷.

6The evidence base

Evaluation of brief interventions (hereafter brief advice) have consistently shown them to be one of the most effective approaches to reducing problem drinking^25,1. Brief advice of various forms, delivered in a variety of settings, have been shown to be effective in reducing alcohol consumption among hazardous and harmful drinkers in a number of large-scale reviews of research studies,^19,2,4,23,7. There are a number of key UK documents that have outlined the evidence for brief interventions in primary care and Accident and Emergency (A & E) settings²⁵ and this is condensed in a National Public Health Service Report ²⁰.

In particular, primary care has been shown to be an effective setting in which to deliver brief interventions and through which to have a major impact on public health²⁵.

7Timescales for delivery

Giving brief advice can take as little as five to 10 minutes to complete, and even a single session with a client can be effective ^{25, 29}.

In practice, the time that it takes to give brief advice will depend on a variety of factors, including what the patient/ client wants and how they feel about their drinking, the skills and confidence of the practitioner, the level of drinking involved, and the time available for both client and practitioner²².

If the practitioner or patient needs/wants to end the conversation at any stage, the provider of the brief advice should ‘leave the door open’ for further discussion at a later date.

There is no evidence that multiple sessions or follow-up sessions to discuss alcohol consumption increase the effectiveness of the initial intervention^18.

By considering which approach to brief advice is most appropriate for each patient/client, the amount of time spent discussing things that they already know can be minimised. For example, some individuals may already be aware that they drink too much and may not need further information or advice about this. They may need to build their confidence or consider their options for cutting down. Similarly, some people may not want to cut down, in which case there would be little point in discussing with them how to cope with stressful or high-risk situations.

If the individual is unsure whether they want to cut down, but there is not enough time to fully explore the advantages and disadvantages of their current drinking behaviour, the practitioner could give the person the option of thinking about this themselves, away from the consultation. A further option would be to refer the person to another service or professional if they would benefit from, or are interested in, longer discussion.

8Suitability of brief advice

Brief advice is suitable for anyone who is regularly drinking more than the recommended upper limit. The Department of Health advice on drinking limits for people aged over 18 years in the UK is as follows:

• For men, regular consumption of between three and four units of alcohol a day, and no more than 21 in a week, by men is unlikely to accrue significant health risks. Consistently drinking four or more units of alcohol a day (or more than 21 units a week) is not advised.

• For women, regular consumption of between two and three units a day, and no more than 14 in a week, by women is unlikely to accrue significant health risks. Consistently drinking three or more units of alcohol a day (or more than 14 units a week) is not advised. Pregnant women or women trying to conceive should avoid drinking alcohol⁹.

• All drinkers should have at least two alcohol-free days per week.

However, there are also many circumstances in which alcohol should not be consumed. If adults are drinking alcohol in these circumstances, brief advice may also be appropriate.

9When brief advice is not suitable

There is no evidence to suggest that brief advice is effective in reducing alcohol consumption among people who are dependent on alcohol^25,29. Alcohol dependence is a term used to describe a range of symptoms and effects resulting from excessive alcohol consumption, where drinking alcohol becomes a much higher priority for a particular individual than other activities that previously had a greater value¹⁰. Other signs may include a strong desire or sense of compulsion to take alcohol, physical withdrawal symptoms or drinking to relieve or avoid withdrawal symptoms, or evidence of alcohol tolerance.

It is important to raise the issue of alcohol with this high-risk group, some of whom will wish to be referred to specialist services. Some people with alcohol dependence recover without specialist treatment but current evidence shows that brief interventions do not improve outcomes for this group.

10Settings

There is strong evidence²⁵ that brief advice is effective in primary care and some evidence of effectiveness in A & E departments. Thus it is proposed that brief advice can be effectively delivered through:

• doctors and nurses in the general practice setting in primary care

• midwives and obstetricians in a primary care, community or hospital setting

• doctors or nurses as part of a patient’s care initiated in an A & E department. The intervention may be delivered either in the A & E department or during follow-on care from A & E in the acute setting, such as an outpatient fracture clinic or in a hospital ward following admission.

