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that reported an association between unemployment and increased suicide and homicide also found increased deaths directly from alcohol abuse. The missing link is that concurrent alcohol intoxication could be a factor in as many as 65% of suicides.3 That is no more improbable than alcohol being a factor in some irresponsible car crashes or unpremeditated murders. The alcohol and violence special interest group of the UK Public Health Association has been focusing on the need to make policy makers aware that people with alcohol problems usually have multiple needs and they typically present for health care on the basis of those other needs.4 Risky drinking often overlaps with experiences such as clinical depression or homelessness or domestic abuse but, for example, a depressed woman ﬂeeing from a violent spouse whose hungry children now lack shelter seems unlikely to begin her engagement with a clinician by saying “Doctor, my priority today is to discuss my concealed drink problem”. We already know that alcohol and unemployment interact3 and heavy drinking precedes much fatal self harm. Andreas Lundin and Tomas Hemmingsson’s prescient Comment1 stresses the “moderating eﬀect of unemployment beneﬁts” on suicide. Does this make the present punitive approach of the UK beneﬁts system towards people with alcohol problems5 seem a little imprudent? I am a founder member of the UK Public Health Association special interest group for alcohol and violence.
Woody Caan [email protected]
Anglia Ruskin University, Cambridge CB1 1PT, UK 1 2
Lundin A, Hemmingsson T. Unemployment and suicide. Lancet 2009; 374: 270–71. Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. The public health eﬀect of economic crises and alternative policy responses in Europe: an empirical analysis. Lancet 2009; 374: 315–23. Alcohol Concern. Brieﬁng 5: suicide & alcohol misuse. http://www.alcoholconcern.org.uk/ servlets/doc/613 (accessed Sept 23, 2009). Caan W. Misfortunes never come singly. Persp Public Health 2009; 12: 210–11. Caan W. Beneﬁts and alcoholics: feasibility study. BMJ 2009; 338: 1162.
Knowledge of drinking guidelines does not equal sensible drinking The report Reducing alcohol harm: health services in England for alcohol misuse1 concluded that the UK’s current approach to alcohol-related policy, prevention, and treatment is ineﬀective and uncoordinated. Among the recommended platforms for action were revision of policies for the pricing and promotion of alcohol, mandatory labelling, and revised sensible drinking guidelines. The focus on clear labelling and guidance carries with it the assumption that providing such information and facilitating its comprehension will reduce irresponsible drinking behaviour. In our opinion, such eﬀorts are not suﬃcient to aﬀect drinking behaviour; to demonstrate this, we explored the relation between drinking behaviour and knowledge of sensible drinking guidelines in a sample of medical students at a London institution. 203 social drinking undergraduate medical students (66% female, mean age 25 years [range 18–52]) completed a short online questionnaire. 114 (56%) reported heavy and binge drinking (deﬁned as a score on the alcohol use disorders identiﬁcation test [AUDIT]2 of ≥7 for men and ≥5 for women) in the past 6 months. Further AUDIT data showed that 158 (78%) consumed alcohol hazardously, 83 (41%) were at risk of alcohol dependence, 131 (65%) reported experiencing alcohol-related harms, and 49 (24%) reported at least one occasion where they were not able to stop drinking once started. More than half the respondents classiﬁed as heavy and binge drinkers (63 [55%]) were not considering engaging in sensible drinking. This high-risk drinking behaviour occurred despite the fact that 199 (98%) of the overall sample correctly reported current UK drinking guidelines, and all had received a structured curriculum incorporating speciﬁc education on alcohol and other drug misuse.3
Policies that focus on factors associated with the purchase and consumption of alcohol, and, where appropriate, enforce legislative measures, seem eﬀective and cost-eﬀective in reducing alcohol-related harm.4 However, we argue that these population-wide interventions are not a panacea. Advances in our understanding of intoxication and the link between alcohol consumption and the more complex societal harms of drinking, such as antisocial behaviour and violent crime, suggest that such measures would be ineﬀective in moderating the behaviour of individuals once they have already consumed alcohol.5 There remains a need for policy-driven research for those who will continue to experience and cause alcohol-related harm despite population-wide interventions. To achieve this, we call for a Government-led consultation throughout the broader scientiﬁc community, involving key stakeholders from Government and industry, to guide the development of a coordinated national evidence-based policy and associated research agendas. We declare that we have no conﬂicts of interest. Funding for the collection of the data reported was provided by grant RHB0017 from St George’s, University of London awarded to ACM. Ethics approval was provided by the Wandsworth Research Ethics Committee.
Antony C Moss, *Kyle R Dyer, Ian P Albery [email protected]
Department of Psychology, London South Bank University, London SE1 0AA, UK (ACM, IPA); and Division of Mental Health, St George’s University of London, UK (KRD) 1
House of Commons Public Accounts Committee. Reducing alcohol harm: health services in England for alcohol misuse. London: The Stationery Oﬃce, 2009. Aalto M, Alho H, Halme JT, Seppä K. AUDIT and its abbreviated versions in detecting heavy and binge drinking in a general population survey. Drug Alcohol Dependence 2009; 103: 25–29. Utko F, Checinski K. Medical students and alcohol. BMJ 2008; 337: a2798. Anderson P, Chisholm D, Fuhr D. Eﬀectiveness and cost-eﬀectiveness of policies and programs to reduce the harm caused by alcohol. Lancet 2009; 373: 2234–46. Moss AC, Albery IP. A dual-process model of the alcohol-behaviour link for social drinking. Psychol Bull 2009; 135: 516–30.
www.thelancet.com Vol 374 October 10, 2009