There is no evidence to suggest that brief advice sessions are counterproductive in any setting, but further research is needed to demonstrate their wider effectiveness²⁵. There is a need to expand the evidence base around brief advice in alternate settings and pilot work is underway across the UK to test whether professionals other than those based in primary care and A &E can effectively deliver brief advice.

The evidence on brief advice clearly indicates that ‘training is required in order to deliver effective brief advice’ ^25,29.

11Putting brief advice into practice

There are two essential aspects to the delivery of brief advice – the what is said and the how it is said.

Throughout the delivery of brief advice remember to maintain rapport and empathy, whilst emphasising the client’s personal responsibility for their decisions.

Figure 2.Delivering Alcohol Brief Advice

12When to ask about alcohol

The following presentations should alert the practitioner to the possibility that the issue of alcohol may be relevant:

12.1Social issues

• Relationship problems and domestic violence.

• Criminal behaviour (e.g. driving offences, breach of the peace, shoplifting).

• Unsafe sex/sexual risk taking.

• Personal risk taking.

• Financial problems.

• Bereavement (which can lead to use of alcohol as a coping strategy).

12.2Occupational effects

• Repeated absenteeism, especially around weekends.

• Impaired work performance and accidents.

• Employment difficulties.

12.3Effects on mental health

• Anxiety and panic disorders.

• Depressive illness.

• Amnesia, memory disorders and dementia.

• Treatment resistance in other psychiatric illnesses and as a factor in relapse.

• Self-harm.

12.4Effects on physical health

• Accidents/injuries.

• Gastrointestinal system, including dyspepsia (indigestion), gastritis and pancreatitis.

• Various liver abnormalities.

• Cardiovascular system, including cardiac arrhythmias, hypertension and stroke.

• Reproductive system, including impotence, problems with libido and unexplained infertility.

• Cancers of the mouth, pharynx, larynx, oesophagus, breast and colon.

• Other effects, including seizures, gout and eczema.

Confidence, based on a sound knowledge of when and how to ask a patient/client about alcohol, is key to delivering brief advice about alcohol. Such knowledge must encompass what conditions and issues can be affected by, or caused by, alcohol consumption (see above), and the way in which alcohol affects these conditions. Practitioners must keep their knowledge of this subject up to date.

Thinking through the words to use comfortably and in a natural way, is an important preparatory step for the practitioner.

13Taking the first step: raising the issue of alcohol

Brief advice is generally initiated in one of three ways:

Figure 3. Raising the issue of alcohol

14Alcohol brief advice – the vital ingredients

14.1Rapport and empathy

A good rapport is essential if a patient/ client is to feel able to have an open and honest conversation about their alcohol consumption. The practitioner providing the advice must have good listening skills and be able to demonstrate empathy with and understanding of the individual’s circumstances.

The acronym OARS can help practitioners to remember the key listening skills²⁹:

• Open-ended questions: allowing the patient to talk about issues from their own point of view.

• Affirming: statements of appreciation and understanding.

• Reflective listening: allowing the practitioner to check his or her understanding of what the individual has said.

• Summaries: bringing together the key points that the patient has mentioned.

Together with empathy, it is important that the practitioner adopts a non-judgemental approach and a neutral tone, for example, ensuring not to register shock or surprise at what the patient/ client reveals.

14.2Personal responsibility

Intervention through brief advice is distinguished by the underlying principle that the patient/ client is best placed to know their own circumstances and concerns, and therefore to decide what is best for them at any given time. When a brief advice session is going well, the conversation with the patient should feel like ‘dancing, not wrestling’²⁴.

Confrontation has no place in the provision of brief advice; the emphasis is on the individual’s freedom to make choices and the practitioner’s role in providing information to inform those decisions in an objective fashion.

The practitioner should encourage the patient to take ownership of any decision to change their behaviour by challenging any statements the person makes which imply that they do not have a choice.

An example is illustrated in Figure 4 below:

Figure 4. Demonstrating Brief Advice

15Screening/identifcation tools

15.1Knowing who will benefit from brief advice

Alcohol brief advice is suitable for hazardous drinkers, but there is no evidence that such an approach is effective for dependent drinkers. This raises the issue of how to categorise people’s drinking behaviour.

To identify those who might benefit from brief advice, the practitioner must ask the patient/ client a set of questions about their drinking, to enable the practitioner to make an objective assessment of their level of risk of alcohol. This is usually referred to as screening or increasingly as identification. This permits the objective assessment of the person’s level of risk without the introduction of stereotypes or other assumptions.

A formal screening tool (questionnaire) may not be necessary if a patient tells the practitioner that they are drinking above recommended limits. The action of using a screening tool can have benefits however, in respect of providing an objective assessment and in some cases of motivating the individual to change. In addition, the rigour of a screening tool may be essential to monitoring and evaluation of a programme of delivering brief advice.

15.2Alcohol Screening Tools Available

Many different tools have been tested and found to accurately identify hazardous and harmful alcohol users in healthcare settings.

15.2.1Primary Care, Health Checks and A&E settings

AUDIT (Alcohol Use Disorders Identification Test) is regarded as the gold standard, but as it contains 10 questions, so may be impracticable for busy settings. The AUDIT tool is also an effective method for detecting hazardous and harmful drinkers. Shortened versions of AUDIT have been developed and used in practice.

The Fast Alcohol Screening Test (FAST) has a high level of accuracy in detecting hazardous and harmful drinkers across a range of settings, and contains only four questions^{13, 12}. Moreover, many people who are screened with the FAST tool only need to be asked one question in order to obtain a positive result.

Although the FAST tool is not designed to detect alcohol dependence, if any signs of dependence are evident, the practitioner could then use a further screening tool to rule out dependence. Both the AUDIT and CAGE tools can be used to identify dependence.

Manuals are available that describe the use of the FAST¹² and AUDIT¹ tools in more detail.

15.2.2Antenatal settings

Current guidelines recommend that pregnant women should avoid alcohol altogether,⁹ and a formal screening tool is therefore not necessary in antenatal settings. Simply asking pregnant women the following initial screening question: ‘Are you drinking alcohol at all at the moment?’ leads to the next step if the answer is “Yes”, which would be to obtain a clear picture of how much and how often she is drinking, and to consider whether more in-depth support is required to help her to cut down.

Practitioners may encounter a range of other screening tools for detecting hazardous and harmful drinking and a guide to a range of screening tools has been produced by the Primary Care Alcohol Information Service²⁴.

16Delivery of brief advice

The practitioner can judge how to approach the next stage of giving brief advice by listening to the reaction of the patient on hearing the result of the screening questionnaire.

Options at this point include:

• delivering brief advice if the patient/ client is receptive

• ending the conversation at this stage, leaving the door open for a further discussion in the future.²²

Table 1. Approach to delivering brief advice

Patient response	Brief advice approach
‘No, I’m not interested.’	Exit strategy, but ensure that the person knows where they can obtain further information in the future.
‘What do you mean?’	Information and advice (individualised): Focus on the benefits of cutting down, and the risks linked to alcohol. Discuss drinking limits.
‘I don’t think I drink too much.’	Enhance motivation.
‘I think I could make some changes. What could I do?’	Menu of options that would lead to a reduction in risk (individualised).
‘I think it would be really hard to cut down.’	Build confidence.
‘I have been trying to cut down, but sometimes it’s not easy.’	Coping strategies (individualised).

17Summary of the five alcohol brief approaches

17.1Information and advice (with permission)

If the patient is receptive to advice, the practitioner should take the opportunity to provide accurate information about how to reduce the harmful effects of drinking, and about the benefits of cutting down. The more relevant the information is to the person’s particular situation, the more valuable this approach will be. This approach may be sufficient for some patients to decide to cut down, and if they know how to go about this and are not looking for any further help, the brief intervention could end here.

17.2Enhancing motivation

If the patient is in two minds about changing their drinking habits, it might be useful for the practitioner to help them explore the situation further and to weigh up the advantages and disadvantages of their current drinking habits against the advantages and disadvantages of changing their drinking behaviour. The practitioner adopts a neutral approach but reinforces any comments made by the patient which acknowledges harm or risk which might be caused by their current drinking habits. This technique uses a tool called the motivation matrix²⁸ .

17.3Menu of options

Some patients may wish to cut down their drinking, but are unfamiliar with the concept of units of alcohol, and may be unaware of the fact that small changes to their drinking behaviour can dramatically reduce the risk of potentially harmful effects associated with alcohol consumption. In this situation, the practitioner will ideally support the person in identifying ways to reduce the risks associated with their drinking. This can lead to negotiation with the patient with regard to the specific goals that they would like to set for changing their drinking behaviour, based on their individual needs and circumstances.

17.4Building confidence

A person is more likely to change their behaviour if they have confidence in their ability to change. The practitioner can help the patient to increase their confidence in three ways:

1. by reminding them of occasions in the past when they have been successful in making changes

2. by looking at role models (i.e. other people in a similar situation who have succeeded in making changes)

3. by highlighting the fact that significant individuals in the person’s life (including the practitioner) have belief in his or her ability to change.

This approach also uses a tool called the ‘Readiness Ruler.’ ⁶ 

17.5Coping strategies

It is particularly helpful to ask the patient to identify any especially stressful events or circumstances that might trigger a return to their previous drinking patterns, and to discuss these situations with them. This enables the individual to avoid potential triggers and high-risk situations, and to develop appropriate coping strategies and support networks that will enable them to resist pressure to return to their previous drinking patterns, and to get back on track if they do have a lapse.

18Appropriate referral to another service or professional

A practitioner may wish to consider referring a patient to another service if:

• the individual wants to speak to someone else or might benefit from additional help or support

• discussion with the individual indicates signs of alcohol dependence or they have screened positively for dependence

• the individual has any problems that the practitioner cannot adequately support or address (e.g. other substance use or mental or physical health problems)

• there is a concern about child protection.

In addition, the practitioner may wish to refer a patient to a source of additional information on alcohol.

19Summary

The delivery of brief advice is much more than a conversation in which the topic of alcohol is mentioned. It is an interaction that is structured by the practitioner and which aims to help the patient to consider their drinking and its consequences in a way that supports and encourages change. Brief advice is based on evidence of what approaches are effective, and practitioners are likely to benefit from training to develop the skills and techniques for delivering brief advice in practice. The next section Frequently asked questions, includes further information on the training that is available in Wales.

20Frequently asked questions

20.1Common concerns about providing brief advice in practice

Most of the people I help don’t want to change their drinking pattern. How do I know that this will really work?

There is strong evidence that providing an intervention through brief advice (particularly in a primary care and A & E settings²⁵) can be very effective. Alcohol consumption can be reduced for periods of a year or more among people who are drinking more than the recommended drinking limits, but who are not dependent upon alcohol.^{18,25,29, 1}

Although relatively modest , at a reduction of 15–35% in consumption levels, positive health and social benefits are that are significant both for the individual and, if many people make small changes, for society as a whole.²⁹ Like any health intervention, brief advice does not work for everybody, but such advice is often rated as the single most effective intervention for reducing alcohol consumption, comparing extremely favourably with many other health interventions in terms of effectiveness and cost-effectiveness.²⁹ It has been calculated that one in every eight patients who receive brief advice delivered in the recognised manner is likely to benefit in terms of reduced health risks, compared with one in every 20 people who receive brief advice to stop smoking.²⁹ 

If a client does not want to discuss their drinking, that is their right. It is preferable for the practitioner to end the conversation about alcohol but to ‘leave the door open’ for further discussion at a later date. In most cases it would also be helpful for the practitioner to offer the client some written information and guidance in the form of a leaflet, including details of where to seek advice should they decide that they need help in the future.

What if people don’t want to change their drinking?

Central to the delivery of brief advice is the patient’s/ client’s right to choose not to act on that advice. The practitioner must recognise that a person’s motivation to change is not fixed, and that the techniques employed in delivering brief advice can increase a person’s willingness to change. The practitioner can always ‘leave the door open’ for further discussion at a later date. If the client is unwilling to discuss the matter further, it is important that the practitioner respects this and does not try to force the issue.

How do I raise the Issue of drinking too much without offending someone?

It may be surprising but the evidence suggests that people are not offended by professionals asking them about their drinking habits. This has been endorsed by recent market research conducted in Wales³. Research indicates that people are co-operative and appreciative when professionals take an interest in their health²⁵. If a practitioner asks a patient about their drinking, it is done in the context of exploring if cutting down on alcohol will help them deal with any health and/or social issues that they may have. This is done in a non-confrontational and supportive manner that provides the individual with the assurance and encouragement that they may need in order to reflect on their alcohol use and modify their drinking behaviour if necessary.

The brief advice approach is not compatible with telling someone that they drink “too much”. A basic principle of brief advice is that the individual is the expert on what is right for them, and that the responsibility for change lies with that individual. The philosophy of brief advice is that it is up to the individual to decide what level of alcohol consumption is ‘too much’ for them. Consistent with decisions regarding other lifestyle issues, such as diet and exercise, people make choices based upon the level of risk with which they are comfortable.

Making a comparison with smoking, most people who smoke are aware of the risks, whilst many people who are drinking more than the recommended drinking limits will not necessarily be aware that they are putting their health at risk. Brief advice ensures awareness of the risks and a balancing of those risks with the perceived benefits from their current drinking patterns. Acting on this information is the responsibility of the individual, with the practitioner in a supportive role if desired.

20.2Questions about current drinking limits

Are the drinking limits set too low?

The current recommendations are that men should drink no more than three – four units of alcohol per day, and no more than 21 units per week, and that women should drink no more than two – three units of alcohol per day, and no more than 14 units per week. All drinkers should have at least two alcohol-free days per week.

Although these limits may appear to be low compared with what many people drink in Wales, they are based upon medical and scientific evidence of the short and long term effects of alcohol. The UK Department of Health has set the recommended limits at the level that the best evidence suggests carries minimal risk of harm.

The evidence indicates that drinking in excess of these limits progressively increases the risk of damage to health. This means that any increase in consumption above the recommended drinking limits increases a person’s risk of alcohol-related health problems. Conversely, however, any reduction in drinking will reduce the risks, so even if a person does not feel that they can reduce their alcohol consumption to below recommended limits immediately, they will still benefit from reducing their drinking by even a small amount.

Given the large number of people who report drinking more than the recommended daily limits, those practitioners delivering brief advice may well themselves examine their own personal lifestyle and behaviour choices when working with and supporting people to improve their health. However, the practitioner who finds that they sometimes drink more than the recommended drinking limit should not feel unable to deliver brief advice provided they are aware of this fact and adopt an objective approach to discussing alcohol with patients/ clients. It is not usually appropriate or necessary for you to disclose or discuss your own personal lifestyle choices or drinking habits when delivering brief advice.

What about weekly drinking limits?

Weekly limits are not used in current guidance. The guidance on safer levels of alcohol consumption was changed from weekly to daily limits in 1995,³ but it has taken a long time for this information to be fully understood by the public. There is still widespread lack of awareness of, and confusion about, the limits. This confusion is reflected in the findings of market research conducted on behalf of the Welsh Assembly Government⁸.

What about the reported benefits of alcohol- are they true?

The simple message is that there is no benefit in drinking more alcohol than the daily limits for any age group.

It is not considered appropriate to advise people who currently do not drink alcohol to begin to do so, or for those who drink occasionally to increase their alcohol consumption.

Some evidence exists that for men over 40 years and postmenopausal women, there is some beneficial effect of moderate alcohol consumption, mainly the protective effects against coronary heart disease obtained from drinking no more than one or two units of alcohol per day. This protective effect can be obtained from any form of alcohol, including wine, beer and spirits.

21What training will I need to deliver brief advice?

The training that is required by an individual practitioner in order to deliver brief advice will depend on their previous training and practice, and their current level of skill, knowledge and understanding. The Welsh Assembly Government is funding a programme of alcohol brief advice training which is designed to enable practitioners to competently, confidently and appropriately raise and respond to alcohol-related issues with their patients/ clients, and to deliver brief advice in line with existing evidence.

The training is suitable for practitioners who have varying levels of knowledge about alcohol and brief advice skills, and includes the following elements:

• Understanding what brief advice is, the evidence base and policy background.

• Examining the attitudes of the practitioner and others to alcohol, and how those attitudes impact on practice.

• Exploring the obstacles to the implementation of brief advice by practitioners, and how these barriers and concerns can be resolved.

• Recognising good practice and the key skills involved in effectively delivering brief advice.

• Understanding current units and drinking limits, and the various terms commonly used to describe people’s relationship with alcohol.

• Being comfortable with the wording that can be used when raising the issue of alcohol with clients, and the health and social problems to which alcohol can be a contributory factor.

• Utilising screening tools to accurately assess the health risks associated with a person’s drinking, and giving appropriate feedback.

• Developing key skills for, and confidence in, delivering each of the five brief advice approaches outlined in paper and in delivering a complete brief advice from start to finish.

• Being able to observe and critique the delivery of a brief advice by oneself and others.

• Review and evaluation of one’s readiness to deliver brief advice, including any further support that is needed.

22Further reading

22.1Screening

• Manual for FAST; www.aerc.org.uk/documents/pdfs/FinalReports/AERC_FinalReport_0007.pdf

• Manual for AUDIT; whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf

• Guide to screening tools; www.alcoholconcern.org.uk/files/20030910_143338_Screening%20factsheet%20final%20for%20web%202.pdf

22.2Brief Interventions/Advice

• National Treatment Agency for Substance Misuse (2006). Assessment and measuring treatment outcomes. In: Review of the Effectiveness of Treatment for Alcohol Problems; www.nta.nhs.uk/publications/documents/nta_review_of_the_effectiveness_of_treatment_for_alcohol_problems_fullreport_2006_alcohol2.pdf

• Scottish Health Action on Alcohol Problems (SHAAP). Guide to Brief Advices; www.work-interactive-test.co.uk/UserFiles/File/Screening%20and%20brief%20interventions.pdf

23References

1. Babor and Grant (Eds) (1992). Project on the Identification and Management of Alcohol-Related Problems. Report on Phase II: A randomised clinical trail of brief interventions in the primary health care setting. World Health Organization, Geneva.

2. Ballensteros et al. (2004). Efficiency of brief interventions for hazardous drinkers in primary care: systematic review and meta-analysis. Alcoholism: Clinical and Experimental Research, 28, 608-618.

3. Beaufort Research for National Public Health Service Alcohol Intervention Study. Research Report 2009, Cardiff

4. Bertholet et al. (2005). Brief alcohol intervention in primary care: systematic review and meta-analysis. Archives of Internal Medicine, 165, 986-995.

5. Catto S, Gibbs D (2008). How Much Are People in Scotland Really Drinking? A Review of Data from Scotland’s Routine National Surveys. NHS Health Scotland, Glasgow.

6. COLES E, PATES R. for WELSH ASSEMBLY GOVERNMENT. The Economic and Social Costs of Class A drug and alcohol abuse in Wales. Cardiff: Welsh Assembly Government (Unpublished).

7. Cuijpers et al. (2004). The effects on mortality of brief interventions for problems drinking: a meta-analysis. Addiction, 99, 839-845.

8. Department of Health (1995). Sensible Drinking: the Report of an Inter-Departmental Working Group. Department of Health, London.

9. Department of Health (2007). Updated Guidance on Alcohol Consumption in Pregnancy. Department of Health, London. www.tin.nhs.uk/sys_upl/templates/PT_Directory_RSS/PT_Directory_RSS_details.asp?id=102152&pgid=2470&tid=163

10. Fitzgerald (2008). Common definitions and terminology for use in health behaviour change and related training for NHS Health Scotland – agreed terms. Unpublished paper.

11. GILMORE I and SHERON N. (2007) Reducing the harms of alcohol in the UK. British Medical Journal, 2007, 335: pp 1271 – 1272

12. Health Development Agency and the University of Wales College of Medicine (2002). Manual for the Fast Alcohol Screening Test (FAST). Fast screening for alcohol problems. Health Development Agency, London.

13. Hodgson et al. (2002). The Fast Alcohol Screening Test. Alcohol and Alcoholism, 27, 61-66.

14. HOME OFFICE. Crime in England and Wales 2006/07. London: Home Office, 2007

15. HOME OFFICE. Young People and Crime: Findings from the 2005 Offending, Crime and Justice Survey Home Office Statistical Bulletin 17/06. London: Home Office, 2006.

16. HOME OFFICE. Statistical Bulletin, Crime in England and Wales 2006/07. London: Home Office, 2007.

17. HM Government. Safe Sensible Social. The next steps in the national Alcohol Strategy. London: HM Government, 2007.

18. Kaner et al. (2007). Effectiveness of Brief Alcohol Interventions in Primary Care Populations (Cochrane Review). John Wiley & Sons, Chichester.

19. Moyer et al. (2002). Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction, 97, 279-292.

20. National Public Health Service, 2009, Scoping a Community-based Screening and Brief Interventions Service for Hazardous Drinkers

21. NATIONAL PUBLIC HELATH SERVICE FOR WALES. Alcohol and health in Wales: A major publish health issue. Cardiff: National Public Health Service for Wales, 2006.

22. NHS Health Scotland (2009). Alcohol Brief Interventions Training Manual. NHS Health Scotland, Edinburgh.

23. Poikolainen (1999). Effectiveness of brief interventions to reduce alcohol intake in primary health care populations: a meta-analysis. Preventive Medicine, 28, 503-509.

24. Primary Care Alcohol Information Service 92001). Factsheet: Screening Tools for Healthcare Settings. Alcohol Concern, London.

25. Raistrick et al. (2006). Review of the Effectiveness of Treatment for Alcohol Problems. National Treatment Agency for Substance Misuse, London.

26. Rolnick, S. Miller, W. R., and Butler, C.C. (2008) Motivational Interviewing in Healthcare. The Guildford Press, London.

27. Rollnick et al. (1999). Health Behaviour Change: a Guide for Practitioners. Churchill Livingstone, Edinburgh.

28. Scottish Health Action on Alcohol Problems (2007). Alcohol and Health Factsheet. Scottish Health Action on Alcohol Problems, Edinburgh.

29. Scottish Intercollegiate Guidelines Network (2003). Guideline 74. The Management of Harmful Drinking and Alcohol Dependence in Primary Care. Scottish Intercollegiate Guidelines Network, Edinburgh.

30. A profile of Alcohol and Health in Wales, Wales Centre for Health/NPHS, 2009

31. WELSH ASSEMBLY GOVERNMENT, Welsh Health Survey 2005-06. Cardiff: Welsh Assembly Government, 2007.

32. WELSH ASSEMBLY GOVERNMENT, 2008 ‘Working Together to Reduce Harm’ The Substance Misuse Strategy for Wales 2008 – 2018

33. World Health Organization. International statistical classification of diseases and related health problems. 10^th ed. Geneva: The Organization; 1992.

Date: 26 July 2010

Version: 0f

Page: 28 of 